The Global Partnership for HIV-Free Survival (PHFS): Quality Improvement and Breastfeeding / ART compliance

Transcription

1 The Global Partnership for HIV-Free Survival (PHFS): Quality Improvement and Breastfeeding / ART compliance TOPS Breastfeeding Seminar Washington, DC May 10, 2017 Amy F. Stern, URC Improvement Director 1

2 The PMTCT care spectrum Non-pregnant: Family planning (FP) counseling Preconception Care Partner HIV testing Antepartum: PITC in ANC CD4 Testing ART treatment or prophylaxis Adherence support Infant feeding (IF) counseling Safe Motherhood Birth Preparedness Intrapartum: CD4 testing ARV prophylaxis Safe Delivery IF counseling FP counseling Adherence support 1-8 Weeks Post PMTCT PITC Maternal in L&D Care Partum: Spectrum from 2-6 Months Pregnancy Post to Months months Post Post Maternal Partum: Partum: postpartum follow- Partum up Enrollment into HIV care ART treatment or prophylaxis during BF FP counseling IF counseling Adherence support Repeat CD4 (6 months pp) ART treatment or BF prophylaxis FP counseling IF counseling Adherence support ART treatment or BF prophylaxis FP counseling IF counseling Adherence support 9-12 Months Post Partum: ART treatment or BF prophylaxis FP counseling IF counseling Adherence support Months Post Partum: ART treatment FP counseling Adherence support Repeat CD4 Effective PMTCT includes a series of biomedical and psychosocial interventions administered throughout the reproductive life of the woman living with HIV 2

3 Drop of ARV uptake before and after delivery 38% 51% Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response 3

4 The Partnership for HIV-Free Survival PHFS in six countries: Uganda, Tanzania, Kenya, Lesotho, Mozambique, South Africa AIM: Decrease HIV transmission & improve nutrition, infant feeding Deliberate focus on in-country and cross-country learning Design for sustainability country owned & led ASSIST QI demonstration sites Kenya - 16 Lesotho - 12 Tanzania - 30 Uganda

5 The Partnership for HIV-Free Survival Nutrition in 1 st 1000 days (optimal infant feeding, nutrition and health practices) Option B+ (effective ARVs to reduce HIV transmission) HIV-free survival of infants born to HIVinfected mothers 5

6 Improvement approach Engages teams of providers and other staff Focuses on client needs Analyzes systems and processes Empowers teams to make changes to improve outcomes Guided by data to measure results Peer-to-peer learning Langley et al, 1999, The Improvement Guide 6

7 Basics of collaborative improvement Learning Session Collaborative-level sharing and synthesis of best practices Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care QI team representative Site-level summary QI team site QI team site QI team site QI team site QI team site QI team QI team site QI team site 7 QI team site QI team site site Site-level testing of changes and analysis of results

8 Applying improvement to achieve HIV-free survival WHAT ARE WE TRYING TO ACHIEVE? HIV-positive mothers who are alive and in care Exposed infants who are HIV-free, alive and in care Improve data system to identify areas for improvement Improve retention of mother-baby pairs Provide critical package of care at ROUTINE VISITS Provide critical package of care at SPECIAL VISITS (6w PCR and results visit, 6 and 12m visit, 18m visit) 8

9 Retention of mother-baby pairs at baseline Percentage of mother-baby pairs retained in care at baseline 10% 9% 8% 7% 6% 5% 4.6% 4% 3% 2% 1% 0% 0.8% 1.0% 2.2% Kenya Lesotho Tanzania Uganda 9

10 KEY LESSON 1: Improve the availability and quality of data KEY LESSON 1 Uganda 10

11 KEY LESSON 2: Work on retaining mothers and their babies in care Reasons for missing appointments Motivations for remaining in care % 90% 80% 70% 60% 50% 40% 30% 20% % of clients No. of clients % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2 10% 0 0% Forgot appointment date, other activities, transport, lack of privacy, disclosure concerns. Know weight for self and baby, be treated for other conditions, know more about IYCF, transport, need for more counselling. 11

12 Increasing retention of mother-baby pairs in care, 22 PHFS and 3 comparison sites, Uganda Proportion of mother-baby pairs retained in care each month in PHFS and nonintervention sites in Uganda 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Feb-13 May-13 Aug-13 Nov-13 Feb-14 May-14 Aug-14 Nov-14 Feb-15 May-15 Aug comparison sites 22 PHFS sites Number of mother-baby pairs who should be accessing care that month (PHFS sites) Number of mother-baby pairs who should be accessing care that month (comparison) 0 Feb-13 May-13 Aug-13 Nov-13 Feb-14 May-14 Aug-14 Nov-14 Feb-15 May-15 Aug-15 12

13 Proportion of mother-baby pairs retained in care each month, 22 PHFS sites, Uganda All 22 PHFS sites One high-volume site (~150 pairs/month) One low-volume site (~85 pairs/month) 100% 90% Dec 2013: Set specific / separate day June 2013: Peer mothers involved in to see M-B pairs counselling mothers 80% on appointment keeping 70% 60% 50% May 2013: Merged EID and 40% ART services at one services point and gave same appointment date 30% Sept 2013: Assigned EID focal person to pair cards and call mothers Nov 2013: ART and EID merged Mar 2014: Phone calls to mothers 20% 10% Apr 2013: Pairing of mothers and babies June 2013: Peers escort MB pairs to the clinic May 2013: Pairing of mother s and babies July 2013: Family support group meetings used to identify MB pairs and see them then 0% Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Denominator: Number of mother-baby pairs who should be accessing care that month 13 0 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15

14 Percentage of HIV-positive mother-baby pairs attending HIV services in Nzega, Mufindi, and Mbeya, Tanzania 10 facilities in Nzega District 10 facilities in Mufindi District 10 facilities in Mbeya Region 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% July-Oct 2013: No system in place for mothers and babies having the same appointment Dec 2013: Introduction of QI principles and formation of QI teams Apr 2014: Community outreach conducted by EGPAF Jan-Feb 2014: Insertion of HEI cards in mother s CTC2 cards and orientation of H/C staff on importance of M-B pair retention 0% Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15 Dec-15 Common changes Giving same day appointment for the mother and infant to come to the services Tracked mothers with missed appointments through mobile phones or HBC Stapling together mother s CTC2 cards to the HIV Exposed Infant (HEI) cards Denominator: Number of HIV exposed infants who are registered and tested in Nzega, Mufindi, and Mbeya 0 Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15 Dec-15 14

15 Retention of mother-baby pairs at baseline and end of intervention Percentage of mother-baby pairs retained in care, at baseline and end of intervention 100% 90% 80% 82% 91% 92% 70% 66% 60% 50% 40% 30% 20% 10% 0% 0.8% 1% Baseline 4.6% 2.2% End of intervention Kenya Lesotho Tanzania Uganda 15

16 KEY LESSON 3: Define the package of care to be given at each visit Tally Sheet for Routine Visits Mother s ART CTX/ NVP (baby< 6 weeks) given IYCF counselling done? (Specify topic) Nutrition assessment for mother and baby? Appointment for next visit given and explained what will happen at next visit? 16

17 Increasing HIV+ pregnant women currently on ART, 10 sites each in three districts,tanzania (Nzega, Mufindi, and Mbeya) % % 84% Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 Denominator: Total number of HIV+ pregnant and lactating women in the program Apr-13 Jun-13 Aug-13 Oct-13 Dec-13 Feb-14 Apr-14 Jun-14 Aug-14 Oct-14 Dec-14 Feb-15 17

18 Infant and young child feeding (IYCF) results SO WHAT HAPPENED TO THE IYCF? 18

19 Percentage of HIV-positive mothers who receive IYCF counselling at each visit, 22 PHFS sites and 3 comparison sites, Uganda 3 comparison sites 22 PHFS sites 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% May-13 Aug-13 Nov-13 Feb-14 May-14 Aug-14 Nov-14 Feb-15 May-15 Aug Number of HIV positive pregnant and lactating mothers attending in the reporting period (PHFS sites) Number of HIV positive pregnant and lactating mothers attending in the reporting period (comparison) 0 May-13 Aug-13 Nov-13 Feb-14 May-14 Aug-14 Nov-14 Feb-15 May-15 Aug-15 19

20 Increasing adherence to IYCF practices, 22 sites, Uganda Percentage of exposed infants reporting to be adhering to recommended IYCF practices in Uganda 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul Denominator: Number of exposed infants who attend the EID care point in the given month 0 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 20

21 In summary.the key lessons learned Robust data system Empower mothers and create supportive systems Retain motherbaby pairs in care Early initiation on ART Provide a standard package of care 21

22 Improving processes can improve outcomes 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% % of mother-baby pairs who receive a standard package of care at routine visits Denominator: Average of 1034 mother-baby pairs seen each month Key results from PHFS in Uganda % of HEI in PMTCT programs who are alive at 18 months and HIVpositive Denominator: Average of 56 babies discharged from EID care point each month 100% % of mother-baby pairs retained in care Denominator: Average of 1513 MB pairs who should be accessing care each month Global target of <5% transmission 91% 0% Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul % 22

23 Mother-Baby pair retention in PHFS spread sites, northern Uganda 23

24 Acknowledgements The support of the American people through USAID Tim Quick, USAID U.S. President s Emergency Plan for AIDS Relief WHO and UNICEF PHFS partners IHI, HEALTHQUAL, FANTA and LIFT Country implementing partners USAID ASSIST project staff and MOH counterparts in Kenya, Tanzania, Uganda, and Lesotho 24

25 For more information about PHFS quality improvement Amy Stern: Anisa Ismail: Tim Quick: To view the PHFS learning platform, visit: partnership-hiv-free-survivallearning-platform 25