QI COLLABORATIVE OVERVIEW

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

In November 2015, members of the Regional QI Implementation Group and local QI teams were approved by the order of the Head of Zaporizhzhya Regional Healthcare Department. Between December 2015 and January 2016, seven local QI teams were created around the existing ART sites (since March, 2016, it’s twelve QI 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 following regional NGOs: “100% of Life Network. Zaporizhzhya”, “Vse Mozhlyvo”, and “Spodivannya”.

Regional QI Implementation Group (RIG): Regional Coordinator – Alla Tsyhankova, QI Mentors – Larysa Saprykina and Olena Velyhodska, Data Quality Mentor – Tetiana Skybina.
 

Site QI Coach
Zaporizhzhya Regional AIDS Center Tetyana Tarasova
Melitopol City AIDS Center Lyudmyla Konovalska
Berdyanck City Clinic Kateryna Dihtyar
Energodar City Medical Unit Alla Lutsenko
Tokmak Central Rayon Hospital Nadiya Zhandarova
Vasylivka Central Rayon Hospital Lyudmyla Murashko
Pology Central Rayon Hospital Nataliya Ivchenko
Andriivka Central Rayon Hospital Kateryna Skupenko
Kuibysheve Central Rayon Hospital Svitlana Ivanets

Employees of the following healthcare facilities: Zaporizhzhya Regional TB Hospital, Berdyansk TB Hospital, and Melitopol TB Hospital joined the local QI teams.

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Evidence-based Interventions Supported by RESPOND

Site

Intervention and NGO
Strengthening HIV Services
Continuum at the ART Sites
(including PLHIV Partner’s Health)
CF “Vse Mozhlyvo”		 Strengthening HIV Services
Continuum at the ART Sites
(including Steps Towards Health)
CF “100% of Life Network. Zaporizhzhya"
Zaporizhzhya City X  
Vasylivka rayon X  
Pology rayon X  
Berdyansk City X  
Melitopol City   X
Melitopol rayon   X
Berdyansk rayon   X
Pryazovske rayon   X
Kamyansk-Dnistrovskyi rayon   X
Yakymivka rayon   X

 

Milestones of the QI Collaborative in the Zaporizhzhya Region

  • On September 8, 2015, the MOU between RESPOND, UCDC, and Zaporizhzhya Regional Healthcare Department was signed to improve HIV care and treatment using the QI methodology.
  • On September 16-17, 2015, a regional meeting was conducted for 36 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 Zaporizhzhya region.
  • A training session for 12 QI coaches was conducted on November 10-13, 2015.
  • The QI Charter was developed and signed on December 18, 2015. It was approved by the Zaporizhzhya Regional Healthcare Department, Zaporizhzhya Regional AIDS Center, “Vse Mozhlyvo” Charitable Foundation, regional branch of the “100% of Life Network”, regional branch of the Red Cross Committee, and others. The QI Charter includes the gap analysis, changes to be tested, and improvement activities.
  • The first regional QI learning session was conducted for 12 QI teams/58 people on March 15-16, 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 12 QI teams/59 people on June 30 – July 1, 2016.
  • Twelve computers were purchased for ART sites for running the Simplified Treatment Management Application (STMA) database.
  • Trainings on HCT and HIV/TB were conducted for 59 healthcare practitioners in April, 2016.
  • Information materials on HCT and HIV treatment for patients and physicians were provided by RESPOND.
  • On September 19-21, 2016, RIG and representatives of local QI teams participated in the second cross-regional learning session in Kyiv.
  • The third regional QI learning session was conducted for 12 teams/33 people on December 7-8, 2017.
  • On March 28-29, 2017, RIG and representatives of QI local teams took part in the third cross-regional learning session in Kyiv.
  • The forth regional QI learning session was conducted for 12 QI teams/47 people on July 4-5, 2017.
  • RIG and the RESPOND staff regularly conduct QI mentoring visits to local QI sites (123 in the period of January 2016 – June 2017).

 

 

 

 

QI Collaborative Change Package in the Zaporizhzhya Region (12 ART sites)

Gap

Change

Jan-Mar, 2016

Apr-Sept,

2016

Oct, 2016 – Mar, 2017

Apr-Sept, 2017

1. HIV testing and referral

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

–

9

–

 14

1.4. Implement a patient tracking system (vouchers, coupons or invitations)

–

9

–

 –

1.5. Provide escorting to patients by medical staff

2

–

–

 –

1.6. HTS for sexual partners of PLHIV

–

–

12

 11

2. Linkage and retention 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

X

–

–

 3

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

X

–

–

 –

2.3. More frequent transporting of biomaterial to the lab

X

–

–

 –

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

–

12

13

 13

2.5. Lab tests based in local blood transfusion center

X

–

–

 –

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

X

–

–

 –

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

X

9

4

 4

2.8. Engage PHC physicians into care for PLHIV

5

9

–

 –
  3.1. Initiate and manage ART  at ART site – – – 7

 

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

–

9

2

 2

3.3. Identification and treatment of PLHIV in discordant couples

–

–

9

 11

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

–

12

–

 –

3.9. Enroll to ARV treatment within 60 days after diagnosis

–

–

12

 –

4. Cross-cutting

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

X

12

–

 2

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

X

–

–

 –

4.4. Train physicians and nurses on HTS

X

–

–

 –

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

–

9

9

 11

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

–

–

9

 9

4.10. Introducing a position of social worker at health care facility/ART site

X

–

–

 –

Total Changes Implemented

13

14

8

 11

Х – number of QI sites implementing the change is undefined

Key Achievements

  • In August – September 2017, 100% of people screened positive for HIV were registered with AIDS service within the 30 days since the HIV test result.
  • Introduced Medical Information System made it possible to return all the patient lab test results through the Internet.
  • 64% of PLHIV receive treatment at place of residence (in comparison to 40% in April – June 2017).
  • As of October 1, 2017, 81% of PLHIV had undetectable viral load (in comparison to 78% as of July 1, 2017).

Challenges

  • Delays in ART supplies.
  • Delays in supplies of the CD4/viral load test kits.
  • End of the rapid HIV test kits supplies from the Clinton Foundation.

Next Steps

  • Three new ART sites are to be opened through the end of 2017.
  • Rapid HIV test kits procurements from local budgets.
  • Continue decentralization of the HIV-services in the region.
  • Continue active home visiting of PLHIV lost to follow up.

Key Achievements

  • 64% increase in the number of PWID screened for HIV in comparison to the same period of 2016 (Apr-June 2016 – 83 people, Apr-June 2017 – 136 people).
  • 10% increase in the number of PLHIV registered with AIDS service in Apr-June 2017 in comparison to the same period of 2017 (Apr-June 2016 – 106, Apr-June 2017 – 117).

Challenges

  • Problems with initiation on ART resulted from untimely supplies of ARVs. 10% decrease in the number of new patients on ART in comparison to the same period of 2016 (Apr-June 2016 – 129, Apr-June 2017 – 116).
  • Irregular transportation of the blood samples from some district health facilities to the lab leads to decrease in the proportion of newly identified PLHIV provided with the required lab tests over one patient visit and delays registration with AIDS service.
  • PLHIV don’t want to disclose the HIV status to their sex partners and don’t provide the information about them to healthcare practitioners.

Next Steps

  • Continue the transferring of patients from the Regional AIDS Center to local ART sites: Bilmatskyi district, Kamyansko-Dniprovskyi district, and Mykhailivskyi district.
  • Continue the decentralization of the HTS and create new ART sites in Orihiv, Prymorskyi, Vilnyanskyi, and Veselivskyi districts.
  • Open the site of integrated MAT/ART services on the basis of in-patient clinic in the Regional AIDS Center. 
  • Continue to implement home visits by medical and social service providers.

Key Achievements

  • Two newly opened ART sites started to implement STMA (ART sites of the Territorial Medical Unit of the Mykhaylivskiy rayon and Kamyansk-Dniprovskyi Central Rayon Hospital).
  • During January-March 2017, regional ART sites have had the following indicators increased: number of people tested for HIV increased in 16.3% compared to Jan-Mar 2016; number of PLHIV sexual partners tested for HIV increased in 23.7%, and the proportion of people tested positive increased in 28.7% (121 people against 94 in 2016).
  • Proportion of PLHIV initiated on ART as of April 1, 2017 is 83% against 77% in 2016. Its increase is due to well-coordinated work of NGO social workers and ART site physicians.

Challenges

  • Low HIV detection rate (2%) is resulted from testing of general population mostly, instead of key populations. Since March, 2017, ART sites will use the surplus of rapid tests to testing of key populations only.
  • Shortage of ARVs in the region.
  • Broken CD4 testing machine  for CD4 evaluation at the Melitopol Regional AIDS Center.
  • The following ART sites are not ready to provide ART to PLHIV locally: Bilmak Central Rayon Hospital, Kamyansk-Dniprovskyi Central Rayon Hospital, and the Territorial Medical Unit of the Mykhaylivskiy rayon.

Next steps

  • Assign an alternate nurse in Zaporizhzhya Regional AIDS Center for returning of CD4 and viral load results via Internet.
  • To implement at the regional ART sites algorithm for adherence improving among PLHIV.

Key Achievements

  • By the end of 2016, HIV screening with two rapid tests is made in all the cities of the Zaporizhzhya region and in thirteen rural districts out of twenty. 
  • The proportion of people tested for HIV with rapid tests has increased from 8.5% in 2015 to 13.9% in 2016; detection rate is respectively 14.3% and 26.1%.
  • 2,5 times increased number of PLHIV sexual partners tested for HIV (731 in 2016).
  • 45% of newly detected PLHIV are detected by specialty physicians.
  • Number of PLHIV registered with AIDS service at the 12 ART sites increased by 21% in 2016, up to 731 people.
  • 44% increased number of patients initiated on ART in 2016, from 477 people in 2015 to 688 in 2016.

Challenges

  • Difficulties with opening ART sites in Zaporizhzhya City Clinics #8 and #9.
  • Biomaterial for CD4 and viral load lab testing is delivered from rural areas to the Zaporizhzhya Regional AIDS Center not more than once per week.
  • Insufficient coverage of key populations with HTS.

Next steps

  • Simplify patient pathways for PLHIV visiting Zaporizhzhya Regional AIDS Center.
  • Develop algorithm for improving adherence to ART.
  • Implement decentralizing of HIV-services from the Zaporizhzhya Regional AIDS Center to local ART sites.

Key Achievements

  • Specialty physicians of the city clinics started HTS. 
  • HTS with rapid tests in healthcare facilities of the 17 areas in the Zaporizhzhya region (in comparison with 4 areas in 2015).
  • HCT for PLHIV sexual partners is been made with support from NGOs.
  • Increased number of PLHIV registered with AIDS service during 30 days after HIV detection. 
  • Improved collaboration with the Passport Offices in search of LTFU patients.

Challenges

  • Difficulties in distribution the rapid tests between the physicians.
  • Excessive workload on physicians of the Zaporizhzhya Regional AIDS Center.
  • Lack of information about discordant couples in the region.

Next steps

  • Open four new ART sites (through 2016), provide training for new QI coaches.
  • Engage social workers into improving of HIV testing, treatment, and adherence in the areas covered with NGO activities.
  • Start accounting the discordant couples using best practice from Energodar city.
  • Scale-up the successful QI changes.
  • Provide quality assurance in risk behavior screening and HTS.

Key Achievements

  • Increased coverage with NGO activities in the region.
  • HIV detection rate has reached 15.9% of total number of tested.
  • High detection rate among sexual partners (9.2%).
  • Specialty physicians engaged into HTS providing.
  • Extended working hours at all existing ART sites (8 am – 5 pm).
  • Implemented returning of the positive HIV test results to ART sites through the Internet the next day after it’s ready.
  • All the existing ART sites run STMA.

Challenges

  • Delays in delivery of the rapid HIV test kits and ELISA testing systems.
  • ART site physicians have poor counseling skills on the HIV status disclosure to a PLHIV sexual partner. 
  • Most of the detected PLHIV have third and fourth clinical stage of the HIV infection.
  • Most of the LTFU patients are among those referred to ART sites by specialty physicians.
  • Data analysis, visualizing, and using are to be improved at the local level.

Next Steps

  • Improve HTS with rapid tests by specialty physicians.
  • Analyze the LTFU patient records.
  • Develop and implement local protocol on HTS and registration with the regional AIDS Center.
  • Improve collaboration between NGOs and ART sites so to cover PLHIV sexual partners with HTS.

Key Achievements

  • HTS with two rapid tests for urgent informing of a patient in case of positive result and further referral to Trust Office/AIDS Center.
  • Two ART sites introduced the social worker position.
  • Rapid HIV test kits purchased from local budgets (cities of Energodar and Pology).
  • Providing all the required lab tests together with the confirmatory ELISA at the four ART sites.
  • Optimized delivery of blood samples to Zaporizhzhya Regional AIDS Center.

Challenges

  • Delays in delivery of the rapid HIV test kits and ELISA testing systems.
  • Lack of NGOs in majority of districts in the region.
  • ARV stocks suffice only for a quarter because of the lack of clear delivery schedules.
  • Difficulties in returning to care LTFU patients.
  • Difficulties in engaging specialty physicians into providing HCT.
  • Insufficient data input to the STMA.
  • Excessive workload on physicians of the Zaporizhzhya Regional AIDS Center.

Next Steps

  • Engage two new ART sites to the QI Collaborative.
  • Introduce the HTS with two rapid tests.

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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