A COLLABORATIVE APPROACH TO ESTABLISH PREDICTORS AND TRUE DEFAULTERS, AND RETURN THE DEFAULTERS BACK INTO CARE AT NTCHISI DISTRICT HOSPITAL, A RURAL HOSPITAL IN NTCHISI DISTRICT IN MALAWI

CDC/PEPFAR HIV Service Delivery Partner, 2012-2018 7 Districts Clinical mentorship TA and training QI projects Health system strengthening Improving and using data at district and site level

Background Globally, the use of antiretroviral therapy (ART) has led to a huge decrease in morbidity and mortality among people living with HIV (PLHIV) Retention on ART is the essential component in increasing positive health outcomes of those on treatment. National scale-up of ART has been successful in Malawi, with more than 53% of eligible PLHIV already on ART. Defaulter and LTFU affect retention thus quality of Care

Retention as part of an ART Cascade VIRAL SUPPRESSION Adherence Retention ART Initiation Link to Care Diagnosis towards the goal of Retention as part of an ART Cascade 90% 90% The key to viral suppression is adhering to clinic appointments and treatment Defaulter tracing and returning them into care remains an important intervention Courtesy -MK at TD’s 90%

Issue Malawi currently has: 1.1 million PLHIV 38,000 new infections (2015) every year 31,000 AIDS-related deaths per year (as of 2015) 551,566 on ART 85% ART coverage among HIV-positive pregnant women National ART program, shows defaulter rates remain high, on average ranging from 10% to 30% Ntchisi District Hospital currently has approximately 1,568 patients active on ART 3,882 patients ever enrolled -Many patients considered defaulters may not be true defaulters

Ideal and functional appointment and client tracing system Client visit Give date for return Record date in AP register/ book and for client Check and record client contact details Day before appointment: list of clients to expect or pull cards Record outcome of follow up and update records Client LTFU Client returns and update records RECORD?? RECORD who attended ARRANGE FOLLOW UP of those who missed Day of Appointment Many of you have seen this common appointment cycle and how it is completed from various sources. Tracing is not only looking at bringing defaulters back into care but also helps to update facility records esp,for establishing retention - Same process for following up defaulters and Missed Appointment

Description Ntchisi District Hospital is one of the few facilities that uses Electronic Medical Records In November 2014, a list of 55 patients who defaulted on treatment since January 2014 was compiled by ART Clerk During a four-day defaulter tracing exercise, EGPAF supported three health surveillance assistants with transport and other logistics to trace these defaulters Outcome of tracing recorded and analyzed using Excel. Further analysis was done using Epinfo StatCalc HSAs- MOH approved cadre of community health workers attached to the Hospitals involved in delivery of various health services including defaulter tracing -Only patients who consent for follow-up at the enrollment are traced/tracked- -This is part of routine care. QI team including ART Coordinator,data clerk and EGPAF Coordinator met to discuss the outcome and how to improve retention Data received by MOH ART clerk to update records.

Lessons learned 50 (90%) were >14 years of age 25 (60%) were female Out of the 55 listed patients: 50 (90%) were >14 years of age 25 (60%) were female 42 (76%) were successfully traced Age disaggregation done as < 14 and >14 years 18/34(58%) confirmed defaulters and LTFU=women

42 (76%) successfully traced 55 Defaulters 13 (24%) lost to follow-up 42 (76%) successfully traced 15 (36%) self transferred 21 (50%) confirmed defaulters 12 (57%) returned and started on treatment 11 on treatment < 12 months with 6 of these on treatment < 4 months 1 on treatment > 12 months 9 (43%) not yet returned back into care 6 (14%) died

Lessons learned cont’d Observations Males OR=2.86 (95% CI 0.82-10.21) Initiation due to universal eligibility (pregnancy and children under 5) OR=3.33 (95% CI 1.66-17.76) Women initiated on Option B+ were 9 times more likely to default within 4 months of initiation than women in WHO stage 3 or 4 OR=9 (95CI1.72-26.45) Patients residing in a distance of <5 km from the hospital were 4 times more likely to return after defaulting OR = 4.52 (1.64-35.51) Could not establish reasons for defaulting as we were not interacting with patients -Option B+ mean: pregnant women initiated on ART through B+ regardless of stage compared with non pregnant women on ART due to stage 3 or 4? -QI team looked at X-stics including distance in order to undertake QI initiatives to possibly improve quality of care and retention

Conclusions and next steps The collaborative approach involving front-line providers (like health surveillance assistants) was shown to be an effective way to conduct defaulter tracing, bringing clients back into care in this particular facility The approach provided insight in predictors of defaulting that will allow the team to address the complex challenges associated with retention of clients on ART, especially intensifying adherence counseling among women initiated on Option B+ We now aim to focus on strategies that may improve adherence and retention Could not establish reasons for defaulting as we were not interacting with patients -Collaborative approach involving lay health providers, ART Clerk, clinicians and Implementing partner -Predictors: Eg distance,ART eligibility

Thank you Acknowledgements: All co-authors from Elizabeth Glaser Pediatric AIDS Foundation and Ministry of Health (Ntchisi District Hospital)