Applying Improvement to Keep HIV+ Mothers and Exposed Infants in Care Anisa Ismail Improvement Advisor University Research Co., LLC 1
What if you found out you were pregnant? What if you knew you were pregnant and HIV+? 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 PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post 1-8 Weeks Post Partum 2-6 Months Post Intrapartum: PITC in L&D CD4 testing ARV prophylaxis Safe Delivery IF counseling FP counseling Adherence support Partum: Maternal postpartum followup Enrollment into HIV care ART treatment or prophylaxis during BF FP counseling IF counseling Adherence support Partum: Repeat CD4 (6 months pp) ART treatment or BF prophylaxis FP counseling IF counseling Adherence support 6-9 Months Post Partum: 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 12-18 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 3
Drop of ARV coverage before and after delivery Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response
What factors impact mother to child transmission of HIV? Poor postnatal retention in care Poor adherence to recommended infant feeding practices Late initiation of mothers with HIV on ART 5
What do we need to do? 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 6
The Partnership for HIV-Free Survival PHFS in six countries- Uganda, Tanzania, Kenya, Lesotho, Mozambique, South Africa. ASSIST- Uganda, Tanzania, Kenya, Lesotho. Community demonstration work in Mozambique. 7
Applying improvement: Making changes in systems and processes to improve outcomes Engages teams of providers and other staff Focuses on client needs Analyzes systems and processes Empowers teams to make changes Guided by data to measure results Langley et al, 1999, The Improvement Guide 8
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 9 QI team site QI team site site Site-level testing of changes and analysis of results
Improvement within PHFS 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) 10
Why are they not coming? Why do you miss doctor s appointments? 11
No of clients % of clients Reasons for missing appointments 20 18 16 14 100% 90% 80% 70% 12 10 8 6 4 2 60% 50% 40% 30% 20% 10% 0 Forgot appointment date Social factors Lack of transport Lack of privacy during counseling Fear of disclosure to partner Long distance to the hospital Was sick Unfriendly health workers 0% 12
No of respondents Factors supporting appointment-keeping 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 0 100 90 80 70 60 50 40 30 20 10 0 freq Percentage Reasons for retaining in care 13
What do we mean by retention? All mother & baby pairs who should be in care in that facility (denominator). Countries may use different sources of data to obtain this denominator (i.e. Uganda EID register, Kenya population estimate). And of those, what percent are coming for care. 14
Proportion of mother-baby pairs retained in care each month in 22 PHFS sites and 3 comparison sites, Uganda 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 3 comparison sites 22 PHFS sites 0% Feb-13 May-13 Aug-13 Nov-13 Feb-14 May-14 Aug-14 Nov-14 Feb-15 May-15 Aug-15 1500 1000 500 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 15
Proportion of mother-baby pairs retained in care each month in 22 PHFS sites, Uganda All 22 PHFS sites One high-volume site (~150 pairs/month) One low-volume site (~85 pairs/month) 100% June 2013: Peer mothers involved in counselling mothers on appointment keeping May 2013: Merged EID and ART services at one services point and gave same appointment date Apr 2013: Pairing of mothers and babies 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Dec 2013: Set specific / separate day to see M-B pairs Sept 2013: Assigned EID focal person to pair cards and call mothers June 2013: Peers escort MB pairs to the clinic May 2013: Pairing of mother s and babies Mar 2014: Phone calls to mothers Nov 2013: ART and EID merged July 2013: Family support group meetings used to identify MB pairs and see them Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 Number of mother-baby pairs who should be accessing care that month 2000 1000 16 0 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15
What did we change? Mother and baby seen together Priority given to MB pairs Give mother and baby the same appointment date and write date on medicine bottle Give mother and baby just enough drugs that will last to the next appointment Pair mothers and babies cards Clinicians/ dispensers remind them of appointments New clients seen where they are tested Provide a special clinic day for mothers and children to be seen Expert patients follow up and counsel lost mothers and mothers who miss their appointments 17
Percentage of HIV-positive mother-baby pairs attending HIV service in Nzega, Mufindi, and Mbeya, Tanzania 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jun-13 Sep-13 Dec-13 Mar-14 Jun-14 Sep-14 Dec-14 Mar-15 Jun-15 Sep-15 Dec-15 1800 1200 600 Percentage of HIV+ Mother-baby pair attending HIV service in Nzega District, Mufindi District, and Mbeya Region, Tanzania 10 facilities in Nzega District 10 facilities in Mufindi District 10 facilities in Mbeya Region 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 18
Percentage of HIV-positive mother-baby pairs attending HIV service 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 1800 1200 600 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 19
Our clients are here, now what? Mother receives antiretroviral therapy (ART) refills The baby, if under 6 weeks of age, receives Nevirapine (NVP) or Cotrimoxazole (CTX) from 6 weeks of age Both mother and baby receive nutrition assessment using either mid-upper arm circumference (MUAC) or body mass index (BMI) for age or weight for age for babies less than six months Infant and young child feeding counselling Vital signs for both baby and mother TB screening for mother An appointment date for the next visit giving details of what will happen during that visit 20
Percentage of mother-baby pairs receiving standard package of care in four faith-based facilities, seven government facilities, and one government hospital 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 200 150 100 50 0 Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 Denominator: Number of mother-baby pairs Nov-13 Jan-14 Mar-14 May-14 Jul-14 Sep-14 Nov-14 Jan-15 Mar-15 May-15 Jul-15 Sep-15 21
Percentage of HIV-exposed infants tested for HIV by 3 months of age (1 st PCR), Kenya 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 60 40 20 0 Denominator: # of HEI reviewed at 3 months of age Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 22
Improving processes can improve outcomes Key results from PHFS in Uganda 100% 90% 80% % of mother-baby pairs who receive a standard package of care at routine visits Denominator: Average of 1034 mother-baby pairs seen each month 100% 91% 70% 60% 50% 40% 30% 20% 10% % 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 % 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 1.6% 0% Jan-13 Apr-13 Jul-13 Oct-13 Jan-14 Apr-14 Jul-14 Oct-14 Jan-15 Apr-15 Jul-15 23
Scaling up the learning Identify what we are trying to accomplish what do we want to achieve with the scale-up? Identify what exactly we want to scale up (changes, QI, change packages) Identify which sites we want to scale up to (high volume/ high yield/high burden) Plan how the scale-up will be executed (methodology to be used, who will scale up, when, resources available) Develop a strategy for monitoring the scale-up (indicators, data sources, etc.)
Acknowledgements The support of the American people through USAID Tim Quick and Amie Heap, USAID U.S. President s Emergency Plan for AIDS Relief WHO and UNICEF PHFS partners IHI, FANTA and LIFT Country implementing partners USAID ASSIST project staff and MOH counterparts in Kenya, Tanzania, Uganda, and Lesotho 25
Interested in learning more? Amy Stern: astern@urc-chs.com Anisa Ismail: aismail@urc-chs.com To join the PHFS learning community, contact: phfs-info@urc-chs.com Visit the PHFS Learning Platform: https://www.usaidassist.org/toolkits/partnershiphiv-free-survival-learning-platform 26