Methodology to Plan-Do-Study-Act closes gaps in the HIV treatment cascade
The HIV treatment cascade is a series of steps that people living with HIV take to suppress the virus. The cascade, also referred to as the HIV care continuum, begins with testing and diagnosis and continues with linking patients to care, keeping patients engaged in their treatment and retaining them in treatment. One challenge faced by HIV programs is strengthening the treatment cascade through reducing the gaps between steps, so that more people attain viral suppression.
As a part of our Clinical and Community HIV/AIDS Services Strengthening (CHASS) project in Mozambique, FHI 360 is improving the number of patients who access appropriate services along the HIV continuum of care and are retained in treatment. The project found that a major gap was in patient enrollment: Approximately 50 percent of newly identified HIV patients never enrolled in care. One idea to increase the percentage of patients who enroll in care was to escort them to the sites where they receive antiretroviral therapy (ART).
To improve enrollment rapidly, CHASS applied the Plan-Do-Study-Act (PDSA) methodology to test and adapt several change ideas. This methodology tries potential solutions on a small scale through four steps in cycles that increase learning and improvement with each cycle:
- Plan a change
- Do try it out on a small scale
- Study the results
- Act to make necessary changes
The project team performed multiple PDSA cycles in six high-priority health facilities in 2016. In the first cycle, case managers escorted a few HIV-positive patients, identified in a voluntary counseling and testing unit, to the sites where they receive ART. In the next cycle, the project team tested and analyzed additional solutions that included having the case managers open patient charts at testing sites, allowing patients to avoid long waits to get ART. Another cycle connected newly diagnosed patients with counselors to help them accept the diagnosis before seeing a clinician to discuss treatment.
In later cycles, the team formalized the patient escort process and scaled it to other health facilities. They also scaled it to other units, such as pediatric and adult triage. In one facility, the enrollment rate of patients in HIV care increased from 60 percent to 78 percent. All the sites that now use patient escorts showed substantial improvements in ART enrollment.
CHASS is continuing to use the PDSA approach to test ideas to close other gaps in the HIV treatment cascade, such as retention in care. These ideas will focus on reducing consultation waiting times and improving patient flow (how patients navigate a health facility and how long the wait time is at each point of interaction).
CHASS works in nearly 400 health facilities in the Mozambique provinces of Manica, Niassa, Sofala and Tete, providing technical assistance and mentorship to support the delivery of quality, integrated HIV/AIDS services and to strengthen the health system. Applying the PDSA methodology across multiple facilities enables the project to accelerate improvement across the HIV care continuum, ensuring that the right interventions are done at the right time in the right places and help more patients benefit from HIV services.
Photo credit: Jessica Scranton/FHI 360