Quality Improvement Collaborative in Dnipropetrovsk Region

Key Achievements

• As of October 1, 2017, all PHC facilities in the region provide HTS with rapid tests. Detection rate is 3% and at some ART sites it may reach 13-16%.
• On the regional level, HIV detection rate is 5.9% and 20% among most at-risk populations.
• Registration of in-patient PLHIV implemented as a routine practice in the AIDS and TB services.
• Search for patients lost to follow up contributed to increased number of newly identified PLHIV from 1,279 to 1,703 in nine months of, respectively, 2016 and 2017.

Challenges

• Decrease in initiation on ART after fulfilling the PEPFAR plan.
• NGO projects wrap up will hinder the search for LTFU patients

Next Steps

• Training of family doctors on HCT and usage of the HIV rapid tests. In total, it’s expected to cover 150 doctors.
• Introducing HTS with rapid tests in hospitals.
• Further control over procurements and utilization of the rapid HIV test kits in PHC facilities.
• Discussing opportunities to engage NGOs to search of the LTFU patients.
• Discussing opportunities for further mentoring visits to ART sites.

Key Achievements

• Increased involvement of specialty physicians (TB doctors, narcologists, dermatologists, neuropathologists, oncologists, and so on) to HTS.
• 7% increased share of HTS by specialty physicians (rapid tests and ELISA).
• Increased share of HTS by specialty physicians using rapid tests (37% – narcologists, 39% – dermatologists, 15% – TB doctors, and doubled for PHC physicians).
• Overall increase in HTS with rapid tests in the region – by 18%, and by 79% for at-risk groups.
• Rapid tests purchased at the expense of Centers for Primary Healthcare.
• Double time expanded network of healthcare facilities implementing written consent form for social support, from 15 to 30 by June 01, 2017.
• Doubled number of PLHIV registered with AIDS service (482 in Apr-June, 2016 and 1009 in Apr-June, 2017).
• Share of PLHIV registered with AIDS service is 98,4% of total new cases.
• Timely registration with AIDS service for patients receiving ART at the TB and mental hospitals.
• Involving of other healthcare services to registration of their in-patients with AIDS service before discharge.
• 92% of new PLHIV are registered with AIDS service (about 150 ppl per month).

Challenges

• Dependence of healthcare facilities from supplies of rapid tests by donor NGOs.
• Delays in supply of rapid tests.
• Patients refuse to sign consent form for social support (about 11% of refuses).
• Impossibility to implement changes at those healthcare facilities that do not cooperate with NGOs and have no social worker position in staff.
• Goals of the PEPFAR Plan on the number of patients initiated on ART are too high (4740 new patients in 12 months while this is 50% more than estimated number of PLHIV in the region by January 01, 2016).
• ART site physicians do not want to increase their workload, and therefore the number of patients registered.
• Some patients do not want to get ARVs by place of residence (risk of the HIV status disclosure, less experienced physicians).
• A significant proportion of patients with high CD4 rate do not want to start ART.
• Many ART patients quit treatment.

Next Steps

• Promote rapid HIV test kits purchase from local budgets.
• Increase HIV testing efficiency.
• Expand the network of healthcare facilities doing HTS with rapid tests.
• Training on post-exposure prophylaxis for healthcare practitioners (especially nurses and paramedics).
• Implement social support in other healthcare facilities, especially in hospitals.
• Promote introducing the social worker position in healthcare facilities.
• Initiate new patients on ART.
• Control over ARVs balances.
• Decentralize ART services so to redistribute workload between the physicians.
• Conduct advanced trainings for ART site physicians.
• Engage NGOs to activities on adherence to treatment.

Key Achievements

• Extensive use of two rapid tests for HIV screening by PHC and specialty physicians, and involvement of nurses to HCT.
• Decentralization of services: transfer of patients from Dnipro City AIDS Center and Kryvyi Rih City AIDS Center to local ART sites. Increased time for the new patient visits at the big sites.
• Written consent for social support during HCT to prevent LTFU patients.

Challenges

• Delays in supply of rapid tests.
• Termination of William Clinton Foundation work in the Dnipropetrovsk region has resulted in the largest ART sites remain without rapid test systems.
• Excessive workload of the ART site physicians.
• Understaffing of the ART sites.
• ART sites that fulfilled the PEPFAR plan now have no possibility for further initiation of patients on ART (no ARVs).
• Delay in supply of ARVs from PEPFAR; the next delivery is scheduled for June, 2017.

Next steps

• The practice of written consent for social support is to be extended to ART sites that do not implement this change.
• Involve social workers to involving of patients to HCT, treatment, and adherence in the areas covered by NGO activities, and where increased number of patients on ART is expected.
• Ensure quality improvement in the following areas: risk behavior screening, HIV testing, and adherence to treatment.
• Control over categories of patients tested for HIV with two rapid tests at the PHC facilities.
• To implement signing of written consent for social support during consent for HTS at the ART sites that do not implement this change.
• Quality assurance: to assess adherence during every patient visit.
• ART by PHC physicians.
• Monthly fulfillment of the action plan to initiate patients on ART in collaboration with NGOs.

Key Achievements

• Extensive use of two rapid tests for HIV screening by PHC and specialty physicians, and involvement of nurses to HCT.
• Decentralization of services: transfer of patients from Dnipro City AIDS Center and Kryvyi Rih City AIDS Center to local ART sites. Increased time for the new patient visits at the big sites.
• Written consent for social support during HCT to prevent LTFU patients.
• Rapid tests purchased at the expense of Centers for Primary Healthcare.

Challenges

• Delays in the supply of rapid tests.
• Excessive workload of the ART site physicians.
• Understaffing of the ART sites.
• NGOs do not provide services in some rayons outside Dnipropetrovsk.

Next steps

• The practice of written consent for social support is to be extended to ART sites that do not implement this change. 
• Involve social workers to cooperation with healthcare practitioners in terms of enrollment to HCT, treatment, and adherence in the areas covered by NGO activities and where increased number of patients on ART is expected. 
• Ensure quality improvement in the following areas: risk behavior screening, HIV testing, and adherence to treatment. 
• Control over categories of patients tested for HIV with two rapid tests at the PHC facilities.

Key Achievements

• HTS with two rapid tests for urgent informing of the patient in case of HIV-positive status and further registration with AIDS service.
• Implemented method of registering with AIDS service the HIV-positive in-patients before they are discharged from the hospital.
• Decentralization of services: transfer of patients from Dnipro City AIDS Center and Kryvyi Rih City AIDS Center to local ART sites. Increased time for the new patient visits at the big sites.
• Written consent for social support during HCT to prevent LTFU patients.

Challenges

• Delays in the supply of rapid tests and ELISA testing systems in the region.
• Absence of NGOs in some rayons of the Dnipropetrovsk region
• Excessive workload of the ART site physicians.
• Understaffing of the ART sites.

Next steps

• Engage secondary healthcare facilities to implementation of the written consent for social support. 
• Engage social workers to cooperation with healthcare practitioners in terms of enrollment to HCT, treatment, and adherence in the areas covered by NGO activities and where increased number of patients on ART is expected. 
• Scale-up effective QI changes to the ART sites that don’t implement them.
• Ensure quality improvement in the following areas: risk behavior screening, HIV testing, and adherence to treatment. 

Key Achievements

• Improved cooperation between healthcare facilities and NGOs, cooperation agreements are signed with all the PHC facilities in the cities of Dnipro and Kryvyi Rih.
• ART sites staff involved to patient data input to the STMA.
• Position of the Infectious Disease (ID) Specialist is introduced within TB hospital so to register with AIDS service the HIV-positive in-patients before they are discharged from the hospital.
• Developed algorithm of transfer of patients from regional and city AIDS centers to rayon ART sites.

Challenges

• Delays in the supply of rapid tests and ELISA testing systems in the region.
• Absence of NGOs in some rayons of the Dnipropetrovsk region
• Excessive workload of the ART site physicians.
• Understaffing of the ART sites.

Next steps

• Scale-up social support by NGOs to those rayons that are not currently covered with this service. 
• Intensify decentralization process at the Dnipro City AIDS Center and Kryvyi Rih City AIDS Center (transfer of patients to local ART sites).
• Engage alternates to STMA keeping. 

Key Achievements

• PHC facilities involved to HIV screening.
• Simultaneous written consent for HTS and social support (Kryvyi Rih).
• HTS with two rapid tests for urgent informing of the patient in case of HIV-positive status and further registration with AIDS service.
• Registering with AIDS service the HIV-positive in-patients of the Dnipro City Mental Clinic and TB Hospital.
• Position of the psychologist is introduced within Pyatykhatky Trust Office.
• Rapid tests and ELISA testing systems purchased at the expense of local budget.

Challenges

• Linkage to care gap.
• Difficulties with involving of the specialty and PHC physicians to HCT.
• Lack of support from city and rayon coordination councils in terms of HIV services.

Next steps

• Intensify involving of the specialty and PHC physicians to HCT.
• Involve NGOs to cooperation with healthcare facilities.