1. 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

2. 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

3. 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

4. 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%

5. 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

6. 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

7. 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.

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

9. 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

10. Lessons learned cont’d
Observations
Males
OR=2.86 (95% CI )
Initiation due to universal eligibility (pregnancy and children under 5)
OR=3.33 (95% CI )
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 (95CI )
Patients residing in a distance of <5 km from the hospital were 4 times more likely to return after defaulting
OR = 4.52 ( )
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

12. 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

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