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Retention of HIV-Positive Adolescents in Care: A Quality Improvement Intervention in Mid-Western Uganda.

ABSTRACT: Background:Low retention of HIV-positive adolescents in care is a major problem across HIV programs. Approximately 70% of adolescents were nonretained in care at Katooke Health Center, Mid-Western Uganda. Consequently, a quality improvement (QI) project was started to increase retention from 29.3% in May 2016 to 90% in May 2017. Methods:In May 2016, we analyzed data for retention, prioritized gaps with theme-matrix selection, analyzed root causes with fishbone diagram, developed site-specific improvement changes and prioritized with countermeasures matrix, and implemented improvement changes with Plan-Do-Study-Act (PDSA). Identified root causes were missing follow-up strategy, stigma and discrimination, difficult health facility access, and missing scheduled appointments. Interventions tested included generating list of adolescents who missed scheduled appointments, use of mobile phone technology, and linkage of adolescents to nearest health facilities (PDSA 1), Adolescent Only Clinic (PDSA 2), and monthly meetings to address care and treatment challenges (PDSA 3). Results:Retention increased from 17 (29.3%) in May 2016 to 60 (96.7%) in August 2016 and was maintained above 90% until May 2017 (with exception of February and May 2017 recording 100% retention levels). Conclusion:Context specific, integrated, adolescent-centered interventions implemented using QI significantly improved retention in Mid-Western Uganda.

SUBMITTER: Izudi J

PROVIDER: S-EPMC5960514 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Retention of HIV-Positive Adolescents in Care: A Quality Improvement Intervention in Mid-Western Uganda.

Izudi Jonathan J Mugenyi John J Mugabekazi Mary M Muwanika Benjamin B Tumukunde Spector Victor V Katawera Andrew A Kekitiinwa Adeodata A

BioMed research international 20180506

<h4>Background</h4>Low retention of HIV-positive adolescents in care is a major problem across HIV programs. Approximately 70% of adolescents were nonretained in care at Katooke Health Center, Mid-Western Uganda. Consequently, a quality improvement (QI) project was started to increase retention from 29.3% in May 2016 to 90% in May 2017.<h4>Methods</h4>In May 2016, we analyzed data for retention, prioritized gaps with theme-matrix selection, analyzed root causes with fishbone diagram, developed s ...[more]

PMID: 29854727

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Project description:Background The goal of antiretroviral therapy is to achieve sustained human immune deficiency virus (HIV) viral suppression. However, research on factors associated with viral load suppression among adolescents in low and middle-income countries is limited. The objectives of this study were to determine HIV viral suppression levels among adolescents in Kabale district and the associated clinical, adherence and psychosocial factors. Methods Cross-sectional and retrospective cohort study designs were used. Two hundred and forty-nine adolescents living with HIV that attended clinics between September and October 2019 at nine health facilities were interviewed and their medical records reviewed. A data abstraction tool was used to collect clinical data from adolescent’s clinical charts, face to face interviews were conducted using semi-structured questionnaire adopted from the HEADS tool and in-depth interviews conducted with ten key informants. Qualitative data was analyzed using thematic content analysis. Logistic regression was used to determine the magnitude by which clinical and psychosocial factors influence viral load suppression. Odds Ratios (ORs) were used for statistical associations at 95% confidence interval considering statistical significance for p-values less than 0.05. Qualitative data collected from Key informants to support our quantitative findings was analyzed using thematic content analysis. Results HIV viral suppression among (n = 249) adolescents was at 81%. Having no severe opportunistic infections was associated with viral load suppression among adolescent living with HIV (OR = 1.09; 95%CI [1.753–4.589]; p<0.001) as well as having no treatment interruptions (OR = 0.86; 95% CI [2.414–6.790]; p = 0.004). Belonging to a support group (OR = 1.01; 95% CI [1.53–4.88]; P = 0.020), having parents alive (OR = 2.04; 95% CI[1.02–4.12]; P = 0.047) and having meals in a day (OR = 5.68; C.I = 2.38–6.12, P = 0.010), were significantly associated to viral load suppression. The findings also indicated that long distances from health facilities, transport challenges and unprofessional conduct of health workers that make adolescent unwelcome at health facilities negatively affected viral suppression among adolescents. Conclusion The findings indicate that HIV viral suppression among adolescents on ART was at 81%. Kabale district was likely not to achieve the third 90 of the UNAIDS 90-90-90 global target for this population category. The findings further indicate that having no severe opportunistic infection and no treatment interruptions, good nutrition status, peer support and support from significant others, were highly associated with viral load suppression.

Project description:BACKGROUND:Strategies to identify and treat undiagnosed prevalent cases that have not sought diagnostic services on their own, are necessary to treat TB in patients earlier and interrupt transmission. Late presentation for medical services of symptomatic patients require special efforts to detect early and notify TB in high risk populations. An intervention that combined quality improvement with facility-led active case finding (QI-ACF) was implemented in 10 districts of Northern Uganda with the highest TB burden to improve case notification among populations at highest risk of TB. METHODS:Using QI-ACF intervention approach in 48 facilities, we; 1) targeted key vulnerable populations, 2) engaged district and facility teams in TB systems strengthening, 3) conducted systematic screening and diagnosis in vulnerable groups (people living with HIV, fishing communities, and prisoners), and 4) trained health workers on national x-ray diagnosis guidelines for smear-negative patients. Facility-led QI-ACF meant that health care providers identified the target population, mobilized and massively screened suspects, and addressed gaps in documentation. Chest X-ray diagnosis was promoted for smear-negative TB among those suspects whose sputum examination was negative. The effect of the intervention on case notification was then assessed separately over the post intervention period. RESULTS:Over all TB case notification in the intervention districts increased from 171 to 223 per 100,000 population between the baseline months of October-December 2016 and end line month of April-June 2017. TB patient contacts had the majority of TB positive cases identified during active case finding (40, 6.1%). Fishing communities had the highest TB positivity rate at 6.8%. Prisoners accounted for the lowest number of TB positive cases at 34 (2.3%). CONCLUSION:Targeting should be applied at all levels of TB intervention to improve yield: targeting districts and facilities with the lowest rates of case notification and targeting index patient contacts, HIV clients, and fishing communities. Screening tools are useful to guide health workers to identify presumptive cases. Efforts to improve availability of x-ray for TB diagnosis contributed to almost half of the new cases identified. Having all HIV patients who were eligible for viral load provide sputum for TB screening proved easy to implement.

Project description:BackgroundAdolescents living with human immunodeficiency virus (HIV) die owing to acquired immune deficiency syndrome (AIDS)-related causes more than adults. Although viral suppression protects people living with HIV from AIDS-related illnesses, little is known about viral outcomes of adolescents in sub-Saharan Africa where the biggest burden of deaths is experienced. This study aimed to identify the factors associated with viral load suppression among HIV-positive adolescents (10-19 years) receiving antiretroviral therapy (ART) in Uganda.MethodsWe conducted a cross-sectional study among school-going, HIV-positive adolescents on ART from August to September 2016. We recruited 238 adolescents who underwent ART at a public health facility and had at least one viral load result recorded in their medical records since 2015. We collected the data of patients' demographics and treatment- and clinic-related factors using existing medical records and questionnaire-guided face-to-face interviews. For outcome variables, we defined viral suppression as < 1000 copies/mL. We used multivariate logistic regression to determine factors associated with viral suppression.ResultsWe analyzed the data of 200 adolescents meeting the inclusion criteria. Viral suppression was high among adolescents with good adherence > 95% (adjusted odds ratio [AOR] 2.73, 95% confidence interval [95% CI, 1.09 to 6.82). However, 71% of all adolescents who did not achieve viral suppression were also sufficiently adherent (adherence > 95%). Regardless of adherence status, other risk factors for viral suppression at the multivariate level included having a history of treatment failure (AOR 0.26, 95% CI, 0.09 to 0.77), religion (being Anglican [AOR 0.19, 95% CI, 0.06 to 0.62] or Muslim [AOR 0.17, 95% CI, 0.05 to 0.55]), and having been prayed for (AOR 0.38, 95% CI, 0.15 to 0.96).ConclusionMore than 70% of adolescents who experienced virologic failure were sufficiently adherent (adherence > 95). Adolescents who had unsuppressed viral loads in their initial viral load were more likely to experience virologic failure upon a repeat viral load regardless of their adherence level or change of regimen. The study also shows that strong religious beliefs exist among adolescents. Healthcare provider training in psychological counseling, regular and strict monitoring of adolescent outcomes should be prioritized to facilitate early identification and management of drug resistance through timely switching of treatment regimens to more robust combinations.

Project description:BackgroundDespite longstanding guidelines endorsing isoniazid preventive therapy (IPT) for people with HIV, uptake is low across sub-Saharan Africa. Mid-level health managers oversee IPT programmes nationally; interventions aimed at this group have not been tested. We aimed to establish whether providing structured leadership and management training and facilitating subregional collaboration and routine data feedback to mid-level managers could increase IPT initiation among people with HIV compared with standard practice.MethodsWe conducted a cluster randomised trial in Uganda among district-level health managers. We randomly assigned clusters of between four and seven managers in a 1:1 ratio to intervention or control groups. Our intervention convened managers into mini-collaboratives facilitated by Ugandan experts in tuberculosis and HIV, and provided business leadership and management training, SMS platform access, and data feedback. The control was standard practice. Participants were not masked to trial group, but study statisticians were masked until trial completion. The primary outcome was IPT initiation rates among adults with HIV in facilities overseen by participants over a period of 2 years (2019-21). We conducted prespecified analyses that excluded the third quarter of 2019 (Q3-2019) to understand intervention effects independent of a national 100-day IPT push tied to a financial contingency during Q3-2019. This trial is registered with ClinicalTrials.gov (NCT03315962), and is ongoing.FindingsBetween Nov 15, 2017, and March 14, 2018, managers from 82 of 82 eligible districts (61% of Uganda's 135 districts) were enrolled and randomised: 43 districts to intervention, 39 to control. Intervention delivery took place between Dec 6, 2017, and Feb 2, 2022. Over 2 years, IPT initiation rates were 0·74 versus 0·65 starts per person-year in intervention versus control groups (incidence rate ratio [IRR] 1·14, 95% CI 0·88-1·46; p=0·16). Excluding Q3-2019, IPT initiation was higher in the intervention group versus the control group: 0·32 versus 0·25 starts per person-year (IRR 1·27, 95% CI 1·00-1·61; p=0·026).InterpretationFollowing an intervention targeting managers in more than 60% of Uganda's districts, IPT initiation rates were not significantly higher in intervention than control groups. After accounting for large increases in IPT from a 100-day push in both groups, the intervention led to significantly increased IPT rates, sustained after the push and during the COVID-19 pandemic. Our findings suggest that interventions centred on mid-level health managers can improve IPT implementation on a large, subnational scale, and merit further exploration to address key public health challenges for which strong evidence exists but implementation remains suboptimal.FundingNational Institute of Allergy and Infectious Diseases.

Dataset Information

Retention of HIV-Positive Adolescents in Care: A Quality Improvement Intervention in Mid-Western Uganda.

Publications

Retention of HIV-Positive Adolescents in Care: A Quality Improvement Intervention in Mid-Western Uganda.

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