USAID World Breastfeeding Week Webinar Series: Every day at 9-10AM EDT July 31st : Barriers to Breastfeeding: Findings From a Systematic Review of Practices in 20 countries August 1st: Working Together to Save Lives in Emergencies: Initiatives and Tools to Support Breastfeeding in Emergencies August 2nd: The Global Partnership for HIV-Free Survival: Quality Improvement and Breastfeeding/ART Compliance August 3rd: Human Milk Feeding for Small/Sick Newborns August 4th: Revitalizing the Baby Friendly Hospital Initiative: Experiences from Malawi For more information, visit: http://www.fsnnetwork.org/world-breastfeeding-week-august-1-7-2017-webinar-day-series

ADDITIONAL RESOURCES USAID Global Health: https://www.usaid.gov/what-we-do/global-health USAID Multi-sectoral Nutrition Strategy: https://www.usaid.gov/nutrition-strategy Breastfeeding Symposium: https://www.fantaproject.org/news-and-events/registration-usaid-breastfeeding-symposium-august-29-2016 Breastfeeding Seminar: http://www.fsnnetwork.org/breastfeeding-seminar-protecting-promoting-and-supporting-breastfeeding-field

The Global Partnership for HIV-Free Survival (PHFS): Quality Improvement and Breastfeeding / ART compliance World Breastfeeding Week Webinar Series | August 2, 2017 Amy F. Stern Improvement Director University Research Company Tamara Nsubuga-Nyombi Senior Improvement Advisor University Research Company Linda Kisaakye Program Officer Ministry of Health, Uganda

The PMTCT care spectrum Non-pregnant: Family planning (FP) counseling Preconception Care Partner HIV testing Antepartum: PITC in ANC CD4 Testing ART treatment or prophylaxis Adherence support Infant feeding (IF) counseling Safe Motherhood Birth Preparedness Intrapartum: PITC in L&D CD4 testing ARV prophylaxis Safe Delivery IF counseling FP counseling 1-8 Weeks Post Partum: Maternal postpartum follow-up Enrollment into HIV care ART treatment or prophylaxis during BF Adherence support 2-6 Months Post Partum: Repeat CD4 (6 months pp) ART treatment or BF prophylaxis 6-9 Months Post Partum: FP counseling IF counseling Adherence support 9-12 Months Post Partum: ART treatment or BF prophylaxis FP counseling IF counseling Adherence support 12-18 Months Post Partum: ART treatment FP counseling Adherence support Repeat CD4 PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post Partum Effective PMTCT includes a series of biomedical and psychosocial interventions administered throughout the reproductive life of the woman living with HIV

Drop of ARV uptake before and after delivery 38% 51% Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response

The Partnership for HIV-Free Survival PHFS in six countries: Uganda, Tanzania, Kenya, Lesotho, Mozambique, South Africa AIM: Decrease HIV transmission & improve nutrition, infant feeding Deliberate focus on in-country and cross-country learning Design for sustainability – country owned & led ASSIST QI demonstration sites Kenya - 16 Lesotho - 12 Tanzania - 30 Uganda - 22

The Partnership for HIV-Free Survival Nutrition in 1st 1000 days (optimal infant feeding, nutrition and health practices) Option B+ (effective ARVs to reduce HIV transmission) HIV-free survival of infants born to HIV-infected mothers

Improvement approach Engages teams of providers and other staff Focuses on client needs Analyzes systems and processes Empowers teams to make changes to improve outcomes Guided by data to measure results Peer-to-peer learning Langley et al, 1999, The Improvement Guide

Basics of collaborative improvement Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care QI team representative Collaborative-level sharing and synthesis of best practices Site-level summary Site-level testing of changes and analysis of results 9

Applying improvement to achieve HIV-free survival WHAT ARE WE TRYING TO ACHIEVE? HIV-positive mothers who are alive and in care Exposed infants who are HIV-free, alive and in care Improve data system to identify areas for improvement Improve retention of mother-baby pairs Provide critical package of care at ROUTINE VISITS Provide critical package of care at SPECIAL VISITS (6w PCR and results visit, 6 and 12m visit, 18m visit)

Retention of mother-baby pairs at baseline and end of intervention

So…WHAT HAPPENED TO THE IYCF? Infant and young child feeding (IYCF) results So…WHAT HAPPENED TO THE IYCF?

Defining a standard package of care to be given at each visit Tally Sheet for Routine Visits Mother’s ART CTX/ NVP (baby< 6 weeks) given IYCF counselling done? (Specify topic) Nutrition assessment for mother and baby? Appointment for next visit given and explained what will happen at next visit?

Percentage of HIV-positive mothers who receive IYCF counselling at each visit, 22 PHFS sites and 3 comparison sites, Uganda

Increasing adherence to IYCF practices, 22 sites, Uganda

Improving IYCF adherence at scale

Providing the standard package of care at scale

What we know now Interpersonal relations are key For mothers, patient-provider relations centered on quality education and counseling and motivating patients to remain in care. For many women, more counseling on how to maintain a healthy lifestyle and keep their babies HIV-free were important improvements in the quality of services. For some mothers, the quality of services before the introduction of improvement methods was fine, but they were able to point out areas where there had been changes. One woman noted that while “services were fine and satisfactory”, changes included providing counseling at every visit, and providing both mother and baby medications at the same visit. Mothers are able to describe the changes in quality Improved and more frequent education on treatment adherence and feeding practices was also noted as a valuable change. For many women, more counseling on how to maintain a healthy lifestyle and keep their babies HIV-free was an important improvement in the quality of services

Sustaining improvement at the national level National evaluation of the MBCP found: 90% of facilities were providing services as per guidelines. Consistency in services reported and actual services received by mothers. Health education, IYCF counselling and ARV refills were almost universal in all facilities.

Improving processes can improve outcomes

In summary, the key lessons learned Robust data system Retain mother-baby pairs in care Provide a standard package of care Early initiation on ART Empower mothers and create supportive systems

Acknowledgements The support of the American people through USAID Tim Quick, USAID U.S. President’s Emergency Plan for AIDS Relief WHO and UNICEF PHFS partners IHI, FANTA and LIFT Country implementing partners USAID ASSIST project staff and MOH counterparts in Uganda

For more information about PHFS quality improvement Amy Stern: astern@urc-chs.com Anisa Ismail: aismail@urc-chs.com Tim Quick: tquick@usaid.gov To view the PHFS learning platform, visit: https://www.usaidassist.org/toolkits/partnership-hiv-free-survival-learning-platform