1 Improving care of HIV-infected breastfeeding mothers and their babies: Early results from the Partnership for HIV-free Survival Initiative in Uganda Tamara Nsubuga-Nyombi, URC IAS- Melbourne, Australia July 22nd, 2014

USAID Applying Science to Strengthen and Improve Systems PHFS in Uganda 2

USAID Applying Science to Strengthen and Improve Systems The Partnership for HIV-Free Survival 3 Nutrition in 1 st 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

USAID Applying Science to Strengthen and Improve Systems Retention of mother-baby pairs in care 4 Apr: Pairing of mothers and babies May 13: Merged EID and ART services at one service points and gave same appointment date Jun 13: Peer mothers involved in counseling mothers on appointment keeping May 13: Pairing of mothers and babies Jun 13: Peers escort MB pairs to the clinic Sep 13: Assigned EID focal person to pair cards and make phone calls to mothers Dec13: Set specific / separate day to see MB pairs Jul 13: Family support group meetings used to identify MB pairs and see them then Nov 13: ART and EID merged so MB pairs receive services in one area Mar 14: Phone calls to mothers Changes At one low volume site ave. 93 pairs / mo At one high volume site ave. 170 pairs / mo

USAID Applying Science to Strengthen and Improve Systems Mother-baby pairs who receive a standard package of care at routine visits 5 Learning session 2; new client flow chart developed Merging of ART and EID services Expert clients trained to do MUAC and assigned responsibility of assessing and nutrition counselling Mothers told about what services to expect so they can remind HW if they forget a service Changes made at example site 20 clinics reporting 21 clinics reporting

USAID Applying Science to Strengthen and Improve Systems Integrating the content and process of providing care 6 Content of care What is done: Guidelines on IYCF (e.g. all children should be exclusively breastfed for 6 months) Guidelines on Option B+ (all HIV positive mothers should be initiated on B+) Process of care How it is done: Improve identification of mothers and babies Improve retention in care Provide routine services Improve IYCF practices and adherence Output/ outcome HIV-positive mothers on ART who are doing well Well nourished, HIV-free babies

USAID Applying Science to Strengthen and Improve Systems Sequencing and simplifying the approach 7 Completeness and accuracy of EMTCT data Work on bringing more mothers and babies to care Every mother – baby pair gets a standard package at routine visits Monitor the babies’ status; initiate newly identified mothers on ART

USAID Applying Science to Strengthen and Improve Systems Basics of Collaborative Improvement Site-level summary QI team representative Site-level testing of changes and analysis of results 8 Collaborative-level sharing and synthesis of best practices Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care

USAID Applying Science to Strengthen and Improve Systems Collaborative improvement model

USAID Applying Science to Strengthen and Improve Systems Challenges and what we are learning Challenges: Not all HIV-positive mothers at the different entry points are identified; need to improve linkages and PICT 2-3 of 15 HIV-positive mothers do not consent to ART initiation immediately; health workers need to follow-up through phone calls What we are learning: Substantial effort has to be put into retaining mothers and their babies in care for 18 months The QI approach enables health workers apply the most effective and efficient changes to improve their work Having more entry points, involving the community and merging ART and EID services improves ART coverage, retention and quality of care 10

11 Acknowledgements The 22 PHFS demonstration sites The Ministry of Health, PEPFAR, and other partners in Uganda (TASO, JSI-SPRING, EGPAF-STAR SW) District quality improvement coaches Colleagues at USAID ASSIST For more information please contact: Dr. Humphrey Megere, Chief of Party, USAID ASSIST Project, URC Uganda 11