Reducing missed appointments and number of lost clients through community tracking using PHAS and zoning to ease follow-up
Butebo Health centre IV is a rural health unit in Pallisa District in Eastern Uganda in East Africa. The health facility has a current cumulative enrollment of 530 HIV positive clients and only 389(73%) are active in care. HIV infection requires long term care and support and this has been achieved through regular visit schedules to an HIV care centre. In many sub Saharan African countries including Uganda, there has been a major challenge in retention of clients on HIV care and treatment. Stigma is cited as one of the main reasons for this; many patients live in denial about their HIV status. Some clients report disclosure as a hindrance to keeping appointments yet others do not have transport to the facility. Prior to the intervention, a sharp rise was noted in the number of clients missing appointment between February and July 2011. Documentation from client cards and appointment book showed that, 188(48%) of HIV positive clients missed at least an appointment between January and July alone, and 33 clients were lost to follow up in the same period. Of those who were lost, 9(27%) were eligible and yet to commence ART while 3(9%) had initiated ART. Only 2(6%) of these clients self returned to the facility.
After analysis of several possible interventions the ART clinic team (Health workers, counselors and PHAs/peer/expert clients) proposed use of PHAs to follow up those missing appointments in the community with support from health facility staff The team went through the following steps in introducing the intervention
1. Meeting with volunteers and PHAS to discuss the problem, the possible interventions and selecting an intervention for implementation
2. Zoning the health facility catchment area into five sub counties
3. Dividing the 12 PHAs among the five sub counties, each PHA following up clients in his/her home sub county
4. Organizing patient files by appointment dates
On each Clinic day each PHA was to identify clients from his/her sub county who missed appointment and arrange for follow up within one week. During each follow up day the client would be educated on importance of continued care and support together with the care givers. In all cases consent was sought from the client if they wanted family members to be part of the visit. The PHA would then give feed back to the clinic about the visit and clients who self returned to the facility were documented.
Since May when the intervention was put in place there has been a progressive reduction in the number of clients missing appointments. The results showed that at four months post intervention, the number of clients missing appointment reduced from 43 at base line to 7 (83.7% drop) in September and down to 2 (95% drop from baseline) in December (7 months post intervention). Only one client has so far missed appointment in February 2012 although 3 missed in January The number of lost clients also reduced from 6 in May to 1 client in October. 15(45%) of the lost clients self returned to the facility, 2 of whom were admitted on their first visit to the facility because the condition had worsened. Some of them had associated their illness to witchcraft. The number of new clients enrolled in care also rose from 56 between January and May 2011 to 76 in the same period between June and October 2011 . This was because community members became more aware of the services and family members of visited clients came for HIV testing.
Motivating the volunteers was difficult as they had to travel long distances to reach some clients. This was partly solved by engaging them in other funded activities in the facility such as HIV testing, Clinic facilitation for break tea and lunch. Some of them were also motivated by having the chance to help others live a better life •
It was only possible to track HIV positive clients within 5 sub counties. Therefore it was difficult to track lost clients from outside these sub counties
Tracking lost clients using PHAs encourages HIV positive clients to return for care and treatment as they were more satisfied that their care was so personalized thus further enhancing patient retention in care and treatment which will likely translate to better out comes for ART
Clients were also more contented with this kind of approach because the peers were fellow community members and less stigma was associated to their visit compared to a situation where a health worker visited. Over all there was a marked reduction in stigma as clients started to freely express themselves
Home visits also encouraged family members and other community members to seek HIV testing services increasing number of new clients enrolled in chronic care