RESPOND

Quality Improvement Collaborative to Strengthen HIV-Services in the Dnipropetrovsk Region, UkraineRegional Cross-Sectional HIV Service Cascade (2015, 2016, and 2017)

31 930

23 211

17 522

9 047

33 680

24 313

18 621

10 276

2 610

37 400

25 614

19 478

12 626

5 729

28 73725 863

23 277

30 31227 281

24 553

33 66030 294

27 265

0

5 000

10 000

15 000

20 000

25 000

30 000

35 000

40 000

0

5 000

10 000

15 000

20 000

25 000

30 000

35 000

40 000

Estimated numberof PLHIV (SPECTRUM)

Officially registered On active follow-up: 1≤ visit per year

On ART VL<1000 copies/mL

as of Jan 1, 2015 as of Jan 1, 2016 as of Jan 1, 2017

90% of PLHIVknow their HIV-status

90% of PLHIV who know their HIV-status,

are on ART

90% of PLHIVwho receive ART,

have undetectible VL

73%

39%

72%

42%

25%

68%

49%

45%н/д

© Public Health Center of MOH of Ukraine; USAID RESPOND, 2017

Progress against UNAIDS '90-90-90' targets, 2015-2017 Dnipropetrovsk region

75% 77%76%

COLLABORATIVE GOAL To strengthen the continuum of HIV prevention, testing, linkage, care and treatment services for PLHIVObjectives• Increase to 90% the proportion of PLHIV who know their status • Increase the proportion of PLHIV in active follow up• Increase to 90% the treatment coverage for PLHIV • Increase to 90% the proportion of PLHIV on ART with undetectable viral load

Collaborative Scale:• 39 QI sites out of the total 40 ART sites in the

region• Six NGO partners: ‘Network 100% of Life’ (Dnipro

and Kryvyi Rih branches), ‘Tsentr Pidtrymky Simyi’, ‘Alliance.Global’, AIDS Healthcare Foundation (AHF) and The Clinton Foundation

• Implementation Period: January 2016 – September 2017

HIV TESTING GAPReasons for the Gap:• Poor quality of pre-test counseling• Lack of motivation for physicians to provide HTS• Lack of information on HTS sites available for patients• Poor awareness on HIV infection among the general population• PLHIV fear of the status disclosure

QI Changes:• HIV testing with two rapid tests or ELISA by specialty physicians and/or PHC

providers • Make HTS info materials available for physicians and patients • Implement a patient tracking system (vouchers, coupons or invitations)• Provide escorting to patients by medical staff • HTS for sexual partners of PLHIV

NGO Interventions:• NGO ‘Network 100% of Life’ (Dnipro branch) • ‘PWID Sexual Partner Health’ – NGO ‘Tsentr Pidtrymky Simyi’• ‘Reach–Test–Treat intervention: model for enrolling MSM to HIV services’ –

NGO ‘Alliance.Global’• Supplies of HIV rapid tests for ART sites, specialty healthcare facilities and

PHC centers – AHF and The Clinton Foundation

SUCCESSFUL QI CHANGES IN HIV TESTINGHIV TESTING WITH TWO RAPID TESTS OR ELISA BY SPECIALTY PHYSICIANS AND/OR PHC PROVIDERSActivities:• Training for specialty physicians on risk behavior and clinical indications

screening, HCT, using of rapid tests and ELISA• Providing specialty physicians with HIV rapid tests• Advocating the rapid test procurements by PHC centers from local budgets• Developing/updating local protocols and patient pathways outlining the role

of PHC providers and specialty physicians in providing HTS

19116 17799 19289 1956822135 22543 21584

25216 24395 25356

1,6% 1,7% 2,0% 2,2% 2,0% 2,2%2,9%

4,1% 3,9% 3,7%

0,0%

1,0%

2,0%

3,0%

4,0%

5,0%

6,0%

7,0%

0

5000

10000

15000

20000

25000

30000

Jan-Mar2015

Apr-Jun2015

Jul-Sep2015

Oct-Dec2015

Jan-Mar2016

Apr-Jun2016

Jul-Sep2016

Oct-Dec2016

Jan-Mar2017

Apr-Jun2017

Number of the HIV screening cases made by specialty physicians and the HIV detection rate, Dnipropetrovsk region, 2015 - 2017

Number of people tested for HIV by specialty physicians HIV detection rate

QI

19116 17799 19289 1956822135 22543 21584

25216 24395 25356

1,6% 1,7% 2,0% 2,2% 2,0% 2,2%2,9%

4,1% 3,9% 3,7%

0,0%

1,0%

2,0%

3,0%

4,0%

5,0%

6,0%

7,0%

0

5000

10000

15000

20000

25000

30000

Jan-Mar2015

Apr-Jun2015

Jul-Sep2015

Oct-Dec2015

Jan-Mar2016

Apr-Jun2016

Jul-Sep2016

Oct-Dec2016

Jan-Mar2017

Apr-Jun2017

Number of the HIV screening cases made by specialty physicians and the HIV detection rate, Dnipropetrovsk region, 2015 - 2017

Number of people tested for HIV by specialty physicians HIV detection rate

QI

HTS FOR SEXUAL PARTNERS OF PLHIV Activities:• Together with NGOs, analyzing the PLHIV register to identify those whose sexual

partners have not received HTS• Motivational counseling for PLHIV to bring their sexual partners for HTS to the

ART site• HTS for PLHIV sexual partners • Analysis of the number of PLHIV sexual partners identified, linked to care and

put on ART

145

197179

277

17 1123

53

12%

6%

13%

19%

0

50

100

150

200

250

300

2013 2014 2015 2016

Number of PLHIV sexual partners tested for HIV, tested positive, and the detection rate,

Dnipropetrovsk region, 39 ART sites, 2013 - 2016

Number of HIV testing cases among PLHIV sexual partners

Number of tested positive for HIV

HIV detection rate

IMPACT OF THE HIV TESTING CHANGES AT THE REGIONAL LEVEL

144

557 538479

442 414

566667 646

568 620509

1,5%

6,7% 6,3% 5,4% 5,2% 5,6% 6,9% 7,2% 6,7% 7,0% 7,5%6% 6%

0,0%5,0%10,0%15,0%20,0%25,0%30,0%35,0%40,0%45,0%50,0%

0

100

200

300

400

500

600

700

800

Jan-Mar 2015

Apr-Jun 2015

Jul-Sep 2015

Oct-Dec 2015

Jan-Mar 2016

Apr-Jun 2016

Jul-Sep 2016

Oct-Dec 2016

Jan-Mar 2017

Apr-Jun 2017

Jul-Sep 2017

Number of people tested positive Number tested positive, 2015 median Testing yield, % Detection rate, 2015 median

HIV Detection: number and proportion tested positive, 2015–2017 Dnipropetrovsk region,39 QI sitesQI

LINKAGE TO CARE GAPReasons for the Gap:

• Poor quality of referrals of PLHIV from NGOs to infectious disease doctors

• Insufficient involvement of social workers in providing social support services

• Patients’ lack of motivation for treatment

• Patients lack funds for transport expenses to visit the AIDS center, for additional lab tests and treatment

QI Changes:

• Return lab results (CD4 and viral load) to ART sites through the Internet• Provide reminder text messages, phone calls or letters to patients• Provide active home visits by medical and social service providers• Register newly detected in-patient PLHIV with AIDS service before they are discharged from

the hospital

NGO Interventions:

• ‘Strengthening the Continuum of HIV Services at ART Sites’ – NGO ‘Network 100% of Life’ (Dnipro branch)

• ‘TB is Curable’ – NGO ‘Network 100% of Life’ (Kryvyi Rih branch)

SUCCESSFUL QI CHANGES IN LINKAGE TO CAREREGISTER IN-PATIENT PLHIV WITH AIDS SERVICE BEFORE THEY ARE DISCHARGED FROM THE HOSPITAL Activities:• In-patients tested positive for HIV sign written consent for transfer of their contact information

to the AIDS service• Hospitals develop procedures for linking to care identified in-patient PLHIV• Transfer of patient contact information to ART site at place of residence• Introducing infectious disease doctor positions in TB and narcological hospitals

3942

3035

42

2328

4753

32

22

33 32

4145

2834

31 29

0 315

20

34

1925

45 48

30

20

31 30

3841

2632

29 28

0%7%

50%

57%

81% 83%89%

96%91% 94% 92% 93% 94%

91% 92% 94% 93% 94% 95%

0%

20%

40%

60%

80%

100%

0

10

20

30

40

50

60

70

Jan2016

Feb2016

Mar2016

Apr2016

May2016

Jun2016

Jul2016

Aug2016

Sep2016

Oct2016

Nov2016

Dec2016

Jan2017

Feb2017

Mar2017

Apr2017

May2017

Jun2017

Jul2017

Number and proportion of PLHIV identified during the hospitalization and whose information had been transferred to local ART sites,

Dnipropetrovsk region, 2016 - 2017

Number of people tested positive for HIV during the hospitalization

Number of cases transferring information of PLHIv aidntified to local ATR sites

Proportion of PLHIV whose information had been transferred to local ART sites

SIGNING WRITTEN CONSENT FOR SOCIAL SUPPORT DURING HIV TESTINGActivities:• Signing agreement on social support services for PLHIV between NGO and healthcare

facilities• Edit the text of informed consent for HTS to allow transfer of patient information and social

support• PLHIV sign written consent for social support together with consent for HIV testing (If tested

with ELISA) or after positive test result (if tested with two rapid tests)• If a PLHIV does not receive the test result or if does not visit ART site/Trust Office, then his\

her contact information is transferred to NGO social worker to find this PLHIV for linkage to care

65%59% 58% 60%

79% 75%73% 68% 67%

43%53%

58%50%

56%64%

84%89% 87%

0%

20%

40%

60%

80%

100%

Jan-Mar2015

Apr-Jun2015

Jul-Sep2015

Oct-Dec2015

Jan-Mar2016

Apr-Jun2016

Jul-Sep2016

Oct-Dec2016

Jan-Mar2017

Introducing the written consent for social support while testing for HIV at the Kryvyi Rih PHC Center, Dnipropetrovsk region, 2015 - 2017

Proportion of PLHIV registered with AIDS service without signing consent for social support

Proportion of PLHIV registered with AIDS service with signing consent for social support

IMPACT OF THE LINKAGE TO CARE CHANGES AT THE REGIONAL LEVEL

329

555 758641

496 454

563

1015

816681

752598 598

0

200

400

600

800

1000

1200

Jan-Mar 2015

Apr-Jun 2015

Jul-Sep 2015

Oct-Dec 2015

Jan-Mar 2016

Apr-Jun 2016

Jul-Sep 2016

Oct-Dec 2016

Jan-Mar 2017

Apr-Jun 2017

Jul-Sep 2017

Number of PLHIV registered with AIDS services Number registered, 2015 median

Registration with AIDS service, 2015–2017

QI

Dnipropetrovsk region,39 QI sites

TREATMENT GAPReasons for the Gap:• Excessive workload on ART site physicians

• Long waiting lines for the patients at three ART sites

• Remoteness of ART sites from patient places of residence

• Lack of capacities to initiate more patients on ART at three ART sites (workload is up to 1,050 patients per one doctor)

QI Changes:

• Transfer ART patients from AIDS Centers to local ART sites

• ART dispensing by a PHC medical provider at the district level

• Manage ART stock at ART site

• Assessment of ART adherence by physician at every patient visit (quality assurance)

NGO Intervention:

• ‘Strengthening the Continuum of HIV Services at ART Sites’ – NGO ‘Network 100% of Life’ (Dnipro branch)

SUCCESSFUL QI CHANGES IN TREATMENT

TRANSFER ART PATIENTS FROM AIDS CENTERS TO LOCAL ART SITESActivities:• Analyzing the patient register at the regional AIDS Center and identifying those who

may be transferred to local ART sites• New ART sites opened• Preparing documentation to transfer ART patients to local ART sites• Transferring ART patients to local ART sites

133 147 158

301356 405 447 494 516 543 563 583

133 147 158 171237 271 305 335

390 395 412 433

100% 100% 100%

57%67% 67% 68% 68%

76% 73% 73% 74%

0

100

200

300

400

500

600

700

Number and proportion of PLHIV on ART, Kryvyi Rih STI hospital, Dnipropetrovsk region, 2016

Number of PLHIV registered with AIDS service Number of PLHIV on ART Proportion of registered PLHIV on ART

IMPACT OF THE TREATMENT CHANGES AT THE REGIONAL LEVEL

473602 604

653 623 680

879

1152

1369

941

690603 603

0

200

400

600

800

1000

1200

1400

1600

Jan-Mar 2015

Apr-Jun 2015

Jul-Sep 2015

Oct-Dec 2015

Jan-Mar 2016

Apr-Jun 2016

Jul-Sep 2016

Oct-Dec 2016

Jan-Mar 2017

Apr-Jun 2017

Jul-Sep 2017

Number of PLHIV initiated on ART Number initiated on ART, 2015 median

Initiation on ART, 2015–2017

QI

Dnipropetrovsk region,39 QI sites

PATIENT SURVEY RESULTS FROM THE 39 ART SITES IN THE DNIPROPETROVSK REGION, JANUARY 2016 (640 PEOPLE)

AND JULY 2017 (687 PEOPLE)

Proportion among patients tested for HIV in the last 6 months (%), Dnipropetrovsk region

84,4

81,2

88,6

63,9

98,2

97,6

86,6

67,3

66,9

73,9

34

96,9

95,8

78,6

I received test on HIV in the day of the first visit (p<0.001)

I received test at a conveniently located health facility, (p<0.001)

I received test at the convinient time, (p<0.001)

I received HIV test results in the day of testing, (p<0.001)

I received clear explanation of HIV test results

I received clear advice regarding the next steps

I received test at a conveniently located health facility, (p<0.001)

Round 1 Round 2

What you do not like about the services of this health facility, Dnipropetrovsk region, % among all respondents

3,3

7,7

2,3

5,2

26,8

1,5

16,9

15,2

14,8

11,9

10,6

39,2

4,7

8,8

Doctor's working hours, p<0.001

Laboratory working hours, p<0.001

Mismatching of doctor's and laboratory hours, p<0.001

Waiting time for test results, p<0.001

Waiting time at doctor's office (lines), p<0.001

Medical staff attitude, p<0.001

Service fees, p<0.001

Round 1 Round 2

ACHIEVEMENTS

•Practice of PLHIV in-patients’ registration with AIDS service before they are discharged from the hospital became a routine practice at the AIDS and TB service

•Specialty physicians (TB, narcology, STI, neuropathology, oncology, and others) actively involved to providing HTS

•Rapid tests purchased from PHC facilities budget

• Involving other healthcare services (therapy, neurology, oncology, and pulmonology) to registration of in-patients with AIDS service before discharge

•Decentralizing HIV services – transfer of ART patients from the AIDS centers to local ART sites. Decreased workload of AIDS center physicians

CHALLENGES

• Decreased initiation on ART and returning of patients lost to follow up back to care after reaching PEPFAR targets for HIV treatment

• Dependence of health care facilitates on rapid test supplies by international donors; procurements from local budgets do not cover the needs in full

• Delays in ARVs supplies

• Some patients do not want to receive ART at their places of residence

NEXT STEPS

• Signing QI Charter – 2020• Introduce the most effective QI changes into routine practice• Further control over procurement and using of the HIV rapid tests at PHC

facilities• Training on HTS with rapid tests for family doctors• Systematic monitoring of the ART stock •Cooperation with NGOs to improve linkage to care

385 381 324 259 219 218 183 163

280 276 241 189 160 158 121 102

414 409 372284 253 248 199 152

513 510 477388 361 343

258 208

569 551516

417 393 360183 151

508 489467

360350

614 520511

263262

0

3283 31362908

2160 1998

1327944 776

Cohort:ELISA at

registration

Registered withAIDS service

Remainregistered

on reportingdate

Enrolled on ART Remainon ART

on reportingdate

Remain on ART 6≤ months

Viral load testwithin last 6

months

Viral load <40copies/ml

Jan 2016 - Sep 2017 Cohort cascade as of October 1, 2017 Jan-Mar 2016 cohortApr-June 2016 cohortJul-Sept 2016 cohortOct-Dec 2016 cohortJan-Mar 2017 cohortApr-June 2017 cohortJul-Sept 2017 cohort

Dnipropetrovsk region, 31 QI sites

147 910

168

82%

69%96%

© USAID RESPOND Project, 2017 © Проект USAID RESPOND, 2017 © Pact, Inc., 2017