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Background: Scaling up continuous quality improvement (CQI) processes could be key in achieving the 95:95:95 cascade and global HIV targets. This paper describes the experiences and outcomes related to implementing CQI processes to help reach these targets, with particular focus on clinical and programmatic settings in 6 countries from the global south.Methods: The HIV program at the University of Maryland, Baltimore (UMB) implemented an adapted CQI model in Kenya, Tanzania, Botswana, Zambia, Nigeria and Rwanda that included the following steps: (1) analysing the problem to identify goals and objectives for improvement; (2) developing individual changes or 'change packages', (3) developing a monitoring system to measure improvements; and (4) implementing and measuring changes through continuous 'plan-do-study-act' (PDSA) cycles. We describe country-level experiences related to implementing this adaptive design, a collaborative learning and scale-up/sustainability model that addresses the 95:95:95 global HIV targets via a CQI learning network, and mechanisms for fostering communication and the sharing of ideas and results; we describe trends both before and after model implementation.Results: Our selected country-level experiences based on implementing our CQI approach resulted in an increased partner testing acceptance rate from 21.7 to 48.2 % in Rwanda, which resulted in an increase in the HIV testing yield from 2.1 to 6.3 %. In Botswana, the overall linkage to treatment improved from 63 to 94 %, while in Kenya, the viral load testing uptake among paediatric and adolescent patients improved from 65 to 96 %, and the viral load suppression improved from 53 to 88 %.Conclusions: Adopting CQI processes is a useful approach for accelerating progress towards the attainment of the global 95:95:95 HIV targets. This paper also highlights the value of institutionalizing CQI processes and building the capacity of Ministry of Health (MoH) personnel in sub-Saharan Africa for the effective quality improvement of HIV programs and subsequent sustainability efforts. [ABSTRACT FROM AUTHOR]

Building capacity in implementation science within health programs is dependent on training in theory and practice of epidemiology, statistics, and research in addition to high self-efficacy toward application of training. This article describes a training program providing technical assistance to more than 300 health facilities in Kenya and Tanzania, its evaluation results, and its ability to improve participants' knowledge, competencies, and self-efficacy on data management, analysis, and dissemination among health care professionals. Two months prior to the training, participants (n = 98) were emailed a pre-course survey including 19 questions using a Likert-type response for planning the content of the workshop. Six to 12 weeks after the training, a post-course survey was emailed to all participants. Five different trainings were conducted indicating 5 participant cohorts. The questions posed involved course satisfaction, course impact on knowledge and skills, and self-efficacy in data analysis and utilization. Post-course survey results revealed that the participants had confidence in data analysis, which was significantly different from the pre-test results (0.05 α). Qualitative commentary complemented the findings of the impact of the workshop. Four manuscripts and 13 abstracts have been submitted post training. Results suggest that a short-term training program can achieve immediate gains in data and research self-efficacy among health care professionals. Although increasing self-efficacy is a necessary first step in developing skills, educators should engage in continuing education for sustainable dissemination practices. There is an urgent need to determine the current infrastructure to promote scientific dissemination. This will assist countries to produce better evidence to support their programs, policies, and overall health programs. [ABSTRACT FROM AUTHOR]

Background: Late initiation of treatment for illness secondary to the human immunodeficiency virus (HIV) remains a major challenge in developing countries. Despite the World Health Organization (WHO) recommendation that treatment be initiated early in disease management, health providers conducting quality improvement monitoring in one region of Tanzania noted that common management practice relies upon clinical signs of advanced disease alone for initiation of combination antiretroviral therapy (ART). Although Tanzanian National Treatment Guidelines followed standard WHO recommendations, few patients initiated ART based on laboratory parameters. As a potential barrier to optimal patient outcomes, further investigation of this inconsistency led to recognition of challenges reflecting patient, healthcare staff, and laboratory levels that might inhibit the use of CD4 cell counts as the entryway to care. Materials and Methods: Using a quality improvement approach, investigations were pursued for six discrete activities of HIV care delivery with before and after measures of selected indicators. With respect to patient engagement, meetings and informal educational sessions were held to promote understanding of the meaning of and need for CD4 testing. For clinic staff: (1) Qualitative interviews were conducted with providers to understand why laboratory data was not being used and (2) on-site interviews were conducted with laboratory personnel to review beliefs, methods, and practices related to measurement of CD4 cells testing. A large scale local campaign was mounted to (1) educate and empower patients to recognize a need for CD4 information in management of their own care; (2) re-educate and encourage providers to use measured, rather than clinical observation alone to initiate ART; and (3) understand and resolve clinical and laboratory challenges. Based upon findings from the interviews: (1) Meetings with hospital administrations were effected to resolve institutional barriers to using CD4 cell testing. Specific on-site training was initiated for both providers, with regard to use of CD4 cell counts, and nurses, with advanced training to initiate routine CD4 testing. These activities were well received because all staffwere able to review unlinked, site-based clinical data to appreciate gaps in a local care. Results: The number of CD4 samples obtained and recorded increased by 114% between May and October 2007 at targeted health facilities. ART enrollment increased by 62% between June and September 2007 without other significant change in care delivery. The median baseline CD4 at enrollment increased from 110 cells/mm3 in June to 150 cells/mm3 in September. Overall retention rate was 77% for 13,333 HIV patients enrolled in seven facilities. In September 2013, the cumulative 6-year overall retention rates are 77% for 53,040 patients enrolled in 42 health facilities in the region. Obstacles were addressed and community empowerment techniques used to stimulate change in established clinical behaviors. Conclusion: This "Know your CD4 campaign" initiative resulted in increased uptake of CD4 testing, treatment initiation and an unanticipated improvement in patient retention. With attention to patient, staff, and laboratory elements in resource-poor settings, decline in immune function and morbidity may be reduced and viral suppression prolonged. Empowering patients to be involved in their own care resulted in better overall adherence with HIV management. Local use of reviewed data can impact overall effectiveness of HIV care delivery. Simple quality improvement approaches impact sustainable change. [ABSTRACT FROM AUTHOR]

Background: Studies have identified several programmatic and nonprogrammatic indicators that affect adherence to highly active antiretroviral therapy (HAART). Depression has been shown to impact adherence to HAART. This cross-sectional analysis of data collected from Nigeria, Uganda, Zambia, and Tanzania in 2008 examined the relationship between levels of depressive symptoms, clinical progression, and adherence to HAART.Methods: A multinational, multicenter, observational, retrospective cross-sectional evaluation of a population of focus comprised randomly selected patients on HAART. The dependent variable was adherence to HAART. The primary variable of interest to be assessed was patients' level of depressive symptom score. A multivariable logistic regression model was used to examine the relationship between explanatory variables and adherence to HAART.Results: A total of 2344 patients were recruited for adherence survey. About 70% of the study sample reported having some level of depression. Logistic regression results show that patients who reported, respectively, low, moderate, and high levels of depressive symptoms are 35% (P < .001), 56% (P < .001), and 64% (P < .001) less likely to adhere to HAART than those who reported having no depressive symptoms. At multivariate analysis, adherence to HAART was independently associated with the levels of depressive symptoms, older age, CD4 count >200 cells/mm3, Truvada (tenofovir [TDF]/emtricitabine [FTC])-based regimens, good knowledge about HAART, and longer period on therapy.Conclusions: These results indicate that mental health and clinical parameters are significant factors in determining patients' adherence to their HAART, which need to be more aggressively addressed as a critical component of care and treatment support. [ABSTRACT FROM AUTHOR]

The article reports on research which was conducted to investigate the effect depressive symptoms and CD4 count had on adherence to highly active antiretroviral therapy (HAART) in HIV-positive patients in sub-Saharan Africa. Researchers evaluated the adherence patterns of 2,344 patients. They found that adherence to HAART was independently associated with the levels of depressive symptoms, older age, a CD4 count of >200 cells/mm3, knowledge about HAART and a longer period on HAART.