HIV Quality Improvement (QI) and the Treatment Cascade: How QI has Impacted Reach, Recruitment, Testing, Treatment, and Retention Efforts in Thailand? Dr. Cheewanan Lertpiriyasuwat, MD, MPH Director of Bureau of Knowledge Management Department of Disease Control, Ministry of Public Health

Scope of presentation From starting point of HIV QI in Thailand to expansion phase Main activities Performance

Starting point of QI for HIV in Thailand NAPHA Program Assessment Data collection for baseline assessment in 3 provinces in the upper North 2003 Thailand started ARV clinics in The National Access to Antiretroviral Program for PLHA (NAPHA) February 2001 – December 2004: 58,133 patients on ART “Do ARV clinics provide services with quality?” Hospitals providing HIV care but national guidelines not followed OI Prophylaxis 69% TB Screening 37% Syphilis screening 3% Pap smear 3% Very little quality improvement activities focusing on the capacity building for personnel on ART and data management

Background: HIV quality improvement (HIVQUAL-T) implementation 2004 Pilot hospitals Launch of HIVQUAL-T program with HIVQUAL-T Software Implementing HIVQUAL-T in 8 hospitals Chiang Mai: Chiang Dao Hospital, Fang Hospital, Sanpathong Hospital and Sansai Hospital Chiang Rai: Wiang Papao Hospital and Mae Lao Hospital Payao: Payao Hospital and Mae Jai Hospital

ตัวอย่างผลการดำเนินงาน HIVQUAL-T ในช่วงแรก จะเห็นได้ว่ามีการพัฒนาตัวชี้วัดอย่างก้าวกระโดดในหลายตัวชี้วัด

Expansion of National HIV Quality Improvement Project for Adults 2003-2005 2006-2007 5 provinces 71 hospitals 7.8 % of gov’t hospitals 2008-2010 61 provinces 233 hospitals 25.9 % of gov’t hospitals provinces 700 hospitals 77.8 % of gov’t hospitals 2006-2007: Scale up of TOT courses for HIVQUAL-T with objective to scale up the program at provincial and regional levels by TOT trainees. But focus only performance measurement. Very little conduct QI activities. 2010: Expansion of HIV quality to 77 provinces under NHSO support 2009 Expansion by NHSO support, Collaboration with HAI for integration in hospital quality program

Main activities

Network development activities 1. QI network Establish regional QI committees for HIV care and treatment in all regions and establish provincial QI committees in provinces to plan, enhance, support and monitor QI activities in hospitals. Set up exchange forums for lesson learned and building capacity 2. Pediatric HIV care network Establish pediatric HIV care networks to develop referral system for pediatric patients among hospitals and develop capacity of health personnel in community hospitals about pediatric HIV care

Pediatric HIVQUAL-T Network Expansion 2005-2006 3 provinces 35 hospitals 2008-2009 2007 2010-2012 16 provinces 159 hospitals 10 provinces 99 hospitals 31 provinces 206 hospitals 2013: Scale up in 71 provinces

Quality improvement activities Develop a curriculum on QI training Training QI teams in 12 regional and provincial levels to be trainers Develop quality assessment tools and indicators for hospital Support budget for QI projects of hospitals by NHSO Integrate HIV QI into HA (e.g. training surveyors, site visit, rewarding system) Rewarding system: certificate, attending in National AIDS seminar or HA forum

Workshops on HIV Care for Pediatric Patients and Family

QI Training จะเป็นการเรียนรู้ผ่านเกม ผ่านการคิด ผ่านการปฏิบัติฝึกฝนจริง ทำให้ใช้เวลาอบรมนาน ช่วงแรกหลักสูตร 5 วัน ต่อมาลดเหลือ 4 วัน

QI Training โดยส่วนใหญ๋ผู้ที่ได้มาอบรม 2013 Change in training process: HIV team came for training with HA team to link HIV with the hospital quality improvement 22/11/61

Examples of CQI Stories on www.cqihiv.com CQI story (until the end of 2015)= 722 22/11/61

Performance by Indicators Focus on process indicator Screening, adherence ART initiation: CD4 200 to 350 we change ARV eligible criteria from 200 cells/mm3 to be 350 cell/mm3 in 2012. 2010 2011 2012 2013 2014

Example Hospital A: QI to improve viral load coverage Cause Review case who did not get VL testing High risk for non VL is poor adherence alcoholic drinking, poor socioeconomic QI Activity Self health group Discharge plan Treatment literacy activity

Example Hospital B : QI to improve viral load suppression QI Activity Self health group emphasize for VL knowledge Review EWI indicator Treatment literacy activity High risk low adherent cases identify by HCWs and Peer

Compare HIVQUAL participating and non HIVQUAL participating hospital by NAP indicator

Method Secondary analysis of cross-sectional data (“EWI and National Treatment and care Indicators”) reported from NAP in 2011-2013, comparing indicators reports of the two groups of hospitals HIV treatment indicators and Early warning Indicators Internet web based for register and data entry for HIV treatment and care

Proportion of new ART with baseline CD4<100 cells/mm3 (N= participating hosp./non- participating HIVQUAL hosp.)  %(range Min-Max) HIVQUAL NON- HIVQUAL P-valuea FY 2013 (N=384/21) 47(0-100) 48(0-60) 0.704 FY 2012 (N=386/21) 53(14-100) 53(15-70) 0.803 FY 2011 (N=178/11) 50(0-88) 45(3-58) 0.183 FY 2010 (N=178/11) 55(19-100) 55(11-77) 0.436 FY 2009 (N=178/11) 60(22-89) 63(8-74) 0.590 No statistic significant between % baseline CD4<100 cells/mm3 aWilcoxon rank-sum test. Note: select hospital that has more than 10 patients

Median CD4 of new ART cases (N= participating hosp. /non- participating HIVQUAL hosp.)  %(range Min-Max) HIVQUAL NON-HIVQUAL P-valuea FY 2013 (N=384/21) 109(17-253) 110(66-412) 0.487 FY 2012 (N=386/21) 89(22-327) 86(56-221) 0.932 FY 2011 (N=178/11) 100(33-274) 124(61-258) 0.124 FY 2010 (N=178/11) 84(24-227) 81(37-304) 0.561 FY 2009 (N=178/11) 73(26-218) 66(43-295) 0.781 No significant between Median CD4 aWilcoxon rank-sum test. Note: select hospital that has more than 10 patients

% VL test ≥1 time for who taking ARV more than 12 months P <0.001 P <0.001 P <0.001 P <0.001 significant HIVQUAL hosp. Non-HIVQUAL hosp.

% VL<50 copies/mL P <0.103 P <0.212 P <0.005 P <0.543 HIVQUAL hosp. Non-HIVQUAL hosp.

% Lost FU ART in 12 months after taking ART (exclude death) P <0.001 P <0.001 P <0.001 P <0.001 HIVQUAL hosp. Non-HIVQUAL hosp.

% Lost FU ART in the assessment year (exclude death) P <0.001 P <0.001 P <0.001 P <0.001 significant HIVQUAL hosp. Non-HIVQUAL hosp.

FY 2012-2013 %(range Min-Max) VL coverage Median percentage   %(range Min-Max) HIVQUAL NON- HIVQUAL P-valuea VL coverage 2012 (N=330/30) 2013 (N=551/41) % VL test ≥1 time for who taking ARV more than 12 months 70 (0-100) 55 (11-82) <0.001* 71 (13-100) 57 (17-87) <0.001 % VL<50 copies/ml 88 (37-100) 87 (71-96) 0.212 89 (52-97) (78-92) 0.103 Loss FU % Lost FU ART in 12 months after taking ART (exclude death) (2012; N = 330/30) (2013;N=551/41) 7(0-43) 13(5-53) 7(0-44) 14(0-53) % Lost FU ART in the assessment year (exclude death) 4(0-57) 8(2-40) 5(0-70) 7(2-85) % Lost FU Non ART (in the assessment year) 29(8-58) 34(13-56) 0.479 29(0-58) 31(8-38) 0.473 aWilcoxon rank-sum test. Note: select hospital that has more than 5 patients

FY 2012-2013 NAT (Median) %(range Min-Max) Death HIVQUAL NON- HIVQUAL P-valuea NON- HIVQUA L % New Death among No ART who still get the service in the assessment year 13 (0-38) 11 (0-36) 0.441 (0-42) 10 0.162 % New Death among No ART who Lost FU (0-29) 1 (0-14) 0.664 (0-20) 4 (0-10) 0.023 % New Death among ART in the assessment year 2 (0-13) 3 (0-7) 0.800 (0-5) 0.327 % New Death among ART who Lost FU (0-100) 8 (0-50) 0.080 (0-75) 7 (0-33) 0.071 % New Death within 12 month after ART (N=178 VS 11) (0-40) (0-18) 0.984 (0-31) 5 (0-16) 0.158 aWilcoxon rank-sum test. Note: select hospital that has more than 5 patients

Conclusion QI has impacted on screening (syphilis, OI, PAP), ARV treatment service and retention to care

Success Factors Strong policy and financial support Network Regional and provincial committees, and coaching team Sharing lessons learned Sharing tools and innovation M&E visit, coaching

Thank you for your kind attention