Continuous quality improvement (CQI) Institutionalization to reach 95:95:95 HIV targets: a multicountry experience from the Global South.

BACKGROUND: Scaling up continuous quality improvement (CQI) processes could be key in achieving the 95:95:95 cascade and global HIV targets. This paper describes the experiences and outcomes related to implementing CQI processes to help reach these targets, with particular focus on clinical and programmatic settings in 6 countries from the global south. METHODS: The HIV program at the University of Maryland, Baltimore (UMB) implemented an adapted CQI model in Kenya, Tanzania, Botswana, Zambia, Nigeria and Rwanda that included the following steps: (1) analysing the problem to identify goals and objectives for improvement; (2) developing individual changes or 'change packages', (3) developing a monitoring system to measure improvements; and (4) implementing and measuring changes through continuous 'plan-do-study-act' (PDSA) cycles. We describe country-level experiences related to implementing this adaptive design, a collaborative learning and scale-up/sustainability model that addresses the 95:95:95 global HIV targets via a CQI learning network, and mechanisms for fostering communication and the sharing of ideas and results; we describe trends both before and after model implementation. RESULTS: Our selected country-level experiences based on implementing our CQI approach resulted in an increased partner testing acceptance rate from 21.7 to 48.2 % in Rwanda, which resulted in an increase in the HIV testing yield from 2.1 to 6.3 %. In Botswana, the overall linkage to treatment improved from 63 to 94 %, while in Kenya, the viral load testing uptake among paediatric and adolescent patients improved from 65 to 96 %, and the viral load suppression improved from 53 to 88 %. CONCLUSIONS: Adopting CQI processes is a useful approach for accelerating progress towards the attainment of the global 95:95:95 HIV targets. This paper also highlights the value of institutionalizing CQI processes and building the capacity of Ministry of Health (MoH) personnel in sub-Saharan Africa for the effective quality improvement of HIV programs and subsequent sustainability efforts.

Bridging the Gap in Implementation Science: Evaluating a Capacity-Building Program in Data Management, Analysis, Utilization, and Dissemination in Low- and Middle-Income Countries.

Building capacity in implementation science within health programs is dependent on training in theory and practice of epidemiology, statistics, and research in addition to high self-efficacy toward application of training. This article describes a training program providing technical assistance to more than 300 health facilities in Kenya and Tanzania, its evaluation results, and its ability to improve participants' knowledge, competencies, and self-efficacy on data management, analysis, and dissemination among health care professionals. Two months prior to the training, participants (n = 98) were emailed a pre-course survey including 19 questions using a Likert-type response for planning the content of the workshop. Six to 12 weeks after the training, a post-course survey was emailed to all participants. Five different trainings were conducted indicating 5 participant cohorts. The questions posed involved course satisfaction, course impact on knowledge and skills, and self-efficacy in data analysis and utilization. Post-course survey results revealed that the participants had confidence in data analysis, which was significantly different from the pre-test results (0.05 α). Qualitative commentary complemented the findings of the impact of the workshop. Four manuscripts and 13 abstracts have been submitted post training. Results suggest that a short-term training program can achieve immediate gains in data and research self-efficacy among health care professionals. Although increasing self-efficacy is a necessary first step in developing skills, educators should engage in continuing education for sustainable dissemination practices. There is an urgent need to determine the current infrastructure to promote scientific dissemination. This will assist countries to produce better evidence to support their programs, policies, and overall health programs.

Early Versus Delayed Mortality among HIV Infected Patients Initiating Highly Active Antiretroviral Therapy in Tanzania.

Development of HAART in the mid-1990's and its continued scale up has revolutionized the treatment of HIV-infected patients and led to remarkable reductions in HIV associated morbidity and mortality. However, recent studies have suggested a higher risk for early mortality in adults receiving ART in low-income countries as compared to those in high-income countries. There is dearth of data from developing countries where the burden of disease is high. The objective is to describe the burden and correlation between early vs. delayed mortality associated with HIV/AIDS in resource poor settings using data from Tanzania in East Africa. We performed a cross-sectional evaluation of routinely collected program data for 991 HIV-positive deceased adult patients who were placed on ART treatment, and died between January 1, 2007 and December 31, 2012. Data used were abstracted from records of patients who were treated at six health facilities in the Lake-zone Region of Tanzania in the timeframe. Bivariate and multivariate regression models were used to identify independent predictors of mortality and to calculate odds ratios. From the population, early deaths (within 3 months of ART initiation) occurred in 359 of the 991 cases, which represented 36.2%; while delayed deaths (after 3 months of ART initiation) occurred in 632 of 991 (63.8%). The average time to death for those who died within 3 months was 1 month compared to 22 months among those who died at > 3 months since initiation of ARV. In multivariate analysis, patients who were on WHO stage IV, had fever and cough symptoms at 6 months prior to death and patients with 0-1, 2-3, and 4-6 clinic visits had a higher risk of death in the first 3 months. Mortality among patients started on ART seems to be high. Where possible, healthcare providers should do more to vigorously monitor patients before starting them on ART for better outcomes. Additionally, public health efforts to encourage early testing and entry into treatment must be scaled up in resource poor countries to gain some lead-time and to keep the virus under control, sustain immune function, and delay the onset of opportunistic infections.

The effect of depressive symptoms and CD4 count on adherence to highly active antiretroviral therapy in sub-Saharan Africa.

BACKGROUND: Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART. METHODS: A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients' level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART. RESULTS: A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy. CONCLUSIONS: These results indicate that mental health and clinical parameters are significant factors in determining patients' adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support.

The effect of depressive symptoms and CD4 count on adherence to highly active antiretroviral therapy in sub-Saharan Africa.

BACKGROUND: Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART. METHODS: A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients' level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART. RESULTS: A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy. CONCLUSIONS: These results indicate that mental health and clinical parameters are significant factors in determining patients' adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support.