RESPOND Quality Improvement Collaborative to Strengthen HIV-Services in the Kyiv Region, Ukraine Regional Cross-Sectional HIV Service Cascade (2015, 2016, and 2017) Progress against UNAIDS '90-90-90' targets, 2015-2017 Kyiv region 9 000 90% of PLHIV 90% of PLHIV 90% of PLHIV 8 000 know their HIV-status who know their HIV-status, who receive ART, 8 000 7 000 are on ART have undetectible VL 7 000 7 700 6 930 7 430 6 543 6 687 6 000 7 270 80% 6 237 6 000 5 889 6 018 5 613 73% 6 150 82% 5 300 5 416 5 000 5 000 66% 5 393 4 833 73% 5 053 4 000 4 000 70% 60% 3 914 3 000 3 000 3 371 40% 46% 3 660 58% 2 000 2 000 2 504 1 950 47% 2 139 1 000 1 000 н/д 1 175 0 0 Estimated number Officially registered On active follow-up: On ARTVL<1000 copies/mL of PLHIV (SPECTRUM) 1≤ visit per year Collaborative Scale: © Public Health Center of MOH of Ukraine; as of Jan 1, 2015 as of Jan 1, 2016 as of Jan 1, 2017 USAID RESPOND, 2017 • 19 QI sites out of total 24 ART sites in the region COLLABORATIVE GOAL • Five NGO partners: ‘Network 100% life. Kyiv To strengthen the continuum of HIV prevention, testing, linkage, care and Region’, ‘Convictus Ukraine’, ‘Alliance.Global’, treatment services for PLHIV ‘Vertical’, and the AIDS Healthcare Foundation Objectives (AHF) • Increase to 90% the proportion of PLHIV who know their status • Implementation Period: • Increase the proportion of PLHIV in active follow up January 2016 – September 2017 • Increase to 90% the treatment coverage for PLHIV • Increase to 90% the proportion of PLHIV on ART with undetectable viral load HIV TESTING GAP LINKAGE TO CARE GAP TREATMENT GAP Reasons for the Gap: Reasons for the Gap: Reasons for the Gap: • Lack of motivation for specialty physicians and PHC providers to provide HIV • Understaffing of ART sites • Understaffing of the Trust Offices/ART sites testing services (HTS) to key populations • Poor patient motivation • Poor access to medical services due to inadequate transport connection between • Delays in rapid HIV test kit supplies • Lack of NGO presence at some ART sites the territories in the region • Stigma and discrimination towards PLHIV • • Poor access to HIV services in some localities in the region (shortage of ART sites) Poor patient adherence to ART • Poor awareness on HIV infection among the general population • • Long waiting time for confirmatory ELISA result Possible inconveniences related to the ART regimen (frequency, number of pills) QI Changes: • Excessive work load on ART site physician • HIV risk assessment by specialty physicians and/or PHC providers QI Changes: QI Changes: • HIV testing with two rapid tests or ELISA by specialty physicians and/or PHC • Administer the required lab tests (confirmatory ELISA, CD4 and blood chemistry) over one providers patient visit to the Trust Office/ART site • Initiate and manage ART at ART sites • Make HTS info materials available for physicians and patients • Extend/adapt the working hours of Trust Offices/ART sites • Transfer ART patients from AIDS Centers to local ART sites • Implement a patient tracking system (vouchers, coupons or invitations) • Transporting biomaterial to the lab more frequently • Manage ART stock at ART site • Provide escorting to patients by medical staff • Return lab results (CD4 and viral load) to ART sites through the Internet • Provide phone calls and home visits to patients who missed their appointments at • HTS for sexual partners of PLHIV • ART site (quality assurance) • Assess behavioral risks and clinical indicators, and provide HTS for in-patients Provide reminder text messages, phone calls or letters to patients • within the first three days of hospitalization • Provide active home visits by medical and social service providers Optimize ART dispensing practices/Dispense three to six-month supply of ART • Double coding during HTS to ensure identification of PWID • Register in-patient PLHIV with AIDS service before they are discharged from the hospital NGO Intervention: • Task shifting on HTS between doctors and nurses • ‘Strengthening the Continuum of HIV Services at ART Sites’ – • NGO Intervention: Medical provider-initiated HTS NGO ‘Network 100% Life’ • External quality assessment of HTS with rapid tests • ‘Strengthening the Continuum of HIV Services at ART Sites’ – NGO ‘Network 100% Life’ NGO Interventions: SUCCESSFUL QI CHANGES IN TREATMENT • ‘Strengthening the Continuum of HIV Services at ART Sites’ – INITIATE AND MANAGE ART AT ART SITE NGO ‘Network 100% Life’ Activities: • ‘PWID Sexual Partner Health’ – NGO ‘Convictus Ukraine • Training for infectious disease doctors of ART sites on initiation of ART, preventing/ • Interventions for MSM within the Global Fund project – SUCCESSFUL QI CHANGES IN LINKAGE TO CARE overcoming side effects, and record keeping NGO ‘Alliance.Global’ PROVIDE REMINDER TEXT MESSAGES, PHONE CALLS OR LETTERS TO • Supplies of rapid HIV tests for ART sites and specialty healthcare services – AHF • Doctors from the regional AIDS Center assigned to provide mentor support to infectious PATIENTS disease doctors from ART sites on complicated cases and record keeping SUCCESSFUL QI CHANGES IN HIV TESTING Activities: • New ART sites opened • Introduced a calendar form to schedule patient appointments and a reminder system (via HIV TESTING WITH TWO RAPID TESTS OR ELISA BY SPECIALTY • Developing a plan of ARVs supplies to ART sites PHYSICIANS AND/OR PHC PROVIDERS text messages/phone calls/reminder letters) • • All the newly diagnosed PLHIV are initiated on ART; complicated cases discussed Activities: Monthly monitoring of the reminders made and the patients who visited the doctor after being reminded through the Skype conferences/phone calls • Training for specialty physicians on HCT and using of rapid tests • To officially approve the reminder procedure, an item on phone calls/text messages to the • Total number of ART patients at the ART site of the Bila Tserkva Central Rayon Providing specialty physicians with job aids on HTS patient was added to the informed consent form Hospital, Kyiv region, Sep 2016 -Jul 2017 50 50% • HTS with rapid tests by specialty physicians 45 46 • Quality monitoring of HTS with rapid tests Number and proportion of PLHIV who received reminder phone call and returned to active follow up, Kyiv region, 12 ART sites, 2016 • 414 40 40% Monthly quality assessment of HTS with rapid tests performed by specialty 395 378 389 physicians and quarterly analysis of number of people tested and proportion 39% 359 356 369 32 32 between the true and false result interpretations 32% 30 26 27 30% 288 25 31% 31% Number of people referred for HTS by specialist, tested positive, 282 276 and HIV detection rate, Kyiv region, 19 ART sites, 2016 25% 24% 19 100% 390 400 20 20% 25% 22% 22% 75% 300 22% 22% 22% 22% 179 165 21% 13 18% 19% 19% 50% 196 200 18% 17% 111 10 8 14% 10% 25% 100 46 86 90 43 36 38 79 79 83 9% 7 4 28 16 8 1 72 73 69 3 5 16 58 0% 0 0 45 52 0 0% 6% 0 0% Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Total number of people referred for HTS by specialist 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 Number of people tested positive for HIV Detection rate JanuaryFebruaryMarch AprilMay June July August SeptemberOctober November December Number of ART patients Proportion of ART patients Number of PLHIV who received reminder phone call Number of PLHIV returned to active follow up Total number of PLHIV identified with provider-initiated HTS, Bila Tsekrva city, Kyiv region, Nov 2015 -Aug 2017 Proportion of PLHIV returned to active follow up TRANSFER ART PATIENTS FROM AIDS CENTERS TO LOCAL ART 35 SITES 30 31 25 24 24 22 22 Activities: 20 20 20 21 18 17 15 14 14 14 15 13 13 12 13 • Analyzing the registry of patients within the regional AIDS Center and identifying those 10 10 10 10 PATIENT SURVEY RESULTS FROM 19 ART SITES IN THE KYIV REGION, 8 5 JANUARY 2016 (141 PEOPLE) AND JULY 2017 (204 PEOPLE) who may be transferred to local ART sites 0 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug 2015 2015 2016 2016 2016 2016 2016 2016 2016 2016 2016 2016 2016 2016 2017 2017 2017 2017 2017 2017 2017 2017 • New ART sites opened Proportion among patients tested for HIV in the last 6 months (%), Kyiv region • Preparing documentation to transfer ART patients to local ART sites MEDICAL PROVIDER-INITIATED HTS • Transferring ART patients to local ART sites Activities: I received consultation or support of social worker 95,6 • Training for healthcare practitioners on clinical indications for HTS, risk behavior 93,7 Number of ART patients transferred from the regional AIDS Center to local ART sites, screening, and HCT I received clear advice regarding the next steps 100 Kyiv region, 17 ART sites, Sep 2016 -Sep 2017 • Healthcare practitioners provided with job aids to conduct risk behavior screening 98,5 40 • Developing/updating local protocols and patient pathways to ensure the role of 36 I received clear explanation of HIV test results 95,8 96,8 35 31 specialty physicians in HTS 29 29 30 Number of patients received provider-initiated HTS, 70 I received HIV test results in the day of testing 25 ART site of the Fastiv Rayon Central Hospital, 2016 - 2017 85,1 25 22 19 250 20 QI 209 I received test at the convinient time 94,6 17 194 15 200 176 89,1 156 15 149 135 10 150 I received test at a conveniently located 98 89,5 10 100 health facility 85,5 5 50 5 2 I received test on HIV in the day of the first visit 82,5 0 0 96,7 0 Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Round 1 Round 2 2016 2016 2016 2016 2017 2017 2017 2017 2017