Using quality improvement to accelerate highly active antiretroviral treatment coverage in South Africa

Abstract

Introduction: The authors report on a health systems strengthening intervention using quality improvement (QI) methods at the subdistrict level to accelerate highly active antiretroviral treatment (HAART) initiation in South Africa.

Methods: Using a phased scale-up design between August 2006 and November 2009, 14 primary healthcare clinics, one community health centre, one district hospital and one tertiary hospital in a subdistrict were recruited into a 'learning network' using QI methods to facilitate cross-facility learning/mentorship/support. Clinic teams consisting of nurses, counsellors, clerks and/or doctors set collective and individual performance targets, analysed their care systems using 'real-time' data feedback, and designed/implemented a set of simple changes to improve HIV testing and HAART initiation rates across the region.

Data analysis: Primary clinic data were used to measure HAART initiation rates (primary outcome) and HIV testing (secondary outcome). We analysed data variation/trends using an interrupted time series design. Logistic regression analysis was applied to examine trends in HAART initiation during the intervention phases.

Results: Clinics in the learning network increased HIV testing by 301.8% from 891/month (SD=94.2) to 3580/month (SD=327.7) (p<0.0001). Monthly HAART initiations increased by 185.5% from 179/month (SD=17.22) to 511/month (SD=44.93) (p<0.0001). During the pilot (phase I), the monthly rate of HAART initiations increased by 3.6 patients. In the prototype collaborative (phase II), there was no acceleration in the rate of increase (3.3/month, p=0.92). Significant acceleration was observed in the rate of increase during the QI scale up (phase III) (10.1/month, p<0.001). The proportion of estimated need for HAART met in the region increased from 35.8% to 72.4% at a time of rapid population growth.

Conclusion: A QI approach, using learning networks to teach simple data-driven methods for addressing system failures, with increased training and resource inputs, can assist districts to quickly reach universal coverage targets.

Conflict of interest statement

Competing interests: None.

Figures

Figure 1

Breakthrough Series Collaborative design—timeline and sequence of activities and support for the Inner City of Johannesburg, Region F. CHC, community health centre; PHC, primary healthcare clinic.

Figure 2

Sequential HIV processes of care and average data performance per month over last 6 months (June–November 2009); used by clinics to identify process steps in need of focused improvements. ARV, antiretroviral.

Figure 3

Sequence of activities and changes leading to increased HIV testing from May 2006 through November 2009 in Inner City Johannesburg, Region F. Green line represents regional HIV testing target, recalculated in October 2008 with increase in estimated population. PITC, provider-initiated testing and counselling.

Figure 4

Control chart on monthly highly active antiretroviral treatment (HAART) initiations for August 2004–November 2009 demonstrating the impact of additional clinics providing testing. Quality improvement (QI) intervention both contributed to the increased average initiation and improved performance across the system. The scale up of HIV testing led to a moderate limited increase in initiation, and was a prerequisite for the large increase seen in 2008 and 2009, accelerated by the expansion of QI efforts; 1=start of phase I: pilot to improve flow at sole antiretroviral (ARV) site; 2=community health centre (CHC) joins pilot; 3=seven primary healthcare clinics (PHCs) start HIV testing; 4=start of phase II: prototype regional health systems strengthening intervention, first learning session (seven PHC HIV testing sites, two HAART initiation sites); third site starts HAART initiation; 5=scale up of HIV testing sites begins (three additional sites); 6=start up of phase III: scale up of regional collaborative, Learning Session; scale up of HIV testing sites ends, all 14 PHCs testing and part of intervention; down referral starts; 7=multiple, constant changes to processes leading to sustained new level of performance. LCL, lower confidence limit; UCL, upper confidence limit.