Implementation of the 90-90-90 Strategy at SUSTAIN Supported Health Facilities

USAID/SUSTAIN supports the Ministry of Health, Uganda (MOH) to offer quality HIV services at 11 regional referral hospitals and one general hospital. In 2014, the MOH adopted the UNAIDS 90-90-90 strategy that aims to have 90% of all people living with HIV know their HIV status, 90% of all people with diagnosed HIV infection receive sustained antiretroviral therapy, and 90% of all people receiving antiretroviral therapy attain viral suppression, by 2020.

Strategies implemented to achieve the target include use of quality improvement approaches, ongoing onsite supervision and mentorship, and supply chain systems support to ensure availability of supplies.



First 90: Ensuring all people living with HIV know their status

The introduction of provider-initiated testing and counselling (PITC) in 2012, with the involvement of facility nursing staff under the supervision of the senior principal nursing officers, improved the number of clients accessing HTC services. In 2015, USAID/SUSTAIN—following new guidelines—changed the testing strategy in order to identify and link greater numbers of people living with HIV to early treatment and care. 

Through quarterly onsite mentorships, the project has mentored facilities to provide HIV testing and counseling (HTC) services that target high-yield areas, especially in patient wards (medical in-patient, TB and nutrition units, children’s wards and key populations). Also, HIV-positive people’s partners and children are targeted for HTC to reach those most at risk and diagnose people early. Through inter-facility meetings, hospital staff analyze and harmonize HTC records in order to improve the linkage of newly-identified clients to care at their chosen facility. This includes using QI interventions, such as:

  • Introducing volunteer linkage facilitators, who routinely physically escort newly diagnosed HIV-positive clients to HIV clinics for enrolment;
  • Providing a second in-depth post-test counselling session to support decision making; and
  • Conducting linkage meetings between various entry/HIV testing points and HIV clinic teams.

Second 90: Expanding quality treatment for all people living with HIV

Using the test-and-treat approach, the project aims to close the gap between clients in care and those on ART for adolescents under 15 years. Interventions include initiating treatment for all children under 15 years, irrespective of CD4 and viral load results, and all positive pregnant women.

Strategies to maximize the proportion of clients in care that are active on ART include supporting facilities to periodically provide a baseline CD4 and one every six months thereafter for clients in care. Clients identified as eligible for ART are notified and given an appointment for enrolment into treatment. A clinic database and file reviews ensures that clinics follow up with eligible clients for enrolment on ART. In addition, triage teams/nurses have been empowered with the skills to requisition for Viral Loads and CD4s, without clinicians’ input.

Third 90: Viral suppression for clients on ART

To support improvement in viral suppression, efforts have focused on identifying early-warning indicators of treatment failure during the project’s ongoing quarterly mentorships and performance reviews. These indicators include prescribing practice, loss to follow up, client retention in care, appointment keeping, and availability of appropriate regimen. Additionally, the project has emphasized support for children, due to the persistent low suppression rates nationally within that cohort.