Between HIV diagnosis and initiation of antiretroviral

Between HIV diagnosis and initiation of antiretroviral therapy:

Assessing the effectiveness of care for people living with HIV in the public primary care service in Cape Town

Vera Scott, School of Public Health, University of the Western Cape Virginia Zweigenthal, School of Public Health and Family Medicine, University of

Cape Town Karen Jennings, City Health, City of Cape Town

Published: Tropical Medicine and International Health

Metro/Provincial HAST task team

Juanita Arendse Virginia Azevedo Judy Caldwell Beth Harley Karen Jennings Pren Naidoo Vera Scott Brenda Smuts Alvera Swartz Annie Jansen van Rensburg Virginia Zweigenthal Plus co-opted members Initiated in November 2002 Piloted 2003, 2004, 2006 Annual or bi-annual in all public primary care facilities in Cape Town since 2007

HAST audits

• Initiated in November 2002

• Piloted 2003, 2004, 2006

Lessons learnt fed into programme development

• Annual or 6-monthly in all public primary care facilities in Cape Town since 2007

• Rolled out to other districts in the Western Cape with Provincial support

• Adapted for use in a rural setting in KZN

Purpose

1. To evaluate and to integrate HIV/TB/STI programmes

2. Build the capacity of facility and subdistrict

managers in improving programme management locally

3. To dovetail evaluation tools

Background to article

Scale up of HIV counselling and testing (HCT) and antiretroviral therapy (ART)

But what about routine preART HIV care? Assumption was that it could be absorbed into the existing service platform

No extra resources, little programme support, no routine health information system

Baseline clinical assessment including:

baseline WHO stage

baseline syphilis test

baseline PAP smear (if no normal PAP result in the last three years)

baseline Body Mass Index

Routine visits including baseline visit :

Diagnose and manage any opportunistic infections (and revise WHO staging if

necessary)

Assess reproductive health care (men and women)

Assess condom use and offer condoms in the consultation room

Symptomatic screen for STIs (and syndromic treatment if screen positive)

Symptomatic screen for TB (and investigation if screen positive)

Cotrimoxazole prophylaxis (unless stage 1 with CD4 > 200)

Nutritional assessment (provision of nutritional supplements if the patient qualifies –

BMI < 18.5 or > 10% weight loss or MUAC<23cm)

Social assessment, including support around disclosure

As indicated:

Ongoing counselling (including sexual and reproductive health): at least 3 sessions post

diagnosis, then annually/6 monthly with CD4 result

Repeat of CD4 count – annually if > 350; 6-monthly if <350

Repeat PAP smear every 3 years unless abnormal result dictates earlier repeat

Refer patient for ARVs if necessary – WHO 4 (excluding extrapulmonary tuberculosis) or

CD4 < 200 (CD4 < 250 for pregnant women)

Package of care defined for preART

Objective

To assess the quality of preART HIV care in Cape Town and its continuity with HCT and ART

Methods

• Routine data review

• Facility manager interview

• Observation

• August 2010 routine annual HIV/TB/STI evaluation

• Used the HAST tools:

• Folder reviews

o HCT

o PreART

o ART

o PMTCT (antenatal and labour ward)

o STI

o TB

o Cervical screening

Evaluation domains:

– access to the target population

– availability of key resources and capacity

– quality of care

– integrated care(HIV/TB/STI/Reproductive Health)

– continuity of care

Logistics

• Routine half-day tool training, and planning the audit logistics

• Sub-district TB HIV coordinators organised and led the audit teams

• Team members included facility and local programme managers

• Routine data drawn from management information systems

Facility visits

• Conducted over one month

• Each took approx 3 hours

• Interviewed facility manager

• Assessment of adequacy of equipment in consulting and counselling rooms

• Set of folder reviews: HCT, preART, ART, STI and TB

Folder sampling

• Non probability, 10 folders sampled from each facility for each programme

• Gathering data from 10x 5 sets of folders is achievable

• HCT folders - HCT register starting a date 1 month before audit, working backwards to select 5 HIV +ve and 5 HIV -ve patients

• PreART folders - HCT register, additional criterion that the client had to have attended at least 2 clinical visits after their HIV diagnosis

Analysis

• Data entered in Excel spreadsheets

• Imported into STATA® version 9

• Weighting factor – HCT - district proportion of HCT clients counselled

in each facility

– PreART - district proportion of HCT clients diagnosed positive in each facility

• Calculations of district proportions and confidence intervals for sampled data

Results

Interviews with 133 facility managers

Folder review of 634 HCTs who tested positive

Folder review of 1115 clients receiving preART HIV care were analysed

Data source Indicator

Pro-

portion

(n)

95% CI

Routine register and

population data

% Annual HCT uptake (adults>15 years

HIV tested)

17.8%

(2729297) N/A*

HCT Folder Review

% Positive HCT clients with CD4 counts 77.5%

(634)

73.3%-

81.7%

% Positive HCT clients clinically staged 46.6%

(633)

41.3%-

51.4%

Facility Manager

Interview

% Facilities offering daily preART HIV

services

92.5%

(133) N/A*

Access

Availability of key resources and staff capacity


Pro-

portion

(n)

95% CI

Facility Manager

Interview

% Clinical staff trained in preART care 65.5%

(1307) N/A*

% Facilities with stock outs of

cotrimoxazole

4.5%

(133) N/A*

% Facilities with functional stock

control mechanisms for a basket of

HIV/TB/STI items

82.4%

(114) N/A*


Pro-

portion

(n)

95% CI

PreART Care Folder

Review

% Clients with notes on the customised

HIV stationery

80.4%

(1115)

76.6%-

84.1%

% Clients evaluated for social

assistance

50.1%

(1115)

45.4%-

54.8%

% Clients with Pap smear (women only) 32.2%

(746)

27.2%-

37.2%

Clients with symptomatic TB screen

and appropriate follow up at last visit

67.2%

(1068)

63.7%-

71.7%

Quality of care


Pro-

portion

(n)

95% CI

PreART Care Folder

Review

% Clients with contraceptive needs

assessed (men and women) at last visit

48.3%

(1072)

43.4%-

53.1%

% Clients with symptomatic STI screen

and appropriate follow up at last visit

61.2%

(1104)

56.9%-

66.1%

% Clients with condoms issued at their

last visit

42.5%

(1102)

37.8%-

47.1%

Extent of positive prevention strategies


Pro-

portion

(n)

95% CI

PreART Care Folder

Review

% Clients clinically staged at last visit 45.7%

(1115)

47.1%-

50.3%

% Clients with CD4 monitoring

according to protocol

88.5%

(1115)

85.6%-

91.4%

% Clients with a management plan

noted at last visit

63.9%

(1115)

59.4%-

68.4%

% Clients eligible for ARVs referred

appropriately

47.2%

(525)

38.4%-

65.1%

Continuity of care

Discussion

• PreART care not adequately implemented

• Break in the continuum of care between HCT and ART

• What is the role of preART and what service delivery model is most appropriate?

• Audit is a viable alternative to a register –comprehensive snapshot, especially useful for assessing inputs and processes

• Integrated approach to evaluation

• Sample size - data for each facility or for the sub district

• What should be measured in a quality improvement process?

Acknowledgements

• Cape Town HIV/TB/STI task team who designed the evaluation tools and provided oversight to the audit process.

• Health Department (Provincial Government of the Western Cape) and the City Health Directorate (City of Cape Town) for their vision and commitment

• Sub district HAST teams and facility staff for their energy and professionalism

Documents

Between HIV diagnosis and initiation of antiretroviral