INCREASING NUMBER OF ELIGIBLE CLIENTS INITIATIATED ON ANTI­RETROVIRAL THERAPY IN BUGEMBE HC IV JINJA DISTRICT

BY

SARAH BYAKIKA & RAHMA KUBAIZA MEDIUM­TERM FELLOWS

JULY 2009

1 Table of Contents List of Tables ...... 3 List of Figures...... 3 Declaration ...... 4 Fellows‛ Roles in Project Implementation ...... 5 Acronyms...... 6 Operational Definitions ...... 7 Acknowledgements...... 8 Executive Summary ...... 9 1 Introduction ...... 10 1.1 Background...... 10 1.2 Current situation...... 10 2 Literature Review ...... 12 2.1 Problem Statement ...... 14 2.2 Justification/Rationale...... 15 2.3 Conceptual framework...... 15 2.4 Project Objectives...... 17 3 Methodology ...... 17 3.1 Identification of Project Site...... 18 3.2 Formation of CQI Team ...... 18 3.3 Problem Area Identification...... 18 3.4 Project Implementation...... 20 4 Outcomes...... 22 4.1 Project Outcomes...... 22 4.2 Lessons Learned...... 25 4.3 Challenges...... 26 5 Summary/Conclusion ...... 27 5.1 Recommendations...... 27 5.2 Next steps...... 27 5.3 Scale up/Sustainability Plan...... 28 6 References...... 29 7 Appendices ...... 30

2 List of Tables

Table 1: Countermeasure Matrix ...... 21 Table 2: Performance Monitoring Indicators ...... 22 Table 3: HIV Clinic Attendance at Bugembe HC IV ...... 24 Table 4: WHO Clinical staging and immunological criteria for initiating ART...30 Table 5: CD4 Cell count criteria for initiation of ART...... 30 Table 6: Bugembe HC IV Continuous Quality Improvement Team...... 31 Table 7: Work plan ...... 32

List of Figures Figure 1: Conceptual Framework ...... 16 Figure 2: Fishbone Analysis...... 20 Figure 3: Eligible clients initiated on ART at Bugembe HC IV ­ June 2008 to April 2009...... 23

3 Declaration

I, Sarah Byakika and Rahma Kubaiza do hereby declare that this end­of­project report entitled, “Increasing number of eligible clients initiated on anti­retroviral therapy at Bugembe HC IV Jinja District”, has been prepared and submitted in fulfillment of the requirements of the Medium­term HIV/AIDS Fellowship

Program at Makerere University School of Public Health and has not been submitted for any academic or non­academic qualifications.

Signed…………………………………………………….Date…………………

Sarah Byakika, Msc. CHHM, MB ChB

Medium­term Fellow

Signed ……………………………………………………Date…………………

Rahma Kubaiza, BLIS

Medium­term Fellow

Signed……………………………………………………Date……………………

Benson Tumwesigye

Academic Supervisor

Signed……………………………………………………Date……………………

Okiror Iporotum

Institution Supervisor

4 Fellows’ Roles in Project Implementation

The two Fellows, Sarah Byakika and Rahma Kubaiza Kirunda from Jinja District Health Office worked as a team for most of the time during the project. Project proposal development was a combined effort of both fellows and the academic mentor.

During the implementation process, Sarah invited the Bugembe Quality Improvement Team for the two training activities and sought for the external facilitators at TASO. Both Fellows were actively involved in preparation and facilitating the training activities.

Sarah carried out the assignment of Chairperson to the monthly Quality Improvement Team meetings while Rahma was the Secretary.

Fellows have been monitoring and documenting progress of project during weekly visits made to Bugembe HC IV as a team and also individually. Final report writing was combined effort of both Fellows.

5 Acronyms

AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral Therapy ARVs Antiretroviral Drugs CDC Centres for Disease Control and Prevention CQI Continuous Quality Improvement DHO District Health Officer HC Health Centre HCT HIV Counseling and Testing HIV Human Immunodeficiency Virus HMIS Health Management Information System IEC Information, Education Communication LMIS Logistics Management Information System MCH Maternal and Child Health MUSPH Makerere University School of Public Health PMTCT Prevention of Mother­to­Child Transmission of HIV QIT Quality Improvement Team STI Sexually Transmitted Infection TB Tuberculosis WHO World Health Organization

6 Operational Definitions

Eligible for ART – Upon HIV diagnosis adult ART eligibility is when patient is classified as WHO stage 4 disease or has CD4 cell count <250 cells/mm 3 or WHO stage 3 disease and CD4 cell count <250 cells/mm 3 . This should be in absence of medical and non­medical contraindications; patient is ready to begin treatment and adherence support available.

Late initiation of ART ­ Initiation of ART when CD4 cell count level is <250 cells/mm 3

7 Acknowledgements

We would like to acknowledge the support of the Jinja District Chief Administrative Officer who recommended the Fellows to undertake the program.

The Fellows also acknowledge the sharing of ideas and learning experience gained from other CQI Medium term Fellows during the training modules at the School of Public Health.

Further acknowledgements go to the staffs of Bugembe HC IV who were cooperative and willing to learn throughout the duration of the project. Their team spirit and dedication made it possible for the project to achieve remarkable results.

We would like to also acknowledge the staff of the School of Public Health, Dr. Elly Rutebembera and his team for their technical support.

Special thanks go to the staff of CDC Fellowship Program; Mr. Joseph Matovu, Mr. Henry Nsubuga and Ms. Susan Mawemuko for their unwavering support during the fellowship program.

We acknowledge the valuable mentorship of our academic supervisor Dr. Benson Tumwesigye, who worked tirelessly to ensure that we keep on track till finishing the project.

Lastly we acknowledge School of Public Health / CDC Fellowship programme as a whole for the financial support which enabled us completed the project activities as planned.

8 Executive Summary Comprehensive HIV/AIDS care which involves treatment and care for people living with HIV: antiretroviral therapy, care and management of HIV/TB co­infection and other co­ morbidity is a key intervention in curbing the high morbidity and mortality rate caused by the AIDS pandemic.

Bugembe HC IV is one of the five HC IVs in Jinja district providing ART. Since September 2006 the centre has been providing comprehensive HIV/AIDS care services comprising prevention of opportunistic infections (Cotrimoxazole use), treatment of opportunistic infections, ART and STI management with a total enrolment of 364 clients, 25.8% eligible for ART and 68% of those eligible initiated on ART. However, from June 2008 to August 2008, 73.3% of clients eligible for ART had not been initiated on ART at Bugembe HC IV likely to lead to prolonged ill health and early death of enrolled clients.

The quality improvement project was designed with a general objective of increasing the number of eligible clients initiated on ART at Bugembe HC IV from 26.7% to 75% between, August 2008 and January 2009. Implementation of this project was expected to build the Fellows’ competencies in Continuous Quality Improvement (CQI) for HIV/AIDS care but also to institutionalize quality improvement in Jinja district health services where the Fellows work. Planned project implementation period was 8 instead of 5 months.

Countermeasures introduced included training in Logistic Management Information System and ART adherence counseling, establishment of two HIV clinic days, institutionalization of the appointment system.

Between January and April 2009 all (34/34) eligible clients were initiated on ART and a functional CQI team was established at Bugembe HC IV.

9 1 Introduction

1.1 Background

Comprehensive HIV/AIDS care involves treatment and care for people living with HIV, antiretroviral therapy (ART) and management of TB co­infection is a key intervention in curbing the high morbidity and mortality ate caused by AIDS pandemic. As a result of the introduction of the UNAIDS ARV’s drug access initiative, and launching of the universal access in 2003 in Uganda, by June 2008 a total of 138,000 HIV positive clients had been initiated on ART (ACP program Report, MoH).

ART delivery is feasible in a resource – limited setting for both adults and children and it’s effectiveness in Uganda is similar to elsewhere. However, challenges that may limit effectiveness of ART include:­ § Late initiation of treatment in advanced HIV with resultant increased mortality § Prevalent concurrent infection like TB § Ensuring uninterrupted ARV drug supply § Lost to follow up of patients that leads to treatment interruptions § Monitoring ART efficacy and safety

Late initiation of treatment may be caused by a number of factors which may be individual/community or service delivery related. Service delivery factors commonly range from inputs to processes e.g. limited personnel to initiate therapy, limited drug stock, inadequate laboratory investigations, inadequate counseling among others.

1.2 Current situation HIV/AIDS has for along time been one of the leading contributors to the widespread poverty among our people. With the prevalence rate at 6.7% in Jinja district and 7.7% in Mafubira sub­county where Bugembe HC IV is located,

10 HIV/AIDS poses a big threat to the livelihood of many people and consequently presents economic repercussions to our districts. The proportion of orphaned children due to HIV is 9.6% in Mafubira sub­county and there are 212 child headed households (Jinja District HIV/AIDS Programme M& E Report 2007). This is a worrying trend to the district leadership because the proportion of households with no income is unacceptable. The district has gone ahead to scale up access to ART by having all HC IVs in the district accredited to provide ART.

Bugembe HC IV is one of the five public HCs in Jinja district providing ART since September 2006. In pursuit of HIV/AIDS control program objectives Bugembe HC IV implements a wide range of interventions in the prevention and control of the HIV/AIDS epidemic. The main ones are; • Information Education Communication (IEC)/Public education • HIV Counseling and Testing (HCT) • Sexually Transmitted Infection (STI) management • Enhancement of infection control • Comprehensive HIV/AIDS care including psychosocial support and basic care package. • Prevention of mother to child transmission of HIV • Monitoring and evaluation

Up to 33 of the 48 health staffs at Bugembe HC IV are directly involved in the implementation of the HIV/AIDS care and prevention activities. The HIV/AIDS clinic is currently run once week (Thursdays) with an average attendance of 40 clients and 11 staffs assigned related duties per clinic day. For a client to be initiated on ART at least six staff are involved (Receptionist, Records Assistant, Nurse/counselor, Laboratory Technician, Clinician (MO/CO) and Dispenser).

With a catchment population of 155,268 and a seroprevalence rate of 6.7% there are an estimated number of 10,403 HIV positive clients to be served by Bugembe HC IV as a Primary Health Care referral facility. From September 2006 to August

11 2009 a total of 364 HIV infected clients were enrolled into general HIV/AIDS care (District HMIS reports) of whom 347 were adults (281 female >14 years, 66 male >14 years) and 17 children. There are older ART sites namely TASO Jinja and Jinja Regional Referral Hospital which are within 6km, which have more clients enrolled into care. Newer sites like Mpumudde HC IV and Walukuba HC IV have lower enrollment than Bugembe HC IV. Monitoring performance of these sites by the district is through support supervision and periodic reports.

2 Literature Review The importance of HIV/AIDS care is noted as complementary and enhances prevention activities, improves the quality of life, maintains the working capacity of the people infected and affected by AIDS, decreases the social impact of AIDS, prevents the secondary spread for children. Early initiation of ART is associated with decreased all­cause mortality in HIV­infected patients who have a baseline CD4 count of 351 cells/mm 3 or greater (1).

Although evidence indicates substantial developments in clinical outcomes and their impact at the population level, some trends raise concern. Recent evidence (2) indicates that many people die after an HIV positive diagnosis and before they can access ART. Further, despite significant gains in survival time since treatment began to be scaled up people in low and middle­income countries still have higher mortality in the first six months of treatment than people in the high­income countries (3). This suggests that late diagnosis, late initiation of therapy, undiagnosed co­morbidity and differential access to health care contribute to unequal treatment outcomes.

Initiation of ART should be based on the level of HIV immune suppression as assessed by WHO HIV stage (presence or absence of certain HIV related symptoms), and CD4 cell count (Appendices 1). Uganda National Antiretroviral Treatment and Care Guidelines, recommend that ART initiation in adults and adolescents be based on the following;

12 • Patient with documented HIV infection • CD4 cell count of 250 cells/mm 3 and below • CD4 cell count above 250 but below 350 cells/mm 3 in those: o Who are co­infected with tuberculosis (TB), or WHO Stage III disease o Women who are pregnant • WHO Stage IV disease irrespective of CD4 cell count • WHO Stage I or II with CD4 cell counts <250/mm 3

Certain patient­specific factors should also be considered before starting ARVs. These factors include: • Interest and motivation in taking therapy • Presence of co­morbidities especially TB. Patients must have a screening history, physical exam and if necessary, laboratory tests to rule out active infection. The treatment of co­existing infection takes priority over starting ART. • Psychosocial barriers • Financial barriers in those eligible but do not want to use the free ARV program • Possible religious barriers • Potential for adherence

Final decision regarding acceptance of treatment should be made by the patients after discussing with the health care providers all issues about the therapy and how they relate to the patient’s own situation.

Despite guidelines recommending earlier initiation of antiretroviral therapy (ART), many patients initiate ART in the advanced stages of HIV disease (4). Late initiation of antiretroviral treatment following diagnosis is contributing to the continuing high death rate among people who present with low CD4 counts in eight sub­Saharan African countries. Data from South Africa show that more than

13 half of people eligible for antiretroviral treatment (ART) at diagnosis waited at least 12 months to begin treatment, while data from eight African countries show that patients in rural areas, those identified with HIV outside a PMTCT programme and those who are not followed up when they miss appointments were most likely to start treatment at a very low CD4 count.. Although patients are often severely immunosuppressed at HIV diagnosis, only half of eligible patients started ART within 12 months (5).

A number of health system and patient­specific factors contribute to the low initiation of eligible clients on ART. These include inadequate stocks of ARVs for example; it was reported at Bugembe HC IV that paediatric formulations are not available despite ordering for them and no child has been initiated on ART. Other factors are, inadequate ART counseling and thus clients not fully aware of the benefits of ART. Myths resulting from rumors about the side effects of ARVs. Lost to follow up due to stigma related issues. Some prefer going health units where they are not known because they do not want to be seen at HIV clinic. Fear of disclosure to partner, such that even when ready they do not turn up for ARVs. A number of women have been blamed or abandoned when they discover they are HIV positive during antenatal care. Because of such experiences others fear to disclose.

All health institutions that administer ART should be prepared to offer quality and dedicated services. This is because ART is life long and complicated. World wide Continuous Quality Improvement (CQI) has been identified as key to delivery of client focused services. In the era of HIV/AIDS which requires chronic care, quality health services are essential in ensuring regular attendance of clinics and more important the initiation and adherence to ART.

2.1 Problem Statement At Bugembe care HIV/AIDS clinic, a low proportion of eligible clients were initiated on ART. Out of the 364 clients enrolled into general HIV care only 64

14 were initiated on ART. During the months of June to August 2008, it was found that 83% of eligible and ready clients had not started ART treatment likely to lead to prolonged ill health and early death. Where ARVs are accessible, all eligible and ready clients are expected to be initiated on ART following the ART policy for Uganda.

2.2 Justification/Rationale HIV/AIDS has for a long time been one of the leading contributors to the widespread poverty among our people. The prevalence rate at district level is 6.7% and 7.7% in Mafubira sub­county where Bugembe HC IV is located. HIV/AIDS poses a big threat to the livelihood of many people and consequently presents economic repercussions to our district. The district scaled up access to ART by having all HC IVs in the district accredited and provide ART. It is therefore imperative that the clients eligible for ART should start on ART in order to prolong their productive life and ensure household income hence contributing the development of the district.

A number of factors contributing to the low initiation on ART are due to performance gaps among health providers. Identifying and analyzing these gaps periodically can help improve the quality and uptake of services. The project is designed to identify gaps and improve the processes on a continuous basis which is a CQI approach. To this therefore the outcome would be; better service delivery to HIV/AIDS clients hence increased number of eligible clients initiated on ART at Bugembe HC IV.

2.3 Conceptual framework Figure 1 presents a model for describing the relationship between the complex mix of patient/individual, health worker, socio­economic/cultural, processes and systems factors that influence the initiation of eligible clients on ART and in turn determine the outcome of initiation of eligible clients on ART (Fig.1).

Health workers are responsible for initiation of patients on ART. In order to do this they must have the appropriate knowledge and skills to educate, counsel,

15 initiate and follow up patients on ART. Interpersonal communication and attitude of health workers regardless of sex and age of clients creates an environment that may either encourage or discourage patients from seeking care at a particular facility.

Health workers are required to operate within existing health system guided by policy and standards in ART provision. Availability of infrastructure including equipment, adequate supplies as prescribed by the treatment guidelines, availability of qualified and adequate human resource and the clinic organization determine where, what, when and how much a health worker can provide. These factors also affect patient accessibility in terms of affordability, geographical accessibility and acceptability of the services.

Social­economic/cultural factors affect patients from community to household level where the vulnerable may be denied access to care. Health workers’ attitude and relationship with patients can also be influenced by the societal norms thus affecting outcomes of care. Figure 1: Conceptual Framework

Processes/Systems Factors

Policy environment Patient Provision of supplies Infrastructure Awareness Human resource Treatment seeking Organizational – Patient flow, behaviour clinic days Sex Age

Outcome Health Worker Household Individual Initiation of Factors Eligible Clients Marital status on ART Spousal Involvement Knowledge Economic status Skills Relationship with patients Attitude Socio­economic/ Cultural Factors

Peer influence Gender norms Cultural norms Political environment 16 2.4 Project Objectives

2.4.1 General Objective The project goal is to increase the proportion of eligible clients initiated on ART at Bugembe HC IV from 26.7% by August 2008 to 75% by January 2009 so as to improve their longevity and quality of life.

2.4.2 Specific Objectives 1. To build capacity of all Bugembe HC IV ART clinic staff in ART Logistics Management Information System. 2. To build capacity of ART clinic support staff in ART adherence counseling. 3. To increase client provider contact time for clinicians and counselors by 50%. 4. To build capacity in Continuous Quality Improvement for HIV/AIDS care at Bugembe HC IV.

3 Methodology Project inception came after the two Fellows completed a two weeks intensive training in Continuous Quality Improvement course at the School of Public Health and went through the project identification and proposal writing process between August and September 2008 from the workplace. a) Briefing Supervisor On return from the two weeks training the two Fellows briefed the Chief Administrative Officer (CAO) who is the head of Civil Service in the decentralized district system about the SPH/CDC HIV/AIDS fellowship program objectives and duration of the fellowship programme. b) Briefing DHT Members The District Health Team (DHT) members were briefed about the Fellowship programme during the monthly DHT in August 2009. DHT members encouraged the initiative and were willing to participate and support the project activities.

17 3.1 Identification of Project Site The two Fellows brainstormed about the identification of the site for the quality improvement project. We listed the six government facility based ART sites in the district namely: Jinja Regional Referral Hospital, Mpumudde HC IV, Budondo HC IV, Walukuba HC IV, Bugembe HC IV and Buwenge HC IV. Bugembe HC IV was agreed upon as the project site because it is located about 6 km from our workplace, had a fairly high client load approximately 386 and administratively is under the District Health Office and therefore could advise on issues pertaining resource mobilization and utilization.

3.2 Formation of CQI Team The two Fellows visited Bugembe HC IV in August 2008 and briefed the health facility staff about continuous quality improvement in HIV/AIDS care project to be implemented at the facility. During the same meeting members of the Bugembe HC IV CQI were identified (Appendices 2) and the CQI team was formed. The purpose of this team is to continuously identify and analyze process problems that affect quality of HIV/AIDS care services using a customer­oriented approach and identify countermeasures which can be implemented with available resources. It is expected that this approach will be institutionalized and applied in future plans.

3.3 Problem Area Identification Another meeting with Bugembe QIT staff was held in September 2008 the main objective was to identify problem areas. Members brainstormed on various customer­focused problem areas (listed below) that were affecting delivery of quality services in Bugembe.

18 1. Lack of HIV care starter cards used for enrolling clients into HIV/AIDS care clinic 2. Few eligible clients initiated on ART. 3. Inadequate storage space for record keeping. 4. Low enrollment of HIV positive clients into ART clinic 5. Congestion in the waiting area on ART clinic day 6. Drug stock­out for various ARV drugs combinations 7. Little time to attend to clients in ART clinic. 8. Delay in accessing appropriate treatment due to stock out of drugs 9. Poor working relationship with partners like AIC affecting the regular supply of logistics for HCT and TB treatment.

The brainstorming session generated the above list of problems and the team agreed that some problems can be merged since they were related and therefore classified the problems as below. 1. There is low enrollment of HIV positive patients into HIV/AIDS care clinic. 2. Few eligible clients initiated on ART. 3. Poor record keeping due to lack of equipment like filling cabinets. 4. Congestion on ART clinic day where all ART clients and OPD patients wait in same area this leads to little time of attending to the client by the Clinician.

Using a multi­voting matrix the QI team identified and prioritized a process problem of few eligible clients attending the HIV/AIDS clinic at Bugembe HC IV initiated on ART. Review of the facility records indicated that from June to August 2008, 73.3% of clients attending the HIV/AIDS care clinic at Bugembe HC IV and eligible for ART were not initiated on ARVs. Problem analysis using “Fishbone diagram” was carried out and a number of contributing factors including organizational, personnel, communication and drug availability were identified. (Fig. 2).

19 Figure 2: Fishbone Analysis

DRUGS PERSONELL

Stocks out of ARVs Few staff on clinic day

Stocks not monitored Delay ordering Absenteeism

Dispenser busy I/C not available Negative Attitude

Poor remuneration Other staff not Many trained Gov’t policy responsibilities Few eligible clients initiated on ART Patients not aware Overload for few staff Little time for attending to clients

Inadequate counseling One clinic day per week Many patients coming same time

Appointment time not specified

More clinic days not planned Few staff trained in Appointment time counseling not institutionalized

COMMUNICATION ORGANIZATION

3.4 Project Implementation The planned project implementation period was five months (September 2008 to January 2009) however, final proposal approval was in November 2009 and funds were accessed in December 2008, thus a 3 months delay in implementation.

Implementation structure included the CQI Team comprised of 10 people from various disciplines at district and the health facility level (Appendices 1). The two Fellows (DHO and DMRO) worked closely with the health facility team to ensure implementation of the project activities within the remaining time. All 10 members of the CQI team were oriented on the concepts and methods of CQI and other health centre staffs were oriented during CME. The district team/Fellows conducted follow up and support supervision visits to Bugembe HC IV. A total of four monthly CQI Team meetings were held to monitor progress.

20 The project activities were aimed at implementing the countermeasures identified using the matrix as shown below.

Table 1: Countermeasure Matrix Root cause Countermeasure Practical Method Output 1. Staff not aware of Training in logistics § Workshop § 10 Staff members maintain minimum management § On­job training were trained in ART and maximum logistics information stock levels management system. 2. Few staff trained in Training of staff in § Workshop § 2­day training for 10 § HIV/AIDS ART adherence Mentoring staffs counseling counseling § Provide Job Aids § Hand outs provided as reference materials

§ ART adherence Job­ Aids not readily available

3. Appointment Institutionalize § Modify and print § Not done. Still using system now well appointment system appointment MoH ART institutionalized by time and date cards appointment cards § Orient staff on § Staff oriented appointment through CME system § On­going client § Sensitize clients sensitization about on appointment new clinic day § Establish diaries § Diaries adopted for for appointments Clinicians appointments adopted for TASO 4. More clinic days Plan for and § Organize staff § Staff meeting held not planned establish more HIV/ meeting § Established 2 clinic AIDS clinic days § Establish the two days (Tuesday & per week clinic days per Thursday) week

21 4 Outcomes

4.1 Project Outcomes

A number of performance indicators were identified and monitored to ensure that all clients attending the HIV clinic were assessed for ART eligibility, recorded, counseled about the benefits of ART and initiated on treatment. The pre­ART clinic registers were used to obtain this information on a monthly basis.

Table 2: Performance Monitoring Indicators Objective Indicator Output Countermeasures To assess all clients for 100% of clients in 623 clients Established two ART eligibility general care assessed for assessed HIV/AIDS clinic ART eligibility at every days in order to visit. reduce on staff workload To record all eligible 100% of all eligible 623 clients Triage clients clients are recorded in recorded Staffs oriented on the pre­ART register CQI principles To counsel all eligible about 100% of eligible clients 38 eligible clients Staffs trained in the benefits of ART counseled on ART counseled ART adherence benefits counseling To initiate all eligible clients 100% of eligible clients 34/34 eligible Triage on ART initiated on ART clients attending Staffs trained in the clinic have ART Logistics been initiated on Management System ART between Jan to make proper drug 09 and April 09 forecasts To compile a monthly 100% 4 monthly reports summary of all eligible compiled and clients and those initiated on submitted to the ART DHO’s office To compile and submit a bi­ 100% 2 reports compiled Staffs trained in monthly order and report for and submitted ART Logistics ARVs timely Management System

22 1. Between January and April 2009 all eligible clients (34/34) who attended the Bugembe HC IV HIV clinic were initiated on ART.

Figure 3: Eligible clients initiated on ART at Bugembe HC IV ­ June 2008 to April 2009

35 INTERVENTION 30 30 27 25 23

20 16 16 15 13 11 12 11 9 9 9 10 7 7 4 5 4 5 5 5 3 3 1 0 Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr

Eligible Initiated

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr 3.3% 11% 17% 44% 46% 33% 19% 63% 56% 100% 260%

2. All staff involved in HIV/AIDS clinic trained in ART Logistics Management Information System (LMIS) to improve on ARV drug monitoring, quantification and ordering.

LMIS Training for Bugembe HC IV staff

23 3. Two HIV/AIDS clinic days per week established at Bugembe HC IV. Client­ Clinician and Client–Counselor interaction time increased to 20 minutes per eligible client at initiation.

The establishment of two clinic days has markedly de­congested the overcrowding on clinic day and clinicians have reported that they are now less stressed. Before the introduction of two clinic days the average number of clients seen on a clinic day was 60 minimum at one time the number increased to 100 patients on one clinic day. After the introduction of two clinic days, the clinic has been seeing on average 25 ­ 30 patients on a clinic day.

Table 3: HIV Clinic Attendance at Bugembe HC IV Month Thursday Clinic Tuesday Clinic Total Week Week 1 2 3 4 1 2 3 4 October 41 26 53 42 0 0 0 0 162 November 35 46 47 57 0 0 0 0 185 December 39 47 42 ‐ 0 0 0 0 128 January 100 54 44 30 0 0 0 0 228 February 65 61 41 29 0 0 0 6 202 March 48 54 33 31 18 28 16 9 237 April 48 53 37 30 18 23 22 22 253

4. Institutionalized Appointment System The appointment system has helped the Peer Educators in following up of clients who have missed their appointment. Further emphasis was put on triage so that at registration patients could be sorted according to those needing the clinician, counselor or refills for cotrimoxazole or ARVs. A patient flow chart was established.

24 5. Continuous Quality Improvement approach in HIV/AIDS care established at Bugembe HC IV. § A CQI team was formed and meets once a month. During these meeting, the various departments give reports or share their experiences. For example reports from Laboratory, MCH, and Counseling, Clinical, etc are shared during these meetings. § Introduction and monitoring of facility based quality improvement indicators at Bugembe HCIV § Team work has been strengthened through improved CQI team functionality. § Improved reporting to the health facility, and the district

6. District level dissemination of the project outcomes to the District Health Management Team and District Council was carried out. A total of forty participants attended.

Public Health impact of this project is;

a. Early access of eligible clients to ART

b. Improved quality of life of HIV positive clients

c. Improved quality of HIV/AIDS care services

d. Increased utilization of services and better health outcomes for HIV positive clients.

4.2 Lessons Learned 1. Health workers need periodic refresher training to improve on skills. 2. Using existing resources and partners can facilitate implementation of new interventions e.g. integration of CQI initiatives in strengthening ART activities under the PMTCT program enabled introduction of CQI approach in the Thursday ART Clinic Team meetings. 3. Joint problem identification and analysis leads to ownership and successful implementation of new interventions (Teamwork)

25 4. Flexibility and effective communication good for coordination and networking. The two Fellows had to visit Bugembe HC IV in the afternoons and always kept time. There was effective communication between the Fellows and the CQI team at Bugembe. 5. Task shifting/delegation enables continuity of work 6. Clients utilize services more when they are tailored to meet their needs.

4.3 Challenges § Delayed project implementation due to delayed access to funds

§ Limited contact/support from academic supervisors. Used informal forum for discussion of project progress.

§ Competing priorities at work interfered with project activities e.g. Fellows would plan to attend CQI Team meetings and a workplace activity takes precedence.

§ Three months a very short time for project implementation because of the above point.

§ Weak leadership at HC IV level thus requiring the DHO to play a steering role for the Health Centre QI team. Vice Chairperson takes the leadership role though cautiously. This is not sustainable.

§ Team members expect additional facilitation/allowances for QI initiatives. Dialogue on the individual benefits of doing the right thing at the right time and the right way as well as the client – focus approach.

§ Due to short project period client satisfaction survey not carried out. This is important in determining the quality of services offered from the client perspective.

26 5 Summary/Conclusion The Bugembe HC IV Quality Improvement project was designed and implemented with a general objective of increasing the number of eligible clients initiated on ART at Bugembe HC IV from 26.7% in August 2008 to 75% by January 2009 so as to improve their longevity and quality of life. Actual implementation of countermeasures commenced in January 2009 and by the end of the end of the project in April 2009 all (100%) eligible clients had been initiated on ART.

The Fellows have been able to introduce and institutionalize HIV/AIDS care quality improvement at Bugembe HC IV and expected to result in better life of HIV positive clients.

5.1 Recommendations § Academic supervisors should be available to guide on proposal development and review § Organize for more formal interactions with academic supervisors. § Set deadlines for Fellows or periodic reports from Fellows to keep pace. § Encourage Fellows to identify team leaders who are committed to QI and not by virtue of position § During training emphasize that this is an institution initiative and not a project. Should be integrated in already existing programmes.

5.2 Next steps Further dissemination of the project implementation and results will be carried out at the School of Public Health to other Fellows and academic supervisors.

Final dissemination will be carried out to other School of Public Health stakeholders and Funders.

The Fellows will seek opportunities for publication in local and international medical journals.

27 5.3 Scale up/Sustainability Plan 1. Jinja District Directorate of health services has embraced the quality improvement initiatives and since April 2009 is introducing quality improvement initiatives in the remaining HC IVs with support from the Ministry of Health ­ HIV/AIDS Care Improvement (HCI) Project. The lessons learnt from the Fellowship programme will facilitate rapid scale up in the remaining HC IVs with Bugembe HC IV acting as a model in quality improvement. During the last district mentorship visit to ART sites under the HCI project the Team Leader from Budondo HC IV remarked, “I am very impressed with Bugembe HC IV. They are far ahead in quality improvement issues and I promise we are going to work hard to catch up”. Both ART sites were enrolled under the HCI project at the same time.

2. With support and mentoring from the District Health Office integration of QI activities in existing initiatives and all programmes is emphasized.

3. DHO plans to collaborate with TASO – Jinja to support computerization of the client appointment system at all HIV clinics in the district.

4. Identify other problems and apply the performance improvement approach (PDCA).

5. Monitoring of QI initiatives at Bugembe HC IV to be integrated in the district HIV/AIDS and TB support supervision activities

6. The district is lobbying for support from the HCI project to facilitate regular follow up/supervision of ART sites and facilitate QI team meetings.

7. Client satisfaction survey to be carried out to determine quality of services offered.

28 6 References 1. Kitahata MM, Gange SJ, Abraham AG, et al; NA­ACCORD Investigators. Effect of early versus deferred antiretroviral therapy for HIV on survival. N Engl J Med 2009; 360:1815–26.

2. Maartens G. ART in Africa: beyond the rollout. 15 th Conference on Retroviruses and Opportunistic Infections, Boston, USA, 3–6 February 2008 (http://www.retroconference.org/2008/Abstracts/33418.htm).

3. Johannessen. A et al. Predictors of mortality in HIV infected patients starting antiretroviral therapy in a rural hospital in Tanzania. BMC Infectious Diseases, 2008, 8:52.

4. Ministry of Health – Uganda. National Antiretroviral Treatment and Care Guidelines for Adults and Children. July 2008

5. Nash D et al. Program­level determinants of low CD4 count ART initiation in cohorts of persons aged ≥ 6 years initiating ART in 8 sub­ Saharan countries. 5th IAS Conference of Pathogenesis, Treatment and Prevention, Cape Town, South Africa, abstract 1882, July 2009.

6. Bassett et al. Who starts ART in Durban, South Africa?...Not everyone who should! 5th IAS Conference on HIV Pathogenesis, Treatment and Prevention abstract 1921, July 2009.

29 7 Appendices

Appendix 1: Table 4: WHO Clinical staging and immunological criteria for initiating ART Clinical stage CD4 cell count Comments 1 CD4 guided Treat if <250 11 CD4 guided Treat if <250 111 Consider CD4 Treat if pregnant or symptomatic & <350 1V Treat Treat

Table 5: CD4 Cell count criteria for initiation of ART CD4 count (cells/ul) Actions <250 Treat irrespective of clinical stage 250 ‐ 350 Consider treatment in patients who are symptomatic (WHO stage III), have TB or are pregnant >350 Do not initiate treatment

30 Appendix 2:

Table 6: Bugembe HC IV Continuous Quality Improvement Team Name Cadre Responsibility 1. Dr. Sarah Byakika District Health Officer Fellow 2. Rahma Kubaiza District Medical Records Officer Fellow 3. Dr. Onzima Felix Senior Medical Officer In­Charge Team Leader 4. Bajabaite Moses Laboratory Technician Secretary 5. Baluka Juliet Clinical Officer Member 6. Balizindwire Justin Dispenser Member 7. Kiboole Margaret Nurse Member 8. Kyemba Herbert Counselor/Asst. Health Educator Member 9. Namusobya Margaret Midwife Member 10. Namiiro Grace Records Assistant Member

31 Table 7: Work plan Cost categories and details Dec Jan Feb Mar Apr Responsible person A. Project proposal development X Sarah & Rahma Proposal writing and submission to SPH/CDC Fellowship Program B. Training 1.Identify staff not trained in counseling X Counselor 2.Identify Trainers X Sarah & Rahma 3.Prepare training materials and venue X 4.Training in ART Logistics management X Sarah & Rahma information system b) Follow up on­job training on LMIS X X Rahma 5.Training in ART Adherence Counseling X TASO trainers skills for 2 days 6.Post training follow up of counselors X Sarah & Rahma C. Establish 2 HIV clinic days Organize staff meeting X HU In charge Hold meeting and agree on 2 clinic days per X HU In charge week Run 2 clinic days per week X X HU In charge D. Institutionalize the appointment system Modify appointment card X Sarah Printing of the cards X Sarah Half day orientation of staff and Peer X Sarah & Rahma Educators on appointment card/system HE session to sensitize clients on X X X Counselor appointment card system Establish diaries X Counselor E. Support by the district team/fellows Project activity supervision X X X X X Sarah & Rahma F. Monitoring and evaluation CQI Team Review meetings X X X X X Sarah & Rahma

32 Appendix 3

Report on Logistics Information Management System Training

Date: 14 th January 2009

Venue: DHO Conference Room

Training objectives: 1. Review of the Logistics management Information system (LMIS). 2. Update health workers on HIV reporting systems. 3. Discuss problems being faced at health facility level in reporting and wayfoward on addressing these problems.

The attendance of the participants was 85% and all the above objectives were achieved.

CONTENT 1. Roles and responsibilities of health workers in managing information and proper documentation of activities in the facility was discussed. 2. The modifications on the LMIS were discussed and participants were told how to fill each section of the monthly report. 3. Demonstrations on how to fill the various logistics data tools were conducted and members learnt how to fill them. 4. A discussion on the challenges and way forward took place and all participants were actively involved.

CHALLENGES • Delayed signing of the reports by the Health Unit In­charge

• Lack of computer software

• Only few staff at the facility had knowledge on how to use the logistics information tools to order drugs timely

WAYFORWARD

• All health workers should learn how to fill the logistics data tools

• Improve on the timeliness of sending the orders to the DHO’s office

• The health unit In­charge should delegate his deputy to sign the order forms while he is away

33 • Records Assistant should assist the dispenser more in ensuring a successful logistics management information system.

List of Participants Name Cadre 1. Baluka Juliet MCO 2. Namiiro Grace R/A 3. Balizindwire Justin DISP 4. Bajabaite Moses MLT 5. Kyemba Herbert AHE 6. Kiboole Margaret E/N 7. Mufumba Emmanuel RPN/PCO 8. Namukasa Esther Midwife 9. Nangobi Florence N/Assist 10. Mbaizwe Yusuf MCO

34 Time Table LMIS Training

TIME ACTIVITY FACILITATOR 8.30­ 9.00 AM Arrival and Registration Rahma

9.00 – 9.30 Welcome remarks and official opening Dr. Sarah AM 9.30 – 10.00 CQI objectives and brief background Dr. Sarah AM 10.00 – 10.30 Introduction to records keeping and its Rahma AM Importance 10.30 – BREAK TEA 11.00AM 11.00­ 11.30 Roles and responsibilities of staff in Rahma AM records management 11.30­12.30 Filling data tools Registers and Rahma summary forms 12.30­1.00 PM Overview of data management Rahma 1.00 – 2.00 PM LUNCH

2.00PM ­ Logistics management Rahma 2.30PM 2.30 ­3.00 PM Filling of the logistics tools ( Dispensing Rahma log book, order­issue voucher) 3.00 ­3.30 PM Discussion (Challenges faced in Plenary logistics and information management) 3.30­ 4.00 PM WAYFORWARD Plenary

4.00­ 4.30 PM CLOSURE Dr. Sarah

35 Appendix 4

Adherence Counseling Training Report

Date: 30 th ­31 st March 2009

Venue: DHO Conference room

Facilitators: 1. Birungi Josephine Medical Coordinator ­ TASO 2. Ms. Nalubega Rose Counseling Coordinator ­ TASO.

Training Objectives: • Train health workers in adherence counseling • Update health workers on HIV care nationally and globally • Review current ART clinic activities and suggest quality changes. • Train staff on how to establish an appointment system

The attendance of the participant’s was100% and all the above objectives were achieved.

CONTENT Three key areas were identified in order to improve services 1. Adherence counseling

2. Appointment system

3. Motivation of the ART clinic staff

CHALLENGES • Limited knowledge in adherence counseling

• Delayed signing of the reports at the HSD level

• Lack of ART Cards

WAYFORWARD • All clients on ART to be counseled on adherence

• Start monitoring adherence of clients.

• The district to regularly organize refresher trainings at least once a year.

36 List of Participants

Name Designation 1. Dr. Onzima Felix SMO

2. Kalinaki Margaret N/O

3. Kyemba Herbert AHE

4. Baluka Juliet CO

5. Kiboole Marghret E/N

6. Suubi mary N/Assist

7. Namukasa Esther Mutesi Reg. Nurse

8. Asiimwe Annie CO

9. Nangobi Walusa E/Nurse

10. Mufumba Emmanuel PCO/RPN

11. Mbaizwe Yusuf MCO

12. Kigomba James ACO

37 Time Table Adherence Counseling Training

TIME ACTIVITY FACILITATOR 8.30­ 9.00 am Arrival and Registration Rahma

9.00 – 9.30 am Welcome remarks and official Dr. Sarah opening 9.30 – 10.00 am Training objectives Dr. Birungi Josephine

10.00 – 10.30 am Introduction to general counseling Nalubega Rose

10.30 – 11.00am BREAK TEA 11.00­ 1.00 pm Counseling of children Nalubega Rose

DAY TWO

9.00­10.30 pm Appointment system Dr. Birungi

10.30­11.00pm BREAK TEA

11.00 ­12.00 pm Group work Dr. Birungi 12.00­1.00pm Presentations

1.00­2.00 pm LUNCH 2.00 ­3.00 pm Developing Action plans Nalubega 3.30­ 4.00 pm Discussion (Challenges faced in Rahma, Nalubega and Dr. counseling clients and wayfoward Birungi, Dr. Sarah 4.00­ 4.30 pm CLOSURE Dr. Sarah

38