Title

Implementing the ''Test and Treat policy: Increasing access to quality HIV care services at 11 USAID / Strengthening Uganda's Systems for Treating AIDS Nationally (SUSTAIN) supported hospitals

Presenter

Pamela Donggo

Authors

P. Donggo, G. Tugume, H. Alima, B. Tumusiime, M. Arinaitwe

Institutions

URC University Research Co., LLC, Kampala, Uganda

Background: Uganda adopted the UNAIDS 90-90-90 strategy in 2015. The second and third 90s stipulate that 90% of people with diagnosed HIV infection should receive sustained antiretroviral therapy (ART), and 90% of these should achieve viral load suppression. However, only 46% of the 36.7 million people living with HIV (PLHIV) had received ART (World Health Organization [WHO] 2015), the majority initiating treatment with advanced HIV infection. Uganda''s Consolidated Guidelines for Prevention and Treatment of HIV (2016) recommend that every HIV positive person should be started on lifelong ART despite their WHO clinical stage or CD4 count- “The Test and Treat” policy. Contrary to this guidance, staff at health facilities countrywide including 11 USAID SUSTAIN supported hospitals were not trained on the new guidelines. By December 2016 3,271 PLHIV in care were not on ART (pre-ART) at the 11 hospitals. Other barriers included low ART stocks, poor client flow and low staff - patient ratio.
Description: In February 2017 USAID SUSTAIN and the Ministry of health conducted a training of trainers followed by 3-day hospital-based trainings of medical, laboratory and data personnel, counselors, community linkage coordinators, clinic volunteers and peer patients. We oriented them on the guidelines and gave them desk job aids, guideline booklets and standard operating procedures. We supported the ART clinic staff to establish quality improvement (QI) projects and assign roles to the QI team to implement the “Test and Treat” policy. Using a Ministry of health assessment tool, we reviewed implementation of the guidelines at one month and conducted mentorship and follow on assessments at three months post-training. We checked progress, identified gaps and made action plans to address them in the following month. Table 1 highlights these QI changes.

A multi-disciplinary team selected and assigned roles to accelerate new ART enrollment including conducting pre-ART counselling, forecasting and ordering adequate Anti retro-viral drugs for both new and old clients.

Continued Medical Education for all ART providers on the Test and Treat policy.

Generating a list of clients eligible for ART using the Uganda electronic medical records system.

Labeling HIV patient files with colored stickers that notify clinicians of clients who are not yet initiated on ART.

Data review meetings to assess progress on enrollment of pre- ART clients on ART

Daily health education sessions for clients on Test and Treat policy and referral of clients for adherence counselling.

[Table 1: Changes tested to increase initiation of HIV positive clients on ART at 11 USAID SUSTAIN supported sites]

The total number of pre- ART clients dropped from 3,271 in December 2016 to only 68 in September 2017 following the increased initiation on ART (Chart 1).

[Chart 1: Total no. of adults and children receiving ART vs pre-ART at 11 SUSTAIN supported sites Oct''16 - Sept''17]

Lessons learned: Training and engagement of multidisciplinary teams increased enrollment on ART.
Post-training mentorships support adaptation to policy change.
Conclusions/Next steps: Systematic, implementation of quality improvement approaches through multidisciplinary teams enabled hospital teams to implement the Test and Treat policy.