QI COLLABORATIVE OVERVIEW

To improve the continuum of HIV services, from HIV testing to linkage to care, treatment and support for PLHIV in the Mykolaiv region, a Quality Improvement Collaborative was established in September 2015.

On December, 2015, members of the Regional QI Implementation Group and local QI teams were approved by the order of the Head of Mykolaiv Regional Healthcare Department. Between December 2015 and January 2016, 9 local QI teams were created around the existing ART sites. 

Each QI team is comprised of the ART site staff, specialty physicians (STI, narcology and OB/GYN), their nurses, primary healthcare practitioners, and social workers of the regional NGOs.

Regional QI Implementation Group (RIG): Regional Coordinator – Iryna Kochergina, QI Mentors – Svitlana Stakhanova, Olena Didorenko, Data Quality Mentor – Halyna Vysotska.
 

Site QI Coach
Mykolaiv Regional AIDS Center Kateryna Hukalyuk
Voznesensk Central Rayon Hospital Svitlana Zhmynda
Yuzhnoukrainsk City Medical Unit №2 Lyudmyla Nezhodynska
Pervomaisk Central Rayon Hospital Olena Masalitina
Bashtanka Central Rayon Hospital Victor Reshetnyk
Novyi Buh Central Rayon Hospital Lyubov Pavlyuk
Pervomaisk City Primary Healthcare Center Olena Pshonyak
Ochakiv Central Rayon Hospital Olha Tkach
Zhovtneve Central Rayon Hospital Halyna Shaforost
Mykolaiv Central Rayon Hospital Nataliya Shatyrko
Nova Odesa Central Rayon Hospital TBD

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Evidence-based Interventions Supported by RESPOND

Site

Intervention and NGO
Strengthening HIV Services
Continuum at the ART Sites
Mykolaiv Regional Branch
of the PLHIV Network		 PLHIV Partner’s Health 
Mykolaiv Regional Branch
of the PLHIV Network		 PWID Partner’s Health 
“Vykhid”
Charitable Foundation
Mykolaiv  X   X
Bashtanka X   X
Voznesensk X   X
Novyi Buh X    
Ochakiv X    
Pervomaisk X   X

 

Milestones of the QI Collaborative in the Mykolayiv Region

  • On June 23, 2015, the MOU between RESPOND, UCDC, and Mykolaiv Regional AIDS Center was signed to improve HIV care and treatment using the QI methodology. 
  • On October 15-16, 2015, a regional meeting was conducted for 30 healthcare managers and representatives of medical facilities and NGOs. Participants were introduced to the QI model and identified key areas for improvement of the treatment and care for PLHIV in the Mykolaiv region. 
  • A training session for 8 QI coaches was conducted on November 23-25, 2015.
  • The QI Charter was developed and signed on December 15, 2015. The QI Charter includes the gap analysis, changes to be tested, and improvement activities. 
  • The first regional QI learning session was conducted for 9 QI teams/37 people on March 28-29, 2016. 
  • On April 25-27, 2016, RIG and the local QI teams took part in the first cross-regional QI learning session in Kyiv.
  • The second regional QI learning session was conducted for 9 QI teams/32 people on July 18-19, 2016.
  • Fifteen computers were purchased for ART sites for running the Simplified Treatment Management Application (STMA) database.
  • Trainings on HCT and HIV/TB were conducted for the 60 healthcare practitioners in April-December, 2016.
  • The third regional QI learning session was conducted for 11 QI teams/29 people on December 7-8, 2016.
  • Information materials on HCT and HIV treatment for patients and physicians were provided by RESPOND.
  • Training on involving PLHIV sexual partners to HTS conducted on February 22-23, 2017 for 11 local QI teams (11 participants).
  • On March 27-29, 2017, RIG and the local QI teams took part in the third cross-regional QI learning session in Kyiv.
  • RIG and the RESPOND staff regularly conduct QI mentoring visits to local QI sites (85 in the period of November 2015 – October 2017).
  • The fourth regional QI learning session was conducted for 9 QI teams/33 people on May 30-31, 2017.
  • Four ART sites participated in capacity assessment using the SIMS methodology, and received good results.
  • Training on adherence to ART conducted for nine ART site nurses on September 13-15, 2017.
  • On September 29, 2017, the QI Charter – 2020 was signed by the Health Department of the Mykolayiv Regional State Administration, Regional Center for Palliative Care, and the partner NGOs. The QI Charter identifies the next steps on strengthening the HIV-service continuum and ensures sustainability in their quality and accessibility within the Healthcare reform in Ukraine.

 

 

 

 

QI Collaborative Change Package in the Mykolayiv Region (11 ART sites)

Gap

Change

Jan-Mar, 2016

Apr-Sept,

2016

Oct, 2016 – Mar, 2017

Apr-Sept, 2017

1. HIV testing and referral

1.1. HIV risk assessment by specialists and/or PHC providers

–

10

–

 –

1.2. HIV testing with two rapid tests or ELISA by specialists and/or PHC providers

Х

5

–

 –

1.3. Make HTS info materials available for physicians and patients

–

9

–

 –

1.5. Provide escorting to patients by medical staff

Х

10

–

 –

1.6. HTS for sexual partners of PLHIV

–

11

11

 –

1.7. Assess behavioral risks and clinical indicators, and provide HTS for in-patients within the first three days of hospitalization

–

10

9

 8

1.8. Double coding at the time of HTS to ensure identification of PWID

–

11

–

 –

1.9. Redistribute responsibilities on HTS among doctors and nurses

–

11

–

 –

2. Linkage and enrollment in care

2.1. Provide the required lab tests (ELISA II, CD4 and blood chemistry) over one patient’s visit/ to the Trust Office/ART site

Х

–

–

 –

2.2. Extend/adapt the working hours of Trust Offices/ART sites

Х

–

–

 –

2.4. Return lab results (CD4 and viral load) to ART sites through Internet

–

–

11

 –

2.6. Provide reminder text messages, phone calls or letters to patients

Х

9

–

 –

2.7. Provide active home visits by medical and social service providers

Х

11

–

 –

2.8. Engage PHC physicians into care for PLHIV

9

9

–

 –

2.9. Registering patient PLHIV with AIDS service before they are discharged from the hospital

–

10

9

 8

3. Treatment

3.2. Transfer patients on ART from AIDS Centers to local ART sites

Х

2

–

 –

3.4. Manage ART stock at ART site, including dispensing of ART through pharmacies

–

11

–

 –

3.5. Optimize ART dispensing practices/Dispense three to six-month supply of ART

–

11

–

 –

3.6. Follow-up visits once in 12 months

–

–

–

 –

3.7. ART dispensing by medical provider at the rayon level

–

–

9

 8

3.10. ART adherence assurance – to ensure social support for patients who do not come to scheduled visits at the primary level

–

–

5

 10

4. Cross-cutting

4.1. Implement electronic database for dynamic individual-level PLHIV service tracking

Х

9

–

 –

4.2. Develop and implement regional and local referral protocols/patient pathways

Х

–

–

 –

4.3. Increase the network of active Trust Offices/ART sites

–

2

–

 –

4.4. Train physicians and nurses on HTS

Х

11

–

 –

4.5. Train physicians on ART

–

2

–

 –

4.6. Train physicians on HIV/TB co-infection treatment

–

2

–

 –

4.8. Meetings of local QI teams at least monthly to analyze changes and data (with special attention to run charts)

–

11

–

 –

4.9. Partnering with NGOs (escorting patients by social workers), to enroll PLHIV from key populations in medical care

–

11

–

 –

4.12. Simultaneous written consent for HTS and social support

–

–

–

 –

4.13. Quality assurance of rapid HIV testing – train the specialists in rapid HIV testing

–

–

11

 –

Total Changes Implemented

9

19

7

 4

Х – number of QI sites implementing the change is undefined

Key Achievements

  • HIV detection rate among PWID has increased from 9.0% to 11.5%; the detection rate among PLHIV sexual partners is 13.7% in August-September and remains steady high.
  • Effective cooperation between the ART sites and PHC facilities on the  risk behavior screening, search for LTFU patients and those not yet registered with AIDS service, and dispensing ART to those patients who cannot visit ART site. Cooperative efforts contributed to the increased number of PLHIV registered from 8,632 to 8,772, increased number of ART patients, and 25% decrease in the number of LTFU patients.
  • Cooperative efforts of the ART sites and NGOs contributed to increased PLHIV adherence to treatment from 83% to 91% and also its increased efficiency to 84% in comparison with 72% in the previous quarter.

Challenges

  • Remoteness of the ART sites from patient places of residence hinders timely PLHIV registration and initiation on ART.
  • PHC providers lack motivation for PLHIV home visiting and ART dispensing at place of residence.
  • Some patients refuse to sign agreement on social support.
  • Shortage of the HIV rapid HIV test kits at the ART sites and lack of them in the hospitals and PHC facilities.

Next Steps

  • Ensure providing of the ART sites, PHC providers, and specialty physicians with rapid HIV test kits from the local HIV/AIDS programs.
  • Conduct motivational interviewing for PLHIV refusing from medical and social support.
  • Engage PHC practitioners and NGO social workers to home visiting of patients lost to follow up and dispensing ART to patients from distant and rural areas.

Key Achievements

  • Increased number of the HIV screenings from 4,799 to 5,455 in comparison with the previous quarter. Detection rate among all people tested remains the same as in the Jan-Mar, 2017 – 2,7%, while detection rate among PWID has increased from 6,5% to 9,0%.
  • Due to the active involvement of PLHIV sexual partners to HIV testing, detection rate in this group has reached 13,6% while the regional indicator is 2,7%. 97% of the sexual partners with HIV were registered with AIDS service and 95% of them initiated on ART.
  • PHC facilities involved to search for PLHIV detected but not registered with AIDS service or miss appointments at the ART sites. Effective cooperation between PHC and AIDS service has increased the group of patients actively followed up from 5,721 people (72% of total registered) in Apr-June, 2016 to 6,799 people (88%) in Apr-June, 2017. The period of April-June, 2017 was also marked with 22% decrease in the number of patients which don’t miss their appointments to ART sites, and adherence increased from 76% to 83%.
  • 5330 people covered with ART services which is 68,5% of total number of registered with AIDS service and 78,4% of patients actively followed up.

Challenges

  • Lack of ART schemes. 
  • Remoteness of patients’ places of residence from regional ART sites hinders their timely appeal for clinical examination and receiving ART.
  • Some patients refuse to sign agreement on social support.
  • Shortage of the HIV rapid test systems at the ART sites and their total absence in the hospitals and PHC facilities.

Next steps

  • Ensure rapid tests from local HIV/AIDS programs.
  • Analysis of available and required number of ART courses so to make a proper order.
  • Conduct motivational interviewing for PLHIV refusing from medical and social support.
  • Engage PHC practitioners and NGO social workers to home visiting of patients missing appointments for more than seven days.
  • Engage PHC facilities to dispensing of ARVs to patients from distant cities and rural areas. 

Key Achievements

  • Due to the active involvement of PLHIV sexual partners to HIV testing, detection rate in this group has reached 12.5% while the regional indicator is 2.5%.
  • PHC facilities involved to search for PLHIV detected but not registered with AIDS service or miss appointments at the ART sites. Effective cooperation between PHC and AIDS service has increased the group of patients actively followed up from 5,231 people (65% of total registered) in Jan-Mar, 2016 to 6,589 people (86%) in Jan-Mar, 2017.
  • Comprehensive intervention Strengthening the continuum of HIV services at ART sites implemented at the three ART sites (Ochakov, Bashtanka, and Voznesensk) contributed to increased adherence to treatment among intervention participants from 78% to 90%.
  • Increased number of patients started ART, 27% more than in Jan-Mar, 2016.

Challenges

  • Low HIV detection rate among in-patients. 
  • Remoteness of patients’ places of residence from regional ART sites hinders their timely appeal for clinical examination and receiving ART.
  • Some patients reject social support and signing of the agreement.
  • Shortage (and even absence at the two sites) of rapid test systems for HIV testing. 

Next steps

  • Reduce the time required for registration with AIDS service by returning of encoded lab test results via Internet.
  • Ensure availability of the rapid HIV test kits from local budgets.
  • Analysis of available and required number of ART courses so to initiate treatment for all PLHIV.
  • Engage PHC practitioners and NGO social workers to home visiting of patients missing appointments for more than seven days.
  • Engage PHC facilities to dispensing of ARVs to patients from distant and rural areas.

Key Achievements

  • Increased number of people tested for HIV and PLHIV detected (18% increase in the number of people tested and 13% increase in the number of PLHIV detected in comparison with July-Sept, 2016).
  • PHC facilities involved to return to care of lost to follow-up (LTFU) patients. Share of patients in active follow-up increased from 63% to 87% due to this cooperation.
  • Strengthening of the three ART sites through implemented interventions on HCT for HIV sexual partners, linkage to care for LTFU patients, and improving ART adherence among patients.
  • 17% increased number of patients initiated on ART in comparison with July-Sept, 2016 (355 patients in Oct-Dec, 2016)

Challenges

  • Low HIV detection rate among in-patients.
  • Poor registration and initiation on ART rates due to the considerable distance between patients’ habitats and ART sites in rayons.
  • Some patients refuse from social support.
  • Shortage of viral load testing systems.

Next steps

  • Reduce time for PLHIV registration with AIDS service by sending the test results via Internet. 
  • Analysis of number of the required ART courses and promotion of the initiating of all the PLHIV on ART.
  • Involve PHC facilities to dispensing ART for patients from distant rayons.

Key Achievements

  • Risk behavior screening by specialty physicians improves referrals and HIV testing (referral rate by specialty physicians have increased from 33,4% of number of people tested in April-June, 2016 to 46,8% in October-December, 216; detection rate increased from 2% to 2,7%).
  • HCT for PLHIV sexual partners (increased HIV detection rate from 11% in Apr-June, 2016 to 18% in Oct-Dec, 2016).
  • Regular analysis of the patients registered to identify those LTFU. Reminder text messages and phone calls contribute to closing of the linkage to care gap and to have 41 new PLHIV registered and 48 new patients on ART. 
  • Support in linkage to care and adherence to ART from NGO social workers.

Challenges

  • Shortage of ARVs to initiate all the PLHIV on ART.
  • Some patients refuse from social support.
  • Poor motivation and skills of specialty physicians in motivational counselling and involving of PLHIV partners to HCT. 
  • Lack of interest among healthcare managers and local authorities in solving of the problem with HIV.

Next steps

  • Involve NGO social workers to work with PLHIV sexual partners: search, counselling, and enrollment to treatment.
  • Teach specialty physicians skills of motivational counselling.
  • Detailed analysis of number of the required ART courses, and promotion of the initiating of all the PLHIV on ART.
  • Scale-up the effective changes to all the ART sites in the region.
  • HTS, improve adherence to treatment.

Key Achievements

  • Two new ART sites started.
  • Training for local QI teams on HCT and HIV/TB co-infection treatment, active involvement of the practitioners to this activity.
  • HCT for PLHIV partners at all the sites, detection rate: 17%.
  • PHC Centers involved to search of the LTFU patients.
  • Analysis of data on registered PLHIV allowed to identify 925 patients to be initiated on ART.

Challenges

  • Low HIV detection rate at the several ART sites.
  • Initiation on ART is made according to CD4 indications, not for all PLHIV.
  • Understaffing of the ART sites.
  • NGOs do not provide services in some rayons outside Mykolaiv.

Next steps

  • Involve NGO to effective cooperation with healthcare facilities at all ART sites.
  • Analysis of the possibility to detect new HIV cases in various rayons of the region, involve new key populations like PLHIV and PWID sexual partners.
  • Discuss the possibility to introduce new positions of physicians and nurses at the ART sites. 

Key Achievements

  • In Pervomaisk city, rapid tests purchased at the expense of local budget.
  • Effective cooperation with STI doctors in terms of HCT: 1030 patients referred to ART sites, of them, 930 tested and 22 PLHIV detected.
  • Increased frequency of transporting biomaterial for lab tests (Zhovtneve ART site).
  • At the four ART sites, new positions of nurses were introduced.
  • Usage of reminder text messages, letters, and phone calls contributed to returning LTFU patients back to care.
  • NGO social workers involved to work at the ART sites.
  • PHC Centers involved to search of the LTFU patients.
  • 90% of the newly detected PLHIV are linked to care.

Challenges

  • Shortage of the rapid tests and ELISA testing systems.
  • Poor skills for HCT among specialty physicians.
  • NGO social workers do not work at several ART sites.

Next steps

  • Train specialty physicians on HCT.
  • Support for local QI teams to improve involvement of the specialty physicians.
  • Involve NGO to effective cooperation with healthcare facilities at all ART sites.

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HIV Screening, 2015-2017

HIV Detection: Number and Proportion Tested Positive, 2015-2017

Registration at AIDS Service and Initiation on ART, 2015-2017