Improving Services for HIV-Exposed Infants in Zambia and Cameroon Using a Quality Improvement Collaborative Approach

To bridge the gap between what is known and what is done, quality improvement collaboratives (QICs) enable health programs to rapidly address quality challenges at scale. Two QICs in Cameroon and Zambia improved coverage of early infant HIV testing and initiating antiretroviral therapy in HIV-exposed infants. The QIC approach empowers health care workers to design solutions tailored for their specific settings. Key Findings Although the designs of the QICs varied to fit local contexts in Cameroon and Zambia, they used similar indicators and methods, and each resulted in improvement of testing coverage and timely return of test results for HIV-exposed infants. The social dynamics of the QIC approach enhanced the sense of shared purpose and community, fostered teamwork and friendly competition, and built leadership support while creating an internal enabling environment at the facility level. The quarterly learning sessions, monthly data collection, and ongoing mentoring for quality improvement led to significant improvements that were sustained for the life of the intervention. Key Implications The use of QIC methodology empowered health care workers to design solutions tailored to their specific settings, and each QIC resulted in a “change package” of successful initiatives that were disseminated within each country. Health sector policy makers should consider institutionalizing the QIC approach and fostering its targeted implementation to address refractory quality challenges, including the inclusion of QIC methods in national policies, guidelines, training, and monitoring systems. ABSTRACT Introduction: Early infant diagnosis (EID) and rapid antiretroviral therapy (ART) initiation are lifesaving interventions for HIV-infected infants. In Cameroon and Zambia, EID coverage for HIV-exposed infants (HEIs) is suboptimal and the time to ART initiation for infants infected with HIV often exceeds national standards despite numerous policy and training initiatives. Methods: ICAP at Columbia University supported the Cameroon and Zambia Ministries of Health (MOHs) and local partners to implement quality improvement collaboratives (QICs) to improve EID coverage and ART initiation at 17 health facilities (HFs) in Cameroon (March 2016 to June 2017) and 15 HFs in Zambia (March 2017 to June 2018). In each country, MOH led project design and site selection. MOH and ICAP provided quality improvement training and monthly supportive supervision, which enabled HF teams to conduct root cause analyses, design and implement contextually appropriate interventions, conduct rapid tests of change, analyze monthly progress, and convene at quarterly learning sessions to compare performance and share best practices. Results: In Cameroon, EID testing coverage improved from 57% (113/197 HEIs tested) during the 5-month baseline period to 80% (165/207) in the 5-month endline period. In Zambia, EID testing coverage improved from 77% (4,773/6,197) during the 12-month baseline period to 89% (2,144/2,420) during the 3-month endline period. In a comparison of the same baseline and endline periods, the return of positive test results to caregivers improved from 18% (36/196 caregivers notified) to 86% (182/211) in Cameroon and from 44% (94/214) to 79% (44/56) in Zambia. ART initiation improved from 44% (94/214 HIV-infected infants) to 80% (45/56) in Zambia; the numbers of HIV-infected infants in Cameroon were too small to detect meaningful differences. Conclusions: QICs improved coverage of timely EID and ART initiation in both countries. In addition to building quality improvement capacity and improving outcomes, the QICs resulted in a “change package” of successful initiatives that were disseminated within each country.