Russia| HIV/AIDS Treatment, Care and Support: Support for Regional Spread Collaborative: Improvement of Access to Basic HIV/AIDS Care and ART Collaborative

Date improvement activities began: 
February, 2007
Date of end of collaborative: 
October, 2010
Aims/objectives: 

Improve access to HIV/AIDS treatment, care and support services.
The main objectives were as follows:
• Improve systems for detection, referral, and medical follow up of HIV-positive patients for better retention in care and larger enrollment of patients on ART
• Improve monthly records of patients medical follow up (dispanserization) at polyclinics and AIDS centers
• Design activities for better involvement of HIV-positive patients into medical follow up at all stages
• Define roles of providers in medical follow up, develop algorithms for medical follow up
• Based on the data, adopt and develop districts plans for patient enrollment on ART
• Train care providers at polyclinics on clinical management of HIV-positive patients

Implementation package/interventions: 

The initial key objective in St. Petersburg was for HCI to develop and scale up a model for the decentralized delivery of HIV/AIDS treatment, care and support services. HCI’s underlying principle was always to utilize and build upon the resources of the existing system to deliver quality care. With support from health authorities of the City and initially selected pilot Krasnogvardeisky districts, HCI staff worked with providers from twenty five facilities, including districts’ polyclinics, TB and substance abuse treatment facilities, City’s AIDS Center, and key NGOs representing PLWH on analysis of the system of HIV care, which described patients’ flows from entry to the system and to the AIDS Center.

Key changes introduced by the teams included the introduction of the following:
• Database on HIV infected individuals residing within a polyclinic’s service area;
• Processes for exchange of information between districts’ polyclinics and the AIDS Center for HIV infected individuals;
• Processes for involving HIV infected individuals into care;
• Processes for engaging HIV-registered patients on medical follow up at polyclinics;
• Processes for testing of HIV patients for TB through X-ray, microscopy and tuberculin as an integral part follow up at polyclinics;
• Design of an HIV patient’s referral to other health and non-health-related services;
• Patient’s recording forms and reporting systems.

Measurement: 

The key measures that were following and reported on during the collaborative were as follows:
• Number of individuals tested for HIV
• Number of service outlets providing counseling and testing
• Number of patients who received annual medical examinations (AME)
• Number of patients registered in care
• Number of service outlets providing AME
• Percent receiving AME in polyclinics each quarter
• Number Screened for TB of with chest X-ray of those examined in polyclinics
• Number who were screened for TB of those who were examined in polyclinics
• Number of service outlets providing screening for TB
• Number of patients enrolled on ART(cumulative by each year)
• Number of service outlets providing ART (cumulative)

Spread strategy: 

After review of achievements demonstrated in Krasnogvardeisky rayon in 2004-2006, as well as in other project sites, HCI identified a number of successful improvements that could be scale up. All 18 administrative districts of St. Petersburg were engaged in this scale up collaborative. The scale up process was administered/supervised by the City Health Care Committee and seen as a City Health Care Committee activity and not as a separate project. HCI continued to use the collaborative improvement methodology as the basis of the scale-up approach. HCI provided technical and management support, but the St. Petersburg and district health authorities committed to co-managing the activities. Whenever possible, the city health administration system was used as a platform for implementation of scale up.

Number of sites/coverage: 

All 18 districts in St. Petersburg plus two districts of Leningrad Oblast participated in the work: 100% of AIDS and TB facilities and 64% of polyclinics with a total of about 26,785 PLWHA registered for follow up in St. Petersburg and 100% of AIDS and TB facilities and 100% of polyclinics with about 2,276 PLWHA registered for follow up in two districts of Leningrad Oblast. In total, 204 state health facilities, social service organizations, and NGOs in St. Petersburg and 3 such facilities in Leningrad Oblast participated in the collaborative.

Coaching: 

The improvement collaborative approach was used to organize inter-disciplinary teamwork and facilitate the sharing of ideas and learning across the collaborative. A team of 15 providers, formed in the Krasnogvardeisky district which became part of a larger HCI collaborative, which included teams in three other Russian cities and was focused on improving access to basic HIV care. Key representatives of the team periodically participated in HCI’s sponsored learning sessions where they shared results with other participants, discussed it with key national and international experts and worked on formulating the next steps. Between the sessions, HCI staff provided coaching to teams in their efforts to improve HIV care processes, and facilitated presentations of results to health authorities and heads of the participating institutions

Learning sessions & communication among teams: 

HCI provided technical assistance to all 18 districts (rayons) of St. Petersburg to improve medical follow-up of HIV patients at polyclinics. As part of the assistance, HCI facilitated learning sessions. HCI also supported trainings on early detection of TB in HIV patients at the primary care level for polyclinic infectious disease (ID) specialists, radiologists and primary level laboratory staff in December 2009 and in June 2010.

Results: 

• A common database on HIV patients was established between the AIDS Center and polyclinics
• Patient referral mechanisms were established between polyclinics, AIDS Center, and TB dispensaries
• An algorithm for enrolling HIV patients in medical follow-up at the polyclinic level was operationalized
• Systematic X-ray screening of HIV patients for TB was initiated at polyclinics
• Based on the results of the pilot activities, in October 2007 the City Health Care Committee issued Decision N529-r to require heads of polyclinics to employ infectious disease doctors and nurses to provide medical follow-up for HIV patients, including those on ART
• In April 2009, the City Health Committee issued Decision N201-r which requires heads of polyclinics to organize and implement TB testing through X-ray, tuberculin skin test, and microscopy

Best practices/conclusions: 

• “Framework for Engagement into HIV Care.” This tool addresses enrollment and retention in the HIV/AIDS care system by defining a continuum of engagement of HIV-infected people into the system. By tracking target populations along this continuum to quantify gaps in service uptake and patient retention, the interventions needed to close these gaps become clear. The framework is developed by HCI/Russia based on our work in St. Petersburg.
• “Practical guidelines on medical follow-up of HIV-infected patients at polyclinics”

 

Countries: 
Report Author(s): 
Victor Boguslavasky
Organization(s): 
USAID Health Care Improvement Project with support from the Ministry of Health and the American International Health Alliance
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