The national HIV prevalence rate in Uganda is 6.7%, with the highest prevalence rates among women and people in the prime reproductive ages of 30-34. At Fort Portal Regional Referral Hospital, located Kabarole District, approximately 375 pregnant women attend the antenatal care (ANC) clinic for the first time each month. Nearly all of these women receive provider initiated HIV counseling and testing services as part of the package of services to prevent mother to child transmission of HIV. In 2011, the HIV prevalence rate among these women was 11%.
Although the uptake of counseling and testing services in the ANC clinic is an opportunity to identify and enroll HIV infected women into care and treatment services, in July – September 2011, only 1% of women who tested HIV positive were enrolled into chronic care services for long-term follow-up and support; and 20% assessed for eligibility for initiation on antiretroviral treatment (within the ANC clinic), using WHO clinical staging guidelines or CD4 count.
Healthcare workers at Fort Portal Regional Referral Hospital identified several factors contributing to the low enrollment into care and assessment for eligibility for treatment including: weak intra-facility linkages and referral systems between HIV entry points in ANC, maternity, labor, and post-natal wards and the HIV chronic care clinic; poor documentation; lack of designated person responsible for ensuring that HIV infected mothers were enrolled into care; and a misconception that enrollment into care required a CD4 test (i.e. women were not enrolled when the test was unavailable).
In December 2011, the clinical team identified several locally appropriate and feasible changes to improve their performance, including:
- Review and discussion of quarterly data through meetings with all stakeholders to identify gaps in performance
- Weekly interdepartmental review meetings to promote team-based problem solving across multiple service delivery points and monthly case conferences.
- Reorganization of the clinic flow: A qualified nurse and a volunteer were designated to escort newly diagnosed HIV infected pregnant mothers from the antenatal clinic, maternity ward, postnatal care clinic, and early infant diagnosis point of care to the HIV chronic care clinic. Two nurses in the HIV chronic care clinic were designated to receive the escorted mothers, attending to them shortly after arrival to avoid creating additional waiting time for these women.
- Use of a linkages register to document when newly diagnosed HIV infected pregnant mothers are received at the HIV chronic care clinic. Referral forms and HIV counseling and testing registers were provided to all service delivery points. These tools were utilized to proactively track performance on a weekly basis.
- Skills strengthening through training, mentoring and coaching for ANC and HIV Chronic Care Clinic service provider teams to effectively provide a continuum of services for HIV infected pregnant mothers and their exposed infants, from diagnosis to care, treatment and subsequent continued follow-up and monitoring.
As a result of data review and initiation of improvement changes in December 2011, both assessment for eligibility for antiretroviral treatment and enrollment into care for HIV positive women markedly improved:
- In January to March 2012, 129 of the 154 women who tested HIV positive in ANC clinic and maternity ward were enrolled into care at the hospital. This achievement of 84% enrolled into care was a marked improvement from only 1% in the July - September, and 20% in October – December 2011 quarters.
- In addition to the 84% enrolled into care at the hospital, 12.2% were referred to or already enrolled in HIV care at nearby health care facilities where they preferred to receive care. Only 2.3% chose not to be enrolled. Thus, only three out of 154 women who tested HIV positive were unaccounted for in the January – March 2012 quarter.
- Assessment for eligibility for initiation of antiretroviral treatment using WHO clinical staging or CD4 test (within the ANC clinic) also increased from 20% in July to September 2011 to 75% in January – March 2012. Subsequently, 47 of the women who tested positive for HIV were initiated on ART for their own health.
Teamwork, regular review of performance data, and identification of feasible, locally available solutions can result in significant improvement in performance. The package of interventions utilized at Fort Portal Regional Referral Hospital will be shared, adapted and replicated for other hospitals implementing HIV/AIDS service delivery.