Increasing HIV-Free Survival of Infants: Reorganizing Care Using Quality Improvement for the Optimal Health and Nutrition of HIV-Positive Women and Their Exposed Infants in Uganda

Nsubuga-Nyombi, Tamara; Karamagi, Esther; Nabitaka, Linda; Namukose, Samalie; Calnan, Jacqueline; Nyakwezi, Sheila; Bachou, Hanifa; Lazarus, Oucul; Amoah, Aurora O.

doi:10.1177/2325958219857724

Cited by 9 publications

(3 citation statements)

References 18 publications

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“…Our results have several implications for policymakers of which we consider the following one as the most fundamental to a successful QI programme. If senior facility management, and subsequently, the HCWs who will be recruited as team leaders, are to accept QI as a tool to improve the quality of standard care, and not as additional to standard care [ 56 ], then QI should be endorsed as policy [ 11 ]. Such endorsement may result in cascading buy-in downwards across the different management levels, ending with QI leaders who know they are supported across all levels.…”

Section: Discussionmentioning

confidence: 99%

“If you work alone on this project, you can’t reach your target”: unpacking the leader’s role in well-performing teams in a maternal and neonatal quality improvement programme in South Africa, before and during COVID-19

Odendaal,

Chetty,

Tomlinson

et al. 2023

BMC Health Serv Res

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The South African National Department of Health developed a quality improvement (QI) programme to reduce maternal and neonatal mortality and still births. The programme was implemented between 2018 and 2022 in 21 purposively selected public health facilities. We conducted a process evaluation to describe the characteristics and skills of the QI team leaders of well-performing teams. The evaluation was conducted in 15 of the 21 facilities. Facilities were purposively selected and comprised semi-structured interviews with leaders at three time points; reviewing of QI documentation; and 37 intermittently conducted semi-structured interviews with the QI advisors, being QI technical experts who supported the teams. These interviews focused on participants’ experiences and perceptions of how the teams performed, and performance barriers and enablers. Thematic data analysis was conducted using Atlas.ti. Variation in team performance was associated with leaders’ attributes and skills. However, the COVID-19 pandemic also affected team functioning. Well-performing teams had leaders who effectively navigated COVID-19 and other challenges, who embraced QI and had sound QI skills. These leaders cultivated trust by taking responsibility for failures, correcting members’ mistakes in encouraging ways, and setting high standards of care. Moreover, they promoted programme ownership among members by delegating tasks. Given the critical role leaders play in team performance and thus in the outcomes of QI programmes, efforts should focus on leader selection, training, and support.

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Section: Discussionmentioning

confidence: 99%

“If you work alone on this project, you can’t reach your target”: unpacking the leader’s role in well-performing teams in a maternal and neonatal quality improvement programme in South Africa, before and during COVID-19

Odendaal,

Chetty,

Tomlinson

et al. 2023

BMC Health Serv Res

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“…Given its prevalence in many settings, including those of high HIV burden, programmes that identify and address intimate partner violence may reduce its negative impact on health outcomes and empower women to seek care. Efforts to strengthen health systems and to fully deliver well‐implemented, quality services can also have important downstream benefits [126‐131]. Because such cross‐cutting approaches did not map to our a priori framework, however, they were not formally included in this review.…”

Section: Discussionmentioning

confidence: 99%

Accelerating progress towards the elimination of mother‐to‐child transmission of HIV: a narrative review

et al. 2020

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Introduction Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother‐to‐child HIV transmission (PMTCT). Methods We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services. Results and discussion From May to November 2019, we identified numerous promising, evidence‐based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility‐based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT. Conclusions A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

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“…Data-driven quality improvement (QI) is an approach that can be highly effective in improving HIV service delivery, in combination with other 'systems engineering' approaches [26]. QI approaches have been shown in several studies to improve different aspects of facility-level PMTCT implementation [27][28][29][30], and could be effective for EID in Uganda.…”

Section: Plos Onementioning

confidence: 99%

Uganda’s “EID Systems Strengthening” model produces significant gains in testing, linkage, and retention of HIV-exposed and infected infants: An impact evaluation

Kiyaga

Narayan²,

McConnell³

et al. 2021

PLoS ONE

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Introduction A review of Uganda’s HIV Early Infant Diagnosis (EID) program in 2010 revealed poor retention outcomes for HIV-exposed infants (HEI) after testing. The review informed development of the ‘EID Systems Strengthening’ model: a set of integrated initiatives at health facilities to improve testing, retention, and clinical care of HIV-exposed and infected infants. The program model was piloted at several facilities and later scaled countrywide. This mixed-methods study evaluates the program’s impact and assesses its implementation. Methods We conducted a retrospective cohort study at 12 health facilities in Uganda, comprising all HEI tested by DNA PCR from June 2011 to May 2014 (n = 707). Cohort data were collected manually at the health facilities and analyzed. To assess impact, retention outcomes were statistically compared to the baseline study’s cohort outcomes. We conducted a cross-sectional qualitative assessment of program implementation through 1) structured clinic observation and 2) key informant interviews with health workers, district officials, NGO technical managers, and EID trainers (n = 51). Results The evaluation cohort comprised 707 HEI (67 HIV+). The baseline study cohort contained 1268 HEI (244 HIV+). Among infants testing HIV+, retention in care at an ART clinic increased from 23% (57/244) to 66% (44/67) (p < .0001). Initiation of HIV+ infants on ART increased from 36% (27/75) to 92% (46/50) (p < .0001). HEI receiving 1st PCR results increased from 57% (718/1268) to 73% (518/707) (p < .0001). Among breastfeeding HEI with negative 1st PCR, 55% (192/352) received a confirmatory PCR test, a substantial increase from baseline period. Testing coverage improved significantly: HIV+ pregnant women who brought their infants for testing after birth increased from 18% (67/367) to 52% (175/334) (p < .0001). HEI were tested younger: mean age at DBS test decreased from 6.96 to 4.21 months (p < .0001). Clinical care for HEI was provided more consistently. Implementation fidelity was strong for most program components. The strongest contributory interventions were establishment of ‘EID Care Points’, integration of clinical care, longitudinal patient tracking, and regular health worker mentorship. Gaps included limited follow up of lost infants, inconsistent buy-in/ownership of health facility management, and challenges sustaining health worker motivation. Discussion Uganda’s ‘EID Systems Strengthening’ model has produced significant gains in testing and retention of HEI and HIV+ infants, yet the country still faces major challenges. The 3 core concepts of Uganda’s model are applicable to any country: establish a central service point for HEI, equip it to provide high-quality care and tracking, and develop systems to link HEI to the service point. Uganda’s experience has shown the importance of intensively targeting systemic bottlenecks to HEI retention at facility level, a necessary complement to deploying rapidly scalable technologies and other higher-level initiatives.

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Increasing HIV-Free Survival of Infants: Reorganizing Care Using Quality Improvement for the Optimal Health and Nutrition of HIV-Positive Women and Their Exposed Infants in Uganda

Cited by 9 publications

References 18 publications

“If you work alone on this project, you can’t reach your target”: unpacking the leader’s role in well-performing teams in a maternal and neonatal quality improvement programme in South Africa, before and during COVID-19

“If you work alone on this project, you can’t reach your target”: unpacking the leader’s role in well-performing teams in a maternal and neonatal quality improvement programme in South Africa, before and during COVID-19

Accelerating progress towards the elimination of mother‐to‐child transmission of HIV: a narrative review

Uganda’s “EID Systems Strengthening” model produces significant gains in testing, linkage, and retention of HIV-exposed and infected infants: An impact evaluation

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