Making Viral Load Monitoring Routine within ART programmes - - PowerPoint PPT Presentation

Making Viral Load Monitoring Routine within ART programmes

Presented by Dr.Henry Sunpath MEDICATE –AIDS NPC Consultant ETHEKWINI HIVVL&DR PROJECT CAPRISA ACC PROGRAM

• n behalf of the TEAM

Kogie Naidoo, Rochelle Adams, Kevi Naidu, Penny Msimango,Mary Mogashoa 07 September 2018

Background

• Since 2014, the landscape of HIV patient

monitoring has changed VL testing has replaced CD4 for monitoring Antiretroviral treatment response

• Low uptake of routine VL testing despite policy

and access

• <40% VL testing coverage since 2014

among eligible patients

• Lack of awareness among patients and

HCW

• Insufficient systems at facility level to ensure

regular and timed testing

Question 1

• What are the key steps in a quality improvement

program

• A. Root cause analysis and ongoing education and

development

• B. Root cause analysis and stakeholder strategy
• C. Root cause analysis ,stakeholder strategy and
• ngoing education and development

Q2.Define VL completion rate

• Proportion of adults in the 12 month cohort, still on

treatment who had Viral load test done in the last year

• Proportion of adults in the 12 months cohort who

should have been on treatment who had a VL test done in the last year

Q3.When is the repeat Vl done after the first high VL >1000 copies/ml

• 1. Visit 2
• 2.Visit 3
• 3. Visit 4

• Q4. Which intervention will impact

most on the reporting of VL completion rate

• 1. NHLS reports
• 2. Improving entry of VL results onto clinical charts
• 3. Ensuring that data capturing takes place daily
• 4. Triangulation of NHLS –clinical records in the

charts and Tier data

• 5. None of the above

Q5.Which factor affects the Tier recording of VL data most adversely

• 1. Problems with the computers
• 2. Problems with the data capturers
• 3. Poor records in the clinical charts
• 4.NHLS failure to provide results timeously

• Q6. Which steps are needed on a

list of quick wins to rapidly improve VL completion rates

• 1. Ownership of the VL monitoring process –

appoint a VL champ

• 2. Institute the VL anniversary concept
• 3. Demand creation by patient education and staff

education

• 4.Pharmacy gate keeping not to issue ART for more

than one month without a VL result

• 6.Use of appointment cards
• 7. All of the above
• 8.All except 4

Quality improvement model

Ongoing education and development Stakeholder strategy Root cause analysis (SIMS)

DBS/ POC Unique Identifier, Biometrics Interlinked electronic systems

Source: Ms Linda Dlamini , KZN ART Manager , 28 May 2018

Bottleneck Analysis 3X4 Matrix

• 1. Know your

indicator, track your response, accountability

• 2. Target setting

and targeting

• 3. Data

management 4. Communication (ACSM, demand creation strategy) Quality of care 6 Infrastructure, medicines, equipment, lab services

• 7. Human

resources (quantity, capacity and skills)

• 8. Service

delivery platforms (incl WBOT's and mobile services)

• 9. Demand:

Service delivery related

• 10. Cascades and

pathways (continuum of care)

• 11. Demand:

Client related

• 12. Inter-sectoral

coordination (social development, private sector, schools)

Adult with Viral load completion (VLD) rate (HIV -8)

• Proportion of adults in the 12 month cohort, still on

treatment who had Viral load test done in the last year Definition:

• Adult viral load done (VLD) at 12 months

Numerator:

• Adult first line regimen + Adult second line regimen

at intervals in 12 month cohort Denominator:

• 80 % VLD rate at 12 months

2016/17 Target (Proposed):

Key clinical contact points –ensure activity

ART initiation

• UTT and

Linkage to Care

6 months post ART initiation

• VL<400
• VL>1000

1 year post ART initiation

• VL<400
• VL 400-1000
• VL>1000

Visit 1

• Clinical

• Management

Visit 2 At 1 month

• Review of issues

Visit 3 At 2 months

• Repeat VL
• Review of

Visit 4 Review of repeat VL

Root cause analysis –summary- PHC

• LOW stats reported for VLD due to

Missed appointments ,delayed reporting to clinics, lack of blood draws due to Poor patient education and health worker investment due to Due to high volume clinics and poor role differentiation of staff due to Lack of ownership of responsibility for Vl monitoring

• Acting on results not according to SOC due to

No dedicated persons and systems to engage pts with high VL due to Lack of staff orientation to protocols due to Lack of training and supervision of NIMART nurses and junior doctors

TIER.NET Challenges

Poor data management due to Incomplete entry of data onto clinical charts Ill defined data flow within facility HR issues and equipment issues

• 1. Facility Data Captures not working as much as they are

supposed to.

• 2. Backlogs-There is a big number of files in backlog resulting in

the increased number of defaulters.

• 3. Broken Computers in our facilities. (Technicians takes too long to

respond to facilities whenever they report broken computers) Three data sources not complementary

VL Health Information Systems

Tier.net Clinical Chart NHLS

Analysis of various sources of VL data-

• Very large numbers of Vl tests done monthly –are

they appropriately done and acted upon

• Are repeat VL being done and acted upon after

VF and adherence intervention?

• NHLS unable to report on VL completion rates
• What is the best way to assess the VL completion

rates ?

• 1. Need to triangulate data between NHLS

database – Tier.net – clinical charts in the catch up phase

• 2. Need to ensure that VL completion rate is

accurately documented in real time

• QIP – CAPRISA ACC :B

:BASELINE ANALYSIS

• IMPLEMENTATION OF QIP

BASED ON ROOT CAUSE ANALYSIS

• PILOT SITE IMPLEMENTATION
• UPSCALE TO OTHER SITES

CAPRISA ACC –Random file and facility audit 2016 (11 Ethekwini sites)

41.7 (762/1826) 36.3 (29/80) 92.2 (703/762) 79.3 (23/29) 32.1 (546/1701) 29.3 (22/75) 88.8 485/546) 68.2 (15/22) 25.9 (364/1403) 19.6 (10/51) 89.8 (327/364) 70 (7/10)

10 20 30 40 50 60 70 80 90 100

Viral Load Conducted (Adults) Viral Load Conducted (Peads) Viral Supression (Adults) Viral Supression (Peads)

Percentage

6 months 12 months 24 Months

Viral Load Coverage in Adult and Paediatric patients Viral Suppression Rates in Adults and Children

Problem statement: Low Viral Load Coverage & Poor identification of ART failure

ACC File and Facility Review in KZN

Two/more Consecutive Unsuppresse d Viral Loads

STEPS TO ACHIEVE THE IDEAL HIV-VL&DR MONITORING PROGRAM –ART CLINIC LEVEL

• 1. HAST CLINICAL MANAGER AND VL

CHAMP in each CHC/hospital and VLC in each ART site assisted by QA teams Terms of reference identified for overall supervision of process Responsible for facility reports to DOH Manage exit plan with partners in 2018 so that M&E takes over.

• 2. MAKE VIRAL LOAD MONITORING

ROUTINE 1. INCREASE DEMAND BY PT EDUCATION AND HCW EDUCATION 2. INSTITUTE VL ANIVERSARY CONCEPT 3. IMPLEMENT GATE KEEPING NOT TO ISSUE REPEAT SCRIPTS WITHOUT VL

• 3. SYNERGISE DATA SOURCES SO THAT

TIER.NET IS OPTIMALLY FUNCTIONAL AND TOTALLY RELIABLE 1. ENSURE THAT VL RESULTS ARE ENTERED INTO CLINICAL CHARTS DAILY SO THAT TIER.NET CAN BE UPDATED . 2. CATCH UP PHASE TO ACCOUNT FOR EVERY PATIENT EVER SEEN IN CLINIC AND NOT ACCOUNTED FOR ON TIER.NET. FINALLY DEPEND ON TIER REPORTS ONLY.-AUDIT OF ENTIRE FILE REGISTRY 3. CREATE A HIGH VL REGISTER FOR IST AND 2 ND LINE ART FROM ALL DATA SOURCES –ROUTINE CLINIC VL RECORDS , NHLS WEEKLY DASHBOARD, TIER.NET RECORDS, PHARMACY RECORDS , COMPLETE FILE AUDIT OF ALL ACTIVE PATIENTS.

• 4. START VL PRIORITY CLINIC ON

SPECEFIC DAY/ DEDICATED TEAM WORKING DAILY 1. Trained EAC team work with trained doctor to manage complex VF in first line and all second line VF 2. Ensure that all patients receive care by a MDT

• 5. SUPPORT PHCs in the area

1. VLC in each PHC to be mentored and supported by local CHC/hospital .Manage all first line VF and refer all second line VF 2. Standardise referral forms for VF and data required for 3RD line ART

DEVELOPMENT OF SOPs and TOOLS

• Making Vl monitoring routine
• Management of FLART failure – with algorithim and flow

charts

• Management of SLART failure –with algorithim and flow

chart

• Application for TLART- clinical management and drug

supply chain

• Roles and responsibilities of clinic teams
• Logistical arrangement of services within the district
• Registers : Baseline file audit log; Vl sample log ; High Vl

register for FLART &SLART

• Tools – Adherence checklist and enhanced adherence

counselling tool (NDOH)

CRITERIA FOR REFERRAL OF PATIENTS TO A VL PRIORITY CLINIC

• 1. FIRST LINE (virologic failure after counselling for two months and repeat VL >1000

copies/ml)

• a. Multiple co-morbidities or co-infections i.e. Anaemia ,cardiac, liver pathology,

malignancy on chemotherapy

• b. On TB treatment or requiring TB treatment.
• c. All Hep B Positive patients
• d. Renal failure (Creat Clearance < 50 mls/min) requiring dose adjustment of NRTIs

/TDF

• e. Total cholesterol > 6
• f. All patients with complex adherence issues that need intervention by

Multidisciplinary EAC teams

• G. ALL PATIENTS WITH VF to be referred to ACC clinic on the same day
• 2. Second Line (PI) ART Failure
• a. Treatment failure with 2 VL > 1000 completed 6 months apart after adequate EAC
• 2. Other Complex Problems on SLART
• a. Intolerance to SLART drugs affecting adherence eg vomiting, diarrhea and difficulty

swallowing Aluvia

• b. Total cholesterol > 6 on SLART
• c. Haemoglobin < 8 on AZT based SLART
• d. Renal failure (Creat Clearance < 50 mls/min) requiring dose adjustment of NRTIs /TDF

How to set up a VPC/ACC clinic- Hospitals /CHC

• SPECIFIC DAY OR DAYS WHEN THE KEY STAFF ARE

AVAILABLE

• 1. ARV CLINIC DOCTOR
• 2. EAC SOCIAL WORKER
• 3. HIV COUNSELLOR- EAC TRAINED
• 4. EAC TRAINED NIMART NURSE /PN
• NB. REFERRAL FORMS FROM ART CLINICS TO REFERRAL

CENTRES AND FORM TO BE USED TO ORDER GRT WILL NEED TO BE FINALISED BY HAST UNIT AND NHLS with input from clinical specialists

Bottleneck Analysis 3X4 Matrix

• 1. Know your

indicator, track your response, accountability

• 2. Target setting

and targeting

• 3. Data

management 4. Communication (ACSM, demand creation strategy) Quality of care 6 Infrastructure, medicines, equipment, lab services

• 7. Human

resources (quantity, capacity and skills)

• 8. Service

delivery platforms (incl WBOT's and mobile services)

• 9. Demand:

Service delivery related

• 10. Cascades and

pathways (continuum of care)

• 11. Demand:

Client related

• 12. Inter-sectoral

coordination (social development, private sector, schools)

Training and Mentorship Model

Didactic central training program Capacity development and onsite mentorship

QI HAST PROJECT Engage with CEOs ,medical /clinical managers and district managers to ensure mentorship of staff and appropriate referral pathways develop Coordinate training plan and mentorship of staff for VL and HIV DR with all partners through resident HAST clinical managers /medical managers

Strategic planning team - DOH

• 1.

Dr.H.Sunpath – District Specialist /Consultant QA HAST program

• 2.

Ms.S.Ntuli and Ms.L.Mthethwa –QA managers DOH

• 3.
• Dr. J.Brijkumar – DOH

consultant

• 4.

HAST managers –Mr. P.Bhengu / Mr. X.Mbangata

• 5. M& E – Mr.Martin Gabela
• 6. KZN HAST UNIT – Ms.L.Dlamini
• 7. District management –

Ms.P.Msimango ,Mr. S. Yose and Ms. S.Mbambo

• Start with 3 HAST pilot sites .

(CWH/WWH/KDH) and repeat audit 31/08/17

• Finalise SOP for VL monitoring

to improve VLD over 12 months from 43% to >80 %

• Get all pts on second line with VF

that are eligible for DRT processed immediately.

• Engage with all Ethekwini ART

facilities to scale up project WITH QUICK WINS ?date

Team leaders – DOH FACILITIES :HAST CLINICAL MANAGERS and VL CHAMP

FACILITY TEAM -PHC

• ONM / VL CHAMP
• QA REPS
• DATA TEAM
• LOCAL GOVT

/MUNICIPAL CLINIC STAFF

• NGOs

FACILITY TEAM-HOSPITALS/CHC

• DR –MEDICAL

MANAGER/HAST CLINICAL MANAGER

• VIRAL LOAD CHAMP
• M&E and QA

MANAGER

• EAC TEAM –SW/HIV

COUNSELLOR

• DATA CAPTURER

PILOT SITE STUDY

Aims and Objectives

Aim

To evaluate implementation of a 5 step plan aimed at improving Viral Load (VL) monitoring in 3 ART sites in eThekwini

Specific Objective

To compare pre and post intervention VL coverage rates among HIV infected patients receiving chronic ART

Methods

• Study design: Pilot prospective cohort study

conducted between November 2016 and November 2017

• Study Team: CAPRISA, District HAST Team, facility

management and NGO partners

• Study sites: 3 DOH Hospital ART clinics in

eThekwini

• Regulatory Approval obtained from UKZN ethics

committee, PDOH research committee and facility management

Intervention: 5 Step plan for Making VL Monitoring Routine

• 1. Establishing a VL CHAMP
• Usually a registered NIMART nurse within facility
• 2. Make Viral Load Monitoring Routine
• Increase patient demand for VL testing
• VL Anniversary
• VL Register
• Gatekeeping by pharmacists
• 3. Optimize use of Data Sources
• Triangulate and optimize all data sources: Chart audit of ART

registry, NHLS, TIER,

• Creation of high viral load registers
• 4. Dedicated Viral Failure Clinics - using established criteria
• 5. Cascade and Support PHCs to do same

Methods

• Cross sectional analysis at baseline, 6 months

and 12 months after intervention

• Calculation of VL Coverage and VL

suppression rates utilizing TIER.Net data.

• Variables assessed:
• Total patients remaining on ART (TROA)
• Validated by DHIS
• Viral Load data:
• Test date and patient visit dates
• VL result
• VL due

Results

Baseline Characteristics of cohorts in 3 Intervention sites

Characteristic Site 1 Site 2 Site 3 Total active ART patients 1542 2760 7125 Children n (%) 90 (5.8) 176 (6.3) 142 (2) Female n (%) 794 (51.5) 1287 (46.6) 4234 (59.4) Average monthly ART initiations over 12 months 16 20 80

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

0 Mo 6 Mo 12 Mo 0 Mo 6 Mo 12 Mo 0 Mo 6 Mo 12 Mo Site 1 Site 2 Site 3

Percentage of viral load tests performed

VL Expected VL Performed

0 Mo VLP/VLE 140/205 68% 84/115 73% 323/504 64% VLS/VLP 112/140 80% 78/84 93% 307/323 95% 6 Mo VLP/VLE 995/1194 83% 793/878 90% 3101/3124 99% VLS/VLP 840/995 84% 758/793 96% 2996/3101 97% 12 Mo VLP/VLE 2262/2636 86% 1742/1824 96% 6636/6636 100% VLS/VLP 1920/2262 85% 1646/1742 94% 6519/6636 98% Cumulative 547/864 63% 497/547 91% 4889/5196 94% 4594/4889 94% 10640/11096 96% 10085/10640 95%

Cochran-Armitage Trend Test for viral load tests performed per site: Site 1: p < 0.0001 Site 2: p < 0.0001 Site 3: p < 0.0001

Cumulative: p < 0.0001

Viral Load Tests performed among those eligible for VL testing- Nov 2016 –Nov 2017

Summary

• 5 point plan ensured that VL completion rates improved

to > 80% within six months, and sustained to > 90% at 12 months

• Despite significant improvement in VL completion

rates, VL suppression rates were maintained

• Multifaceted clinic-centered intervention, is replicable in

both low and high-volume ART clinics

Recommendations

• The 5-step plan should be integrated into existing ART

services

• A collaborative team approach results in significant

improvement in VL monitoring

• Scaling up best practices in improving viral load

coverage informs progress toward achieving the third pillar of the UNAIDS 90-90-90 strategy.

What strategies were tried to improve performance

39 39

• VL Clinical Manager and

VL Champion

• Making VL monitoring

routine (VL Anniversary)

Step One: Achieving Coverage of VL testing

• TIER VL reports, NHLS

RFA reports, triangulation

• Maintain high VL register

Step two: Acting

• n results
• VL priority clinic (EAC)
• Support PHCs in cluster

for advanced clinical care and referral

Step three: Switching Regimens

Key clinical contact points –ensure activity

ART initiation

• UTT and

Linkage to Care

6 months post ART initiation

• VL<400
• VL>1000

1 year post ART initiation

• VL<400
• VL 400-1000
• VL>1000

Visit 1

• Clinical

• Management

Visit 2 At 1 month

• Review of issues

Visit 3 At 2 months

• Repeat VL
• Review of

Visit 4 Review of repeat VL

The Second-Line Cascade: Management of Patients with High Viral Load in Public HIV Clinics in Durban, South Africa

Background

• 1. Identification of patients experiencing first-line ART failure has increased rapidly as access to viral load (VL) testing improves in HIV endemic

settings.. At failure, WHO and most treatment programs recommend 3-6 month monitoring with adherence support, repeat testing, and then clinical decision making. These recommendations are complex in practice, putting patients at risk for persistent failure, disease progression, and transmission of resistant virus. We evaluated the cascade of care after first-line ART failure in three public clinics in Durban, South Africa.

Methods

1.Retrospective chart review of patients with VL >1000 copies/mL on first-line ART during 1st March - 30th June 2016 2.Estimated proportion of patients failing first-line ART who completed each stage of the care cascade including a)completion of at least one adherence counseling visit; b)repeat viral load testing; and c) return for results with maintenance on first-line ART (if repeat VL <1000 copies/mL) or change to second-line ART (if repeat VL>1000 copies/mL). 3.In secondary analyses, we assessed the proportion of individuals who completed the cascade from failure to regimen change within 90 and 180 days

Results

• 1. Of 9782 patients accessing first line ART, 452 had first-line VF. . Only 32% (143/452) of patients with first-line failure re-

suppressed or were changed to second-line (Figure).

• 2. Only 27% (117/452) and 8% (35/452) did so within 180 and 90-days, respectively

Conclusions

• 1. Less than 1/3 patients with viremia on first-line ART were appropriately managed for virologic failure, and less than

10% were done so within 90 days

• 2. As access to VL monitoring improves in the region, efforts to strengthen care for this high-risk and critical patient

population must be prioritized to maintain individual and population-level treatment and prevention goals.

Abstract Number: TUPEC339

UPSCALE OF QUICK WINS TO ART SITES

August 2017 –November 2017

Addington Charles James Prince M RK Khan Hast Manager or MatCH lead MatCH lead Hast manager MatCH lead Hast Manager VL Champion N Y N Y VL anniversary N Y N Y VL due or failure reports Y Y Y Y High VL register Y Y N Y Clinician registered for NHLS RFA report Y Y Y Y Chart audits Y ( MatCH SIMS) Y ( MatCH SIMS) Y (MatCH SIMS) Y

eThekwini South

eThekwini North-CHCs

Tongaat Phoenix Newtown A KwaMashu Inanda C Hast Manager or MatCH lead MatCH- Transition 1.11.17 MatCH – Transition 1.11.17 DOH MatCH/DOH MatCH/DOH VL Champion Y Y Y Y N VL anniversary Y Y Y Y Y VL due or failure reports Y Y Y Y Y High VL register Y Y Y Y Y Clinician registered for NHLS RFA report Y Y Y Y Y Chart audits Y Y Y Y Y (MatCH Sims)

Facility TROA VLD VLD% VLS VLS% Clairwood 6985 6139 88% 5897 96% Wentworth 1889 1698 90% 1599 94% King Dinizulu 2614 2082 80% 1773 85% Mahatma Gandhi 2641 2049 78% 1905 93% Osindisweni 3564 1269 36% 1101 87% Addington 3744 3137 84% 2883 92% Charles James 4870 3703 76% 3504 95% Prince M 4325 3395 78% 3002 88% RK Khan 5256 4284 82% 4056 95% King Edward 3222 2850 88% 2520 88% St Marys 1581 901 57% 790 88% Don Mackenzie 3439 1811 53% 1707 94% KwaDabeka 9672 5053 52% 4692 93% Hlengisizwe 8363 5466 65% 5173 95% Cato Manor 9482 5601 59% 5293 95% Tongaat 5993 4807 80% 4559 95% Phoenix 8065 5624 70% 5311 94% Newtown A 6200 5387 87% 5078 94% KwaMashu Poly 16482 8985 55% 8324 93% Inanda C 9525 5095 53% 4752 93%

Hospitals – August 2017 –October 2017

Facilities TROA VLD VLD % VLS VLS % kz Wentworth Hospital 1729 1672 97% 1572 94% kz Clairwood Hospital 6532 5898 90% 5655 96% kz Addington Hospital 3355 2991 89% 2762 92% kz King Edward VIII Hospital 3059 2726 89% 2444 90% kz RK Khan Hospital 4774 4106 86% 3878 94% kz King George V Hospital 2438 2022 83% 1734 86% kz Charles James TB Hospital 4697 3790 81% 3595 95% kz Mahatma Gandhi Hospital 2480 1920 77% 1795 93% kz Prince Mshiyeni Memorial Hospital 4077 2900 71% 2564 88% kz St Mary's Hospital (Mariannhill) 1487 807 54% 710 88% kz Osindisweni Hospital 3236 1538 48% 1354 88% kz Don McKenzie TB Hospital 3358 804 24% 746 93%

CHCs

Facilities TROA VLD VLD % VLS VLS % kz Newtown A CHC 5805 5130 88% 4840 94% kz Tongaat CHC 5358 4718 88% 4461 95% kz Phoenix CHC 7359 5131 70% 4843 94% kz Hlengisizwe CHC 7898 5461 69% 5181 95% kz Cato Manor CHC 8895 5142 58% 4857 94% kz KwaMashu Poly CHC 15046 8456 56% 7840 93% kz Inanda C CHC 8572 4284 50% 3981 93% kz KwaDabeka CHC 9672 4056 50% 3738 93%

0% 20% 40% 60% 80% 100% 120% 2000 4000 6000 8000 10000 12000 14000 16000 18000

Viral Load Cascade eThekwini Hospitals and CHCs Oct2017

TROA VLD VLS VLD% VLS%

PHCs - Provincial

PHCs - Municipal

Summary stats –Tier reports from nerve centre meetings Source –K.Naidu : MatCH

• Pilot sites -VLD July 2018

– WWH

• CWH
• KDH
• Second line audit report

Ethekwini ART sites (quick wins from August 2017) TRoa VLD – 415851 Increase from 42% AT BASELINE to 74 % in FEB and 88%in July 2018

HIV Clinical Cascade 30 Jun2018

54 eThekwini District 472 272 415 581 373 472 335 752 621 411 559 270 503 343 503 343 453 009

• 100 000

200 000 300 000 400 000 500 000 600 000 700 000

LHIV Known status On ART VLD VLS

Actuals 90-90-90 Target (Test and Offer)

%

Progress against previous pillar

76% 88%

74% 93%

55

19% 74% 105% 96% 105% 110% 88% 0% 20% 40% 60% 80% 100% 120% 20000 40000 60000 80000 100000 120000 140000 January February March April May June July

eThekwini Nerve Centre Viral Load Cascade 2018 Monthly

VL Due VL Done VL Completion Rate

Hospital VL Cascade at 12 months_31Aug2018

56

Facility TROA VLD VLD% VLS VLS% kz Addington Hospital 3773 2942 78% 2685 91% kz Charles James TB Hospital 4292 2640 62% 2465 93% kz Clairwood Hospital 7182 5077 71% 4871 96% kz Don McKenzie TB Hospital 2413 456 19% 403 88% kz King Dinuzulu V Hospital 2797 1943 69% 1717 88% kz King Edward VIII Hospital 3396 2785 82% 2472 89% kz Mahatma Gandhi Hospital 2423 1952 81% 1844 94% kz Osindisweni Hospital 3375 2174 64% 1954 90% kz Prince Mshiyeni Memorial Hospital 4413 2918 66% 2550 87% kz RK Khan Hospital 4655 3758 81% 3520 94% kz St Anne's Clinic_St Marys Hospital 1639 1071 65% 969 90% kz Wentworth Hospital 1412 1274 90% 1163 91%

CHC VL Cascade at 12 months_31Aug2018

57

Facility TROA VLD VLD% VLS VLS% kz Cato Manor CHC 10388 5495 53% 5195 95% kz Hlengisizwe CHC 8607 5924 69% 5590 94% kz Inanda C CHC 10240 5103 50% 4765 93% kz KwaDabeka CHC 9851 5866 60% 5514 94% kz KwaMashu Poly CHC 16731 1184 8 71% 1115 5 94% kz Newtown A CHC 6246 5187 83% 4920 95% kz Phoenix CHC 8400 3527 42% 3273 93% kz Tongaat CHC 6516 4810 74% 4593 95%

LOGISTICAL ARRANGEMENT OF SERVIVES FOR PROJECT MANAGEMENT

• 1. Engagement of chief director through the PDOH and HAST unit to adopt the national strategy for the 90/90/90

project

• 2. District to engage HAST coordinators ,PHC supervisors .QA managers, M&E team leaders together with DSP for form

a district task team for VL and DR monitoring

• 3. Link up with regional centre of academic excellence for training and mentorship of doctors to work as clinical

advisors at CHC and hospitals

• 4. Prioritise implementation of an SOP to make VL monitoring routine and SOP management of first and second line

failure. 5.Enusure the creation of a VL priority clinic at CHCs and hospitals to manage VF and DR at their sites and to PHCs linked to them

• 6. D/O to direct CEOs to appoint HAST clinical manager /medical manager /senior ARV clinic doctor as leader of project

. Address all staff regarding the inclusion of QA activities as part of their KPIs.-national priority program 7.Each ART facility to appoint a VL champ and identify a QA team – QA nurse ; lay counsellor / ENA doing counselling ; pharmacist / PHC nurse ; phlebotomist /ENA data team and FIO . JDs and letetrs of appointment are necessary

• 8. Regular QA team meetings to assess progress and identify bottlenecks –implement QIP.
• 9. Begin with implementing all the quick wins that have been proven to deliver dramatic improvement
• 10. Start with ensuring the triangulation of all data sources and understand how the Vl cascade works

11.Monthly HAST clinic managers meetings with DSP ,and PHC supervisors and clinicaL and HAST program managers

Acknowledgements

The CQUIN Learning Network 59

• Dr Henry Sunpath- Lead Investigator and

Project Co-Ordinator

• CAPRISA ACC Staff
• eThekwini District Management and DOH

Facility staff

• UKZN Department of Infectious Disease
• Maternal and Adolescent Child Health
• REVAMP team

This project was supported by the Grant or Cooperative Agreement Number U2G GH001142, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the presenters and do not necessarily represent the official views of the U.S. Centers for Disease Control and Prevention or the U.S. Department of Health and Human Services