STRENGTHENING THE COORDINATION, DELIVERY AND MONITORING OF HIV AND AIDS SERVICES IN MALAWI THROUGH FAITH-BASED INSTITUTIONS.

STRENGTHENING THE COORDINATION, DELIVERY AND MONITORING OF HIV AND AIDS SERVICES IN MALAWI THROUGH FAITH-BASED INSTITUTIONS.

Acknowledgements This project was fully funded by Center For Disease Control (CDC) HIV resources (all test kits and ART drugs) were provided by the HIV unit in the Ministry of Health

Main Objective To strengthen and improve the quality of HIV services delivery in 7 Mission health facilities from January 2016 to September 2017 7 Hospitals/ Health Centres will use Quality Improvement methods to achieve the 90:90:90 targets By 2020, 90% of all people living with HIV will know their HIV status By 2020, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy. By 2020, 90% of all people receiving antiretroviral therapy will have viral suppression

Theory of Change & Interventions Improving the 90-90-90 HIV indicators in the 7 Mission Hospitals from January 2016 to September 2017 Primary Drivers Engaged Leadership Efficient Supply Chain Knowledgeable Health Workers Culture of continuous Quality Improvement Real time data management Interventions Engaged central level leaders and hospital managers Leaders ensured that all logistics were in place e.g. provide HTC counsellors, funds for outreach clinics Engaged QI team leaders that coordinate QI team activities The HIV unit (MOH) ensured efficient supply of HIV test kits (Rapid tests, PCR and Viral load sample collection tools) Partners (like Riders for Health) provide transportation of PCR and viral load samples to central labs 3 QI team members from each hospital trained as QI mentors All ART staff trained in Quality Improvement methods All teams oriented on the 90-90-90 targets QI teams meeting every 2 weeks/ every month to review their PDSAs and data Active QI team leaders coordinate QI team meetings Collaborative learning sessions ensure sustainability and spread of change ideas within the collaborative Data reviews every 2 weeks/ every month and real time reaction to the data Annotated run charts made visible at the facility

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Number of people tested for HIV 90% of population get tested for HIV 6000 5000 Individuals: Number of people tested for HIV in 7 Mission Health Facilities 14,537 more people tested from March 2016- Feb 2017 than the previous year (March 2015- Feb 2016) We have tested 47% of our catchment population (some of the population in the catchment area go to the government hospitals nearby) 4000 3000 2000 1000 0 UCL LCL QI Mentors Trained (Nov 2015) Start of QI activities Change ideas tested and implemented Ensure availability of at-least 1 HTC counsellor per day at each service points: OPD, wards, ANC and Under-5clinics Fortnightly or monthly PDSA and data review by QI team Intensify Provider Initiated Testing and Counselling by all healthcare providers Outreach clinics in the community to give an opportunity for HIV testing to those who do not come to hospital

Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Number of clients initiated on ART Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Percent clients initiated on ART 90% of HIV positive clients are initiated on ART 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% P Chart: Percentage of HIV positive clients initiated on ART in the 7 Mission Hospitals UCL LCL Start of QI activities Currently initiating 93% (from a baseline of 84%) of HIV positive on ART within 7 days of testing positive There is less variation in the data (data does not go below 80% unlike during baseline would reach 70%) 250 200 150 100 50 0 Individuals: Number of clients initiated on ART in the 7 Mission Hospitals UCL LCL Start of QI activities Change ideas Clients tested positive are escorted to ART provider by expert clients or HTC counselors Test and start, then transfer clients who want to continue at another hospital

Oct-15 Nov-15 Dec-15 Jan-16 90% of ART clients will have viral suppression Percent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Run Chart: Proportion of eligible ART clients with viral load samples taken per month Start of QI project on VL Testes change ideas on viral load testing Triage all clients so that viral load sample is collected before client is reviewed by clinician or collects ART drugs Currently 72% of ART clients that had a viral load test done have viral suppression QI teams are now working on improving adherence to ART by Defaulter tracing to reduce defaulters Intensive adherence counselling (IAC) at each ART clinic Percent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% P Chart: Proportion of viral load results showing viral suppression Start of QI project on VL

Challenges Interruption of project implementation due to logistical issues coaching and mentoring by IAs only started in January to March 2016, then paused and restarted in September 2016 Delayed start of collaborative Learning Sessions (only 2 sessions conducted instead of 4 sessions) Learning Sessions fast track testing and spread of change ideas within the participating hospitals