HIV Peer Mentors in Morogoro

As coverage of HIV prevention, care and treatment services expands and programs mature, greater attention is being paid to strengthening the capacity of health systems to provide and sustain high quality HIV and AIDS services, including antiretroviral therapy (ART), prevention of mother-to-child transmission (PMTCT), voluntary medical male circumcision (VMMC), HIV counseling and testing, integration of HIV services with other clinical services, home-based care and community support, injection safety, and medical waste management.

Improvement methods help HIV and AIDS programs to: 1) provide services for all who need them, 2) retain all those who access services in the continuum of care, and 3) achieve optimal health outcomes for all those who are retained in care.  Strategies to improve coverage of HIV-infected mothers by PMTCT services, especially in antenatal care and at delivery, and improve the follow-up of mother-baby pairs can maximize the uptake of PMTCT services and promote HIV-free survival by assuring that all eligible infants and mothers get needed PMTCT services.  Adult treatment, care, and support can be improved by applying a chronic care model to service delivery and strengthening linkages with community and home-based care.

23rd International AIDS Conference (AIDS 2018)

Amsterdam, Netherlands

USAID ASSIST Project Semi-Annual Performance Monitoring Report FY18

University Research Co., LLC (URC) and its partners have completed 5.5 years of implementation of the USAID Applying Science to Strengthen and Improve Systems (ASSIST) Project. This report is the eleventh Semi-Annual Performance Monitoring Report for ASSIST, summarizing the project’s accomplishments and results during the first two quarters (Q1-2) of Fiscal Year 2018 (FY18).  In late September 2017, the project was awarded a two-year costed extension with additional funding for Zika-related activities.  No further funding was provided for non-Zika work.  The project’s FY18 work plan thus focuses mainly on Zika-related support in eight countries and completion of previously funded work in other countries.

Overall goals
The USAID ASSIST Project fosters improvements in a range of health care processes through the application of modern improvement methods by host country providers and managers in USAID-assisted countries. The project’s central purpose is to build the capacity of host country health and social service systems to improve the effectiveness, efficiency, client-centeredness, safety, accessibility, and equity of the services they provide. In addition to supporting the implementation of improvement strategies, the project seeks to generate new knowledge to increase the effectiveness and efficiency of applying improvement methods in low- and middle-income countries.
USAID ASSIST country programs align with the goals of United States Government’s global initiatives and policies, including preventing child and maternal deaths, achieving HIV epidemic control, combating other public health threats, protecting life, and addressing gender inequalities.

Where we work
During the first half of FY18, USAID ASSIST provided technical support in 23 countries through field and core funding. USAID Mission funds supported work in nine countries: Cambodia, Côte d’Ivoire, India, Indonesia, Lesotho, Mali, Swaziland, Tanzania, and Uganda. USAID core funds from the Office of HIV/AIDS supported activities in seven countries: Kenya, Lesotho, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe.  Funds for Neglected Tropical Diseases supported improvement work to combat the Zika virus in the Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Nicaragua, Paraguay, and Peru.  USAID cross-bureau-funded activities, through the Office of Health Systems, supported malaria prevention activities in Malawi and global and regional initiatives that contribute to local and global learning in improvement.

FY18 Q1-2 accomplishments and results:

  • Improvement in key indicators: As discussed in this report, ASSIST-supported programs demonstrated improved care and outcomes for a range of services, including antenatal and postnatal care, essential obstetric and newborn care, screening of pregnant women and newborns for Zika-related signs and symptoms, Zika care and support, PMTCT, and HIV prevention.
  • Research and evaluation studies: At of the end of the reporting period, the project had 29 research studies in planning, underway or completed in 14 countries. Three are multi-country studies.
  • Promoting the use of improvement methods: During the reporting period, project staff published nine peer-reviewed articles; seven case studies; four technical and research reports; and 10 guides, tools, and job aids. ASSIST staff led six sessions and made eight oral presentations at six regional and international conferences. ASSIST’s work continued to be promoted through the project’s website and social media engagement, with some 27,867 visitors viewing 61,572 pages within the ASSIST Knowledge Portal during the past two quarters.

Measuring productivity and its relationship to community health worker performance in Uganda: a cross-sectional study

The Ugandan Ministry of Health (MoH) established Village Health Teams (VHT) to empower communities to take part in the decisions that affect their health. In Busia District these teams, comprised entirely of volunteers, are responsible for mobilizing their communities for health programs and strengthening the delivery of health services at the household level, especially for people living with HIV.

Tasks that these community health volunteers perform are critical and life-saving, such as:

  • mapping HIV patients in the community; linking patients to care;
  • engaging community groups to provide HIV patients with nutritional, psychosocial and financial support; and
  • supporting patient self-care through health goal setting.

This study, funded by PEPFAR through USAID, explores the relationship between productivity of community health volunteers and their performance. It aims to contribute to the global evidence on strategies to improve community health worker/volunteer (CHW/CHV) productivity and performance with an eye toward better understanding factors that could increase their effectiveness given the essential role that CHWs and CHVs play in health systems worldwide.

Read the full article in BMC Health Services Research.

The cost-effectiveness of three methods of disseminating information to improve medical male circumcision in Uganda

Uganda is working to increase voluntary medical male circumcision (VMMC) to prevent HIV infection. ASSIST has been supporting efforts in Uganda to ensure provision of high-quality, patient-centered VMMC services.

This study compares three methods of disseminating information to facilities on how to improve VMMC quality:

  1. providing a written manual
  2. providing the manual plus a handover meeting in which clinicians shared advice on implementing key changes and participated in group discussion; and
  3. manual, handover meeting, and three site visits to the facility in which a coach provided individualized guidance and mentoring on improvement.

We analyzed the effect each method had on quality of care. Health workers in facilities that received the VMMC improvement manual and participated in the handover meeting and received coaching visits (method #3) showed more improvement in provision of quality VMMC services than those in the other two intervention groups. Simply giving health workers a written manual was the cheapest intervention  but was also the least effective in achieving improvements.

Read the full journal article on PLoS ONE.

Improving the retention of mother-baby pairs at Seshote Health Center in Leribe District, Lesotho

Seshote Health Center is a small facility in the rural, mountainous area of Leribe District in Lesotho. In August 2016, with support from USAID, Seshote's eight-member quality improvement (QI) team established an improvement aim: to increase retention of mother-baby pairs seen at the facility from 0% in August 2016 to 55% by February 2017.

Although mother-to-child transmission accounts for 90% of new HIV infections among children in Sub-Saharan Africa, risks are reduced to below 5% when prevention of mother-to-child transmission interventions are implemented. Three change ideas were tested:

  1. create an appointment book dedicated to mother-baby pairs;
  2. schedule mothers and their babies for appointments on the same day; and
  3. track mothers who did not show up for appointments.

The Seshote Health Center team was able to improve mother-baby pair retention from 0% to 14% between August 2016 and February 2017, and then with a greater sense of ownership, accountability, and motivation, from 14% to 69% between February and August 2017. This improvement contributes to Lesotho's work under the Partnership for HIV-Free Survival. In addition, the Seshote Health Center QI team has implemented structures and processes to sustain their commitment to ongoing improvement.

Read this case study.

Increasing adult ART uptake under Test and Treat in Lesotho through ART initiation at the village health post level

Globally, Lesotho ranks second in HIV prevalence. Prevalence rates vary among Lesotho’s 10 districts and range from 17% in Mokhotlong to 28% in Maseru (LDHS:2014).

In June 2016, per the new Universal Test and Treat (UTT) guidelines released by the World Health Organization (WHO), Lesotho became the first African country to implement UTT guidelines. While these guidelines removed all restrictions to antiretroviral therapy (ART) initiation for HIV-affected people, actual ART coverage remained at 41% for adults and 40% for children. Many facilities face a backlog of patients now eligible for treatment, and many patients faced access challenges, in part due to Lesotho's mountainous terrain and incomplete road system.

With an ART initiation rate of 47% in September 2016, Tebellong Hospital in Qacha's Nek District faced many of these challenges; with support from the USAID ASSIST Project, a quality improvement (QI) team was formed to understand and address root causes of the low ART initiation rate. After deeper analysis and implementation of QI methodology, the QI team tested a change idea in December 2016: dispatching a nurse-midwife to the remote Qabane Health Post for ART initiations. Data collection and analysis revealed that by March 2017, all eligible patients had been initiated on ART, a success that has been maintained as of August 2017.

Read this case study.