1. 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

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

3. 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

4. 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

5. ตัวอย่างผลการดำเนินงาน HIVQUAL-T ในช่วงแรก จะเห็นได้ว่ามีการพัฒนาตัวชี้วัดอย่างก้าวกระโดดในหลายตัวชี้วัด

6. Expansion of National HIV Quality Improvement Project for Adults
5 provinces
71 hospitals
7.8 % of gov’t hospitals
61 provinces
233 hospitals
25.9 % of gov’t hospitals
provinces
700 hospitals
77.8 % of gov’t hospitals
: 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

7. Main activities

8. 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

9. Pediatric HIVQUAL-T Network Expansion
3 provinces
35 hospitals
2007
16 provinces
159 hospitals
10 provinces 99 hospitals
31 provinces
206 hospitals
2013: Scale up in 71 provinces

10. 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

11. Workshops on HIV Care for Pediatric Patients and Family

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

13. 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

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

15. 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

16. 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

17. 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

18. Compare HIVQUAL participating and non HIVQUAL participating hospital by NAP indicator

19. Method
Secondary analysis of cross-sectional data (“EWI and National Treatment and care Indicators”) reported from NAP in , 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

20. 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

21. 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

22. % 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.

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

24. % 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.

25. % 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.

26. 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

27. 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

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

29. 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

30. Thank you for your kind attention