ENROLLMENT OF HIV POSITIVE CLIENTS IN TO CHRONIC CARE AT NAMAWANGA HCIII

Author(s):

NAMAWANGA QI TEAM written by Stephen Orena

Topics: HIV/AIDS basic care and support

Region and Country: Uganda

Organization: Namawanga HClll QI team

The Report

Problem:

Enrollment in to HIV Chronic care

Namawanga HClll is located in lukhonje subcounty,bungokho south health sub district, Mbale local govrnment. the health facility serves apopulation of 35,514.with women in childbearing age amounting to 7,174. the facility has 1 senior clinical officer, 1 mid wife, 1lab. technician, 1lab. assisstant, 2 enrolled nurses, 1 nursing assisstant, 4 vaccinators, 1 porter, and 2 askaris.

The problem we had was enrolling the HIV positive clients in to care.

Intervention:

before the introduction of the quality improvement project we did not have any way of tracking how many people were enrolled in to HIV care, however, we could count the number of people who tested positive from the laboratory registers and the monthly reports. after the workshop held on 21/9/2009. we acquired the knowledge and we set off with the new agenda, Formation of the QI team, introduced the pre-ART register, client cards, monthly journals, monthly meetings, proper filling system. we set off the journey by sharing what others had received from the workshop with those who had not attended. the team was formed and the responsibilities allocated. we agreed to start testing clients assessment for the TB and clinical staging using the WHO standards the two indicators were selected together with proper documentation. 1. clients assessed for TB taking history on the signs and symptoms of TB this was started in November. 2. CME to all the staffs handling the clients. 3. using Job aids, 4. continuous follow up of the clients,5. daily general Health education talks at the OPD,the monthly visits from the District team was abig boost to us.reffering the cllients with low CD4 counts to the near by health centre iv. 6. formation of the pycosocial support ( PSS) groups.

since we were doing two indicators co-currently, for ART eligibility using the WHO staging the following had to be done. the team had CME on how to stage the patients using the WHO standards, most of the team members were green about it so Stephen Orena sat down and wrote the WHO clinical staging on the manilla and put it on the wall.

we also prepared flow charts to try to cut down waiting time, though it did not help alot because of the high patient numbers and few staffs,we decided to give the clients who come for refills to be attended to as early as possible on aclinic day.

start testing for TB within the facility though limited infrastructure, reaching out to the community to do outreaches and also home visits yielded some fruits though transport is a major problem.

currently we are handling patients appointments how to track them with ease so we introduced an appointment book at the beginning of the this year. each time the patient comes for the cotrimoxazole, areturn date is given and is written on the patients card and on the appointment book. it did not achieve abigger percentange at the start because of many books to fill so some times staffs would forget to fill it and yet the cotrimoxazole is issued. the data however would be retrieved from the general OPD register. also we have alocated aclinic day for the clients to return for cotrimoxazole refills.

Results:

the first intervention did not yield much improvement because most of the staffs were not well aquinted with signs and symptoms of TB, and the facility was not in position to do TB tests due to the small infrastructure. here are the results in the table below

month	Oct	Nov	Dec	Jan	Feb	Mar	Apr	May	Jun	Jul	Aug	Sep	Oct
Numerator	4	7	9	7	11	9	13	8	12	21	21	19	20
Denomitor	4	9	10	9	12	10	13	8	13	21	21	19	20
%	100	78	90	78	92	90	100	100	92	100	100	100	100

the table above shows the trend for TB assessment after the various interventions were introduced.

after that was provided the table for the clinical staging was as below;

month	Oct	Nov	Dec	Jan	Feb	Mar	Apr	May	Jun	Jul	Aug	Sep	Oct
Numerator	3	7	7	6	12	9	13	7	13	21	21	19	20
Denominator	4	9	10	9	12	10	13	7	13	21	21	19	20
%	75	78	70	67	100	90	100	100	100	100	100	100	100

after afew month of struggling the activity achieved its goal up to date

using the appointment register here are the results so far

month	Jan	Feb	Mar	Apr	May	Jun	Jul	Aug	Sep	Oct	Nov	Dec	Jan
Numerator	14	18	22	28
Denominator	25	25	25	30
%	56	72	88	93

these appointments tracking is preparing us for management when it comes to giving ARVs if at all we succed to open ART clinic.the results above are encouraging us. see the attached document for the graphs.

with all the steps taken we tested in total 524clients, 89.5% (469), were female, 285 pregnant women in 2009/2010 financial year, 17clients (3.2%) tested positive. 6 pregnant women tested positive.from july 2010 to april 2011 we have tested 960 clients in total, 33 clients tested positive for HIV.731(76%) being women.285 pregnant women, 7 of these women tested positive.1 person co-infected with TB.

from the start of this program we have now enrolled atotal of 67clients in to care. 17 of these tested from other health facilities and preffered to come for chronic care at our facility. ART eligibility was not very successful with only WHO clinical staging so we had to try other methods mostly doing CD4 counts. at first PREFA would pay for CD4 counts for the pregnant mothers and the other group was left out, good news is there is anew partner STAR-E has come to pay for CD4 counts for every person who tests positive,including DNA PCR for the infants. 35clients have got their CD4 counts done, 19 of them need ART. one client has CD4 of 10cells/µl of blood which is very very low. we do reffer this clients but they do not reach there, some do reach but they are not yet enrolled in to care. one of the clients had CD4 of 125cells/µl in 2010 september, now her CD4 is 193cells/µl of blood and yet she is not on ART. if only we could be in position to offer ART many of clients would benefit.

The enrollment in to care has helped us identify other family members who are infected. there is one family with a 15 year girl and 10 year old girl tested positive. they still have a brother who is 8years waiting to be brouhgt for testing, the mother is broken down because her whole family is perishing because of her reason her husband is negative and he is blaming her to be responsible.to make it worse than it is right now her husband is on a hospital bed suffering from intestinal cancer. her 10year old daughter was so sickly when she was a baby as aresult of repeated quinine dose, the girl is now deaf and damp.these family needs help.

Due to staff commitment to the this agenda the district team appreciated us and they requested us to help a nother health centre iv from the district. they came to our unit to see what we were doing to achieve our goals, they returned to their facility and put what they learnt in to practice.

Lessons:

quality improvement can not be achieved as an individual since there are so many areas to be addressed so team work is key to its success.
monthly meetings helped us alot to assess our progress.this also motivated the staff to work willingly.
sensitization of the community and involvement of other stake holders helps, good reecords keeping is very important for the project to succeed, having QI in all the departments in the facility is vital to achieve good results. one time during the monthly meeting our porter asked for heavy duty gloves for her use,she got them and now she has no excuse of not doing her job. our facility is one of the cleanest in the district.
some of the challenges we faced
male involvement was very poor
lack of finances when it comes to movements outside the unit
follow up of the lost clients was abig challenge
some times we would get stockouts of test kits
working on so many things as asmall team is tiresome.

Year:

2011