If you text them, they will come: using the HIV infant tracking system to improve early infant diagnosis quality and retention in Kenya

Abstract

Objective: The objective of this study is to evaluate the impact of the HIV Infant Tracking System (HITSystem) for quality improvement of early infant diagnosis (EID) of HIV services.

Design and setting: This observational pilot study compared 12 months of historical preintervention EID outcomes at one urban and one peri-urban government hospital in Kenya to 12 months of intervention data to assess retention and time throughout the EID cascade of care.

Participants: Mother-infant pairs enrolled in EID at participating hospitals before (n = 320) and during (n = 523) the HITSystem pilot were eligible to participate.

Intervention: The HITSystem utilizes Internet-based coordination of the multistep PCR cycle, automated alerts to trigger prompt action from providers and laboratory technicians, and text messaging to notify mothers when results are ready or additional action is needed.

Main outcome measures: The main outcome measures were retention throughout EID services, meeting time-sensitive targets and improving results turn-around time, and increasing early antiretroviral therapy (ART) initiation among HIV-infected infants.

Results: The HITSystem was associated with an increase in the proportion of HIV-exposed infants retained in EID care at 9 months postnatal (45.1-93.0% urban; 43.2-94.1% peri-urban), a decrease in turn-around times between sample collection, PCR results and notification of mothers in both settings, and a significant increase in the proportion of HIV-infected infants started on antiretroviral therapy at each hospital(14 vs. 100% urban; 64 vs. 100% peri-urban).

Conclusion: The HITSystem maximizes the use of easily accessible technology to improve the quality and efficiency of EID services in resource-limited settings.

Conflict of interest statement

Conflicts of interest

We declare no conflicts of interest.

Figures

Fig. 1. HITSystem targets eight time-sensitive steps in the early infant diagnosis cascade of care

Once enrolled, the infant’s date of birth is used to ensure that alerts for steps 1, 2, 7 and 8 occur by the designated infant age. Alerts for steps 3, 4, 5 and 6 are sent when steps have not been completed within the specified time interval, for example if an infant testing positive for HIV has not initiated ART within 2 weeks of mother notification. The alarm clock on the left of each box indicates the time-sensitive window that triggers electronic alerts requesting subsequent action to resolve them. The tab below each box indicates the location/responsible party for each step of the EID cascade of care. The loop on the left demarks the need for confirmatory PCR testing following all reactive antibody tests conducted at 9 and 18 months. Infants who test HIV-positive at any point in the cascade are initiated on ART. Infants confirmed HIV-uninfected at 18 months (or 6 weeks after breastfeeding cessation) complete and exit the HITSystem.

Fig. 2. HITSystem Dashboard Alerts

This is the first screen that appears when a hospital logs into the HITSystem. The dashboard alerts in the red box are updated in real time and notify EID providers when time-sensitive interventions are overdue. For example, 16 mothers have not yet been informed of their infants’ PCR test results. This alert is triggered if the mother has not been notified within 2 weeks of the laboratory posting the PCR test result. Alerts for retest of infants who initially test HIV-negative are displayed on the top right hand corner. These alerts are triggered by the infant’s age corresponding to the Kenya guidelines for retesting at 9 and 18 months.

Fig. 3. Retention of mother–infant pairs at each point in the early infant diagnosis cascade of care

These data illustrate changes in the number of mother–infant pairs retained between historical controls and during the HITSystem intervention at the urban (3A) and peri-urban (3B) hospitals. The y-axis represents percentage of mother–infant pairs retained at each sequential point along the EID cascade of care (x-axis). Raw numbers are listed within the bar graph for each outcome, and the denominators reflect numbers eligible for each subsequent step in the cascade. All comparisons in 3A are significant at P <0.001. The following symbols illustrate the level of statistical significance in 3B:* P <0.05, **P <0.01, ***P <0.001.