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Interventions in Uganda Lead to Dramatic Increases in Chronic Care Enrollment for HIV-Positive Mothers
At Fort Portal Regional Referral Hospital (RRH) in Uganda, almost all women attending the antenatal care (ANC) clinic were receiving HIV/AIDS counseling and testing services, but only 1% of HIV-positive women were enrolling into chronic care services in September 2011. The USAID-funded Strengthening Uganda's Systems for Treating AIDS Nationally (SUSTAIN) project, managed by University Research Co. LLC , helped increase the enrollment rate to 96% in only 6 months.
SUSTAIN determined that the gap between women testing positive for HIV and enrolling into chronic care was due to several factors:
- A weak referral system between maternal and neonatal care entry points and the HIV/AIDS chronic care clinic,
- Poor documentation of women who received counseling and testing services,
- Lack of designated personnel responsible for ensuring that infected mothers were enrolled into care, and
- A misconception that additional testing was needed to enroll mothers into chronic care.
To address these factors, SUSTAIN aided the clinical team in assessing ways to improve the system so that more mothers would enroll. The team at Fort Portal RRH implemented a few changes that were likely responsible for the major difference for HIV-positive mothers at the hospital:
- Use of a linkages registry, referral forms, and counseling and testing registries to document the referral of newly diagnosed, HIV-positive pregnant women to the HIV/AIDS chronic care clinic and to track weekly performance;
- Strengthening of skills through training, mentoring, and coaching for teams providing ANC and HIV/AIDS care services to enable an effective continuum of services for HIV-positive pregnant women and their exposed infants;
- Designation of personnel to escort HIV-positive pregnant women from the maternal or perinatal point of care to the HIV/AIDS chronic care clinic;
- Review of quarterly data through meetings with stakeholders to identify gaps in performance; and
- Promotion of team-based problem solving through weekly interdepartmental review meetings and monthly case conferences to address individual cases of non-enrollment.
After the team implemented these changes, the rate of HIV-positive mothers enrolled in chronic care rose from 1% (July–September 2011) to 84% (January–March 2012) at the hospital. An additional 12% of HIV-positive mothers were enrolled in HIV/AIDS care at nearby health facilities. Furthermore, the percent of HIV-positive mothers assessed for antiretroviral therapy eligibility increased from 20% (July–September 2011) to 75% (January–March 2012).
One HIV-positive mother described her experience at the clinic after the SUSTAIN interventions: "It's a great honor and a privilege [to be escorted]. You know the nurse. You have someone to talk to as you are seen at the clinic. Your fears of being HIV-positive are calmed down. You get the confidence and strength to move on despite being [HIV-]positive."
The experience at Fort Portal RRH shows that teamwork; regular review of performance data; and identification of feasible, locally available solutions can result in significant performance improvement for hospital teams. The interventions used at Fort Portal RRH will be shared, adapted, and replicated for other hospitals providing HIV/AIDS services in Uganda.
July 24, 2012