The "Blog": Updates on Projects in South Africa to Improve HIV/AIDS Treatment

​Your navigPhoto_Barker_PierreSMALL.jpgators on this voyage of health care improvement in South Africa will be Dr. Pierre Barker (pictured left), Director of IHI South Africa Projects, as well as our on-the-ground staff, Brandon Bennett, Cathy Green, Dr. Michele Youngelson, and our newest addition, Patty Webster. The IHI Developing Countries team will bring you stories from their visits with our partner clinics in South Africa as they increase treatment for people living with HIV/AIDS. 


We are currently active in six projects in five provinces — Western Cape, Eastern Cape, KwaZulu-Natal (KZN), Gauteng, and North West (see map below) — covering rural/urban and adult/pediatric practices. We are at the point now where we have generated a lot of enthusiasm at the sites we are working in, and provincial administrations are showing interest in our work. In particular, the Deputy Minister of Health of South Africa, Nozizwe Madlala-Routlege, has been very supportive of our strategy.

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Projects that IHI is supporting in South Africa

 

New Collaborative to Decrease HIV Transmission to Newborn Infants Launched in Zululand District, South Africa — March 2008

In partnership with the Centre for Rural Health at the University of KwaZulu-Natal, IHI is expanding its support of HIV care programs in South Africa. Today over 50 health workers from 7 hospitals (who support over 50 clinics) came together in Ulundi, KwaZulu-Natal (KZN), to design interventions to reach an ambitious target of decreasing mother-to-child transmission (PMTCT) by over 50% in the next 18 months.

From previous experience, we learned that the District health structures need to be deeply involved in the improvement process from the outset.

  • Leadership from the District office is crucial for legitimacy and generating the will for change.
  • A functioning reliable data system that can feed back site-specific data needs to be in place to support the improvement work.
  • District managers need to be directly involved in the planning and on-the-ground improvement work from the outset.
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  Brandon looks out over his new improvement "fiefdom" of the Zululand District
 
Over the past three months Linda Dlamini, project manager from our partner organization at the Centre for Rural Health, and Brandon Bennett, IHI's KZN provincial improvement advisor, have traveled hundreds of miles over unpaved roads together with Sizathu Mbambo (District PMTCT Coordinator) to introduce the improvement process and methods to the District health office and health facility leadership. In preparation for the launch, Brandon has also worked with the Boston office to refine a simple Excel database to track the processes and outcomes for PMTCT. The database has been installed in the District office and has provided our baseline understanding of the strengths and weaknesses of the program with a focus on identifying failing processes. District Health Coordinators directly responsible for the PMTCT program have been traveling with Linda on every visit.
 
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 District Coordinator opens the first Zululand learning session
 
The first learning session was opened by Sizathu Mbambo, who gave a strong commitment that the District would do whatever it will take to decrease HIV transmission. At current transmission rates, of the 13,500 births each year, we expect over 1,000 infants to be infected with HIV by 6 weeks of age. Without access to further treatment, 800 of these infants will die before their second birthday. The systematic process that has been initiated today is our best chance to eliminate these unnecessary deaths and leave behind a durable mechanism for continuous improvement.
 
A Summer in KZN  September 2007
Jessica Greenberg, a second year medical student at the Harvard Medical School (pictured at right in the photo below), traveled to South Africa for two months this summer to work with clinics on data collection and tracking techniques
 
In the past two years, HIV/AIDS treatment has become more commonplace for adults in some areas of South Africa. Indeed, the growing local knowledge that desperately ill people can recover rapidly after receiving treatment has created an enormous demand for antiretrovirals (ARVs). Despite this, effective treatment for HIV-positive pregnant women during their pregnancies remains a rarity. The main reason for this is that the system designed to prevent mother-to-child transmission of HIV is very dysfunctional.
 
In June aPhoto_GreenbergJessica.jpgnd July of 2007, I worked with the physicians, nurses and HIV/AIDS counselors at two hospitals and six clinics in rural KwaZulu-Natal (KZN). These communities are deeply rural and very poor. Unemployment hovers near 70% and more than one of every three pregnant women are HIV positive. Our project’s goal is to improve efforts to place eligible pregnant women on HAART (Highly Active ART) treatment in order to prevent the transmission of HIV to their children. I sat down with the nurses and counselors at each clinic to understand how pregnant women seeking antenatal care move through the clinic system and why many women are not offered treatment early enough in their pregnancy. Each clinic’s data was illuminating; though many women learn their HIV status, few were having the blood work needed to determine whether treatment was right for them. And of those women having CD4 counts (a method of determining the immune systems health), very few actually learned their test results and were referred for lifesaving treatment. 
 
With some coaching, each of these clinic teams began looking for solutions to improve their success at treating eligible pregnant women. Each clinic began a “lives saved” campaign, creating a clinic poster that counts each two lives saved — the child and the mother — for every pregnant woman put on treatment. The practical solutions the teams devised were often elegantly simple. Mbazwana Clinic simply moved its HIV counseling from outside the clinic in a nearby building to a room adjacent to where antenatal care is provided. In one week, the team went from sending blood tests for 20% of pregnant women, to sending 100% of the necessary tests. Mseleni Hospital began to screen women waiting for an ultrasound to ensure that all women who had blood drawn for CD4 counts got their results. At each site, we held a brief celebration to congratulate the staff on their successes, applauded those who contributed to the change, and asked what more we could do.
 
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Small changes such as these promise tremendous benefits to communities devastated by a growing pediatric HIV epidemic. All of the health workers in this region are touched personally by HIV and AIDS. Many of the nurses and counselors I worked with have children in their own families who are HIV positive. The will to protect children is enormous, and simple tools that harness this will are the key for change to occur.
 
TB/HIV and Sister de Wee  July 2007
Michele Youngleson discusses the tuberculosis tracking system and its many evolutions at the Ikhwezi Clinic.
 
Tuberculosis (TB) and HIV care should go hand in hand, but current health systems in South Africa are not designed to easily integrate care for these two diseases. Last year we analyzed records of 220 adult TB patients at Ikhwezi, a primary health care clinic in Cape Town, and showed that 70% of those who were voluntarily counseled and tested (VCT) were HIV positive and that nearly 60% of these dual infected patients were in urgent need of antiretroviral (ARV) treatment. Yet, less than a third of known dual infected patients had accessed these lifesaving drugs. Our assessment was that there was no system in place to track TB patients through the processes (VCT, CD4, referral) that would successfully lead to initiation of ARVs.
 
This is the story of the ongoing effort to design a tracking system that works. Each attempt has bumped into an obstacle which has demanded a rethink. A year later, we are on the fourth design which attempts to reduce complexity, build on existing strengths, and do away with duplication. But are we there yet? Only continuous assessment of results over time will tell.
 
Design Version 1:
About a year Photo_ComputerSister de Wee.jpgago, Sister de Wee, the TB sister at Ikhwezi Clinic, started a computer-based register (Excel spreadsheet) that tracked each of the many steps in preparing patients for ARVs and automatically highlighted patients for whom further interventions were necessary. This helped Sr. de Wee track the dual infected patients and improve their access to ARVs, but after initial great enthusiasm the computer crashed and was not fixed for four months! By then the data backlog was huge and no one had the heart to restart the tracking system.

 
Design Version 2:
In the interim, Sr. de Wee’s idea had been adapted for a clinic that did not have access to a computer. This adaptation took the form of a box register with cards for individual patients and dividers that indicate where the patient is in the continuum of care (see picture at right). Each divider in the box represents a column in the Excel spreadsheet. The box register was being successfully used by Sr. Jacobs in the Maccassar Clinic TB room, so when Sr. de Wee no longer had her Excel spreadsheet we suggested she try out the "box" system at Ikhwezi. This also went well for a time, but then Sr. de Wee went on a long-term training course and the box lay unused in the corner.
 
Design Version 3:
While Sr. de Wee was away, Bongi, the data capturer, attempted to maintain a separate paper register of HIV+ TB patients. This register worked well initially. However, it duplicated much of the demographic information already recorded in the TB register and she soon lost enthusiasm for this intervention.
 
Design Version 4:
Now SrPhoto_NewLedgersmall.jpg. de Wee is back in the TB room and it’s time to try out something new. The TB clinic already has a detailed register for tracking the TB management of TB patients — demography, folder numbers, 2-month and 6-month sputums, outcomes, etc. The obvious intervention is to insert additional columns to the existing register to track the processes required for HIV testing and referral, but lack of space makes this impossible. The answer comes in a flash of counterintuitive insight! We can add the extra columns to the back of the previous page and expand the existing TB register to the left rather than the right. This will maximize existing strengths and do away with duplication. We also decide to reduce the number of indicators to the bare minimum, and list only whether a patient needs ARVs and whether they have actually been initiated. Sr. de Wee thinks this method will be “fun” and attains the essence of what she liked about the Excel register, the fact that she could follow her patients and make sure they received adequate HIV care. She laughed at how the original idea had become progressively simpler, and feels that the latest version has the greatest chance of success.
 
What Have We Learned?
  • Complex data management tools (such as computer-based systems) are very attractive, but may not be sustainable in a developing country setting where continuous and timely technical support is not dependable.
  • Just about any intervention may work well if it is "driven" by an enthusiastic champion in a specific setting, but unless there is shared ownership of the intervention, it will not be sustained when the champion leaves.
  • Systems that contain redundancy are not sustainable and will not be adopted by front-line staff that have to do the work.
  • The simplest systems are often the most likely to succeed and endure.
  • We need to be able to quickly test and reflect on interventions to ensure we do not get "stuck" with an unworkable system.

 

Unsung Heroes II: Joubert Park  May 2007
Cathy Green reports from the Joubert Park Primary Health Care Clinic.
 
Joubert Park is in the very center of Johannesburg. Home to the city’s Art Gallery, it was once a tranquil site offering a place of retreat and refreshment at the heart of this bustling city. Now it is a notorious hotspot for crime. Despite this, local residents still gather to talk or sleep on its benches and grassy areas. Many are immigrants with no prospect of finding work. These immigrants often call “home” a room in one of the many dilapidated hotels and hostels that distinguish the community of Hillbrow from its more affluent neighbors. In the middle of these inauspicious surroundings lies Joubert Park Primary Health Care Clinic.
 
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When we were first introduced to staff from the clinic, they talked about themselves and their patients being held up at gunpoint and robbed as they provided care or sat in the waiting areas. The clinic was one of nine health care facilities serving inner city Johannesburg that had come together for a collaborative learning event, run through a partnership between the Institute of Healthcare Improvement (IHI), the Reproductive Health Research Unit (RHRU) and the City of Johannesburg. Colleagues immediately committed to work together to try and help resolve or lessen this problem.
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It was during this one-day workshop that the Joubert Park clinic staff really understood the plight of children born HIV+ along with recognition of the contribution they could make to a child's life-expectancy. Over half of HIV+ children die before reaching two years of age because their HIV status is not known and appropriate treatment is not provided. Nurses at primary health care clinics were asked to start performing a simple test (PCR) by taking blood from an infant’s heel to enable an early diagnosis. Positive babies could then be referred to other parts of the health care system for antiretroviral therapy as required. This message was further reinforced when one of Joubert Park’s professional nurses attended a funeral the following day and noticed how many graves belonged to young children. So the clinic committed to beginning the job of testing as many babies born to HIV+ mothers as possible, particularly taking advantage of the mother’s attendance at immunization sessions beginning when the baby is 6 weeks of age.  The impact was dramatic. From testing no children whatsoever, the clinic moved to testing 40 per month in the space of 9 months.
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Lack of space within the clinic continues to present huge problems in enabling the range of confidential conversations necessary to provide basic health care. It is impossible to counsel patients about their own or their child’s HIV status without privacy. 
 
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Undeterred by these substantial challenges, team members have been creative in the way they have utilized space, coming up with a number of ideas to test to establish their practicality and acceptability with patients. IHI and RHRU have worked to facilitate this process, leading improvement meetings within the clinic and teaching rapid tests of change (Plan-Do-SPhoto_Immunization.jpgtudy-Act) methodology. One idea was to move some of the immunization activity out into the main waiting area, cordoning off the space with filing cabinets and screens. This was controversial but was reportedly seen as an acceptable compromise by patients. However, as unprecedented cold weather swept through the country the arrangements needed to change again. It was too cold in the waiting room for babies to be undressed. The staff are once again working to generate alternative solutions to enable them to maximize their HIV testing of adults and children without providing inferior levels of care across other services.
 
It is always a pleasure to work with this group of individuals who show such optimism, commitment, energy, and willingness to innovate as they attempt to continually improve their services in the most challenging of environments.
 
 
 
The Team from Ekombe March 2007
Brandon Bennett reports from KwaZulu-Natal on the incredible improvement of one of the smallest hospitals in the region.
 
Three hours from Empangeni, one long stretch through the Mondi Forest and down maybe the harshest road in South Africa, lays the small community of Qudeni (the Q is pronounced as a click, popping in the roof of the mouth). Five kilometers from this village is Ekombe Hospital. Twenty years without a doctor, this hospital has a solid history of nurse-driven care.
 
When Linda, project manager in Umkhanyakude from the Center for Rural Health, and I arrived at Ekombe Hospital the HIV team there was conducting between 1 and 2 HIV tests per day, but that represented a VCT (Voluntary Counseling and Testing) success rate of 100%. The counselors were doing a superb job of convincing the people they counseled to get an HIV test but they wanted more. They wanted an increase in the total number of people tested. Together we plotted, we planned, and after just one month and three change ideas, implemented using the Model for Improvement, the nurses and counselors at Ekombe (see image below) were able to increase fourfold the number of people tested each day (from 1.7 to 7.5). Before testing any change ideas the Ekombe Hospital was on track to administer just over 400 HIV tests this year and now they are on track to complete 1,800. What an incredible result for Ekombe Hospital.
 
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 Ekombe Hospital Nurses and Counselors
 
The South African IHI projects continue to grow and help scale up HIV/AIDS care  February 2007
Updates from Pierre Barker, Program Director in South Africa, on continued scale up of work in the country
 
In three regions, KwaZulu-Natal (KZN), Western Cape and Gauteng, IHI has recently undertaken expansion — either within current districts or into adjacent districts. In KZN, Brandon Bennett launched a new district collaborative in Uthungulu, a rural area north of Durban that is adjacent to an existing IHI supported collaborative in the Umkhanyakude District, home to nearly one million people.
 
In partnership with the Centre for Rural Health (University of KwaZulu-Natal) we held a learning session that was attended by about 50 health care workers from 11 of the districts’ 14 hospitals. Brandon laid the groundwork during the previous four months, visiting sites, generating excitement around IHI's improvement methods, and getting teams started on small PDSA cycles. At the learning session, the teams pledged to increase capacity to treat all patients who need HAART (highly active antiretroviral treatment), and to decrease perinatal transmission of HIV to less than 10%.
 
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 Brandon Bennett teaching the Model for Improvement at the first learning session
in Uthungulu District, KZN
 
In the Western Cape, Michéle Youngleson has been developing innovations in HIV and tuberculosis (TB) care with teams from clinics and hospitals in half of the Eastern sub-district, located outside Cape Town. She is now helping to introduce more effective HIV and TB care to health care sites for the remainder of the sub-district. Michéle will be training managers and coordinators from this district to ensure sustainability of the improvement methods after IHI leaves.
 
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Shanty town outside Cape Town where IHI is helping to introduce
novel approaches to integrate HIV and TB care
 
In Gauteng Province, Cathy Green has picked up the Johannesburg Inner City project from Justin Yarrow who ended a 12-month stint with IHI in December 2006. Cathy led a highly successful learning session in February, and the project is about to double in size, with the incorporation of an adjacent sub-district into the learning collaborative. This project has an ambitious goal to double initiation rates in 12 months, providing access to HAART to all people in the district who need this treatment.
 
In the next six months we expect to launch three additional major initiatives: (1) a PMTCT (Prevention of Mother-To-Child-Transmission) project covering half the population of KZN province, (2) an inner city project to support clinic-based HAART in partnership with McCords Hospital in Durban, and (3) a district-wide PMTCT project in the North West Province.
 
If we had a prize for Improvement Personality of the Month, it would go to Sister de Wee!  January 2007
Michéle Youngleson describes the Ikhwezi Clinic and one special nurse who has recently taken on new improvement work to better manage patient care and raise joy in her work.
 
Ikhwezi is a primPhoto_IkhweziClinic.jpgary health care clinic in the Helderberg Basin, a peri-urban area about a 40-minute drive north of Cape Town. It serves two informal settlements, Nomzamo and Llwandle. Residents have strong ties with rural Ciskei, a group of indigenous black Africans living on a tribal reserve, and the settlements have grown rapidly as people are drawn to the city in search of work.
 
A menacing sculpture guards the entrance to the settlement. Its alien demeanor contrasts starkly with the community which, despite the dire poverty, retains a sense of warmth and humanity. Adults and children sit or play in the baked-earth alleyways between their small lodgings. Clothes, hung out to dry in the sultry heat, punctuate the shanty town with color while restless dogs scour the ground or lie sullenly in the sparse shadow. A woman sets up a make-shift fruit stall outside the clinic and music blares from a nearby tavern. Photo_IkwehziSculptureSmall.jpg
 
Yet, this sense of harmony belies a stealthy horror: Ikhwezi is at the epicenter of the HIV epidemic in the Helderberg Basin — 60% of all HIV+ people in the area come from Ikhwezi and almost one in three pregnant women are HIV+.
 
Tuberculosis (TB) is rife too. Because HIV suppresses the body's ability to deal with infection, patients with HIV and TB can have very fragile health.
 
Sister de Wee (second from left in picture below) has been in charge of the TB room at Ikhwezi for four years. Initially she was reluctant to take part in the improvement project, but over a few months became curious about what was happening to her paitents living with HIV and TB. Having never used a computer before, she and Bongi, the TB data capturer, began to design an Excel program to track their dual infected patients. Darshna Bhatt, a public health intern from the University of North Carolina offered to assist her with this and together they developed a program that flags patients needing intervention for HIV.
 
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Sister de Wee described how her life has changed because of the program she set up:
“I learned that you can’t just go on doing what you’ve always been doing — you have to be accountable! For the four years I was running the TB room, I’ve been cross. People would come and ask me ‘what’s the ratio of this patient to that patient?’ and I didn’t know so I just wanted everyone to leave me alone. Now when I sit at the computer, I can see what’s happening to every patient. I know how to interpret the data and this has empowered me. Now if there’s a problem I don’t go to the facility manager and ask him to ‘please help me,’ I take the data and say ‘this is the problem, how are we going to fix it?’. Before, I lived my life hiding in a cupboard, but this computer program has taught me that I can take the next step forward! It’s changed my life, not only in the clinic but outside — now I have a destiny. I have so many new ideas, I just have to find a way of making them happen.”
Unsung Heroes and Heroines: Cathy's Reflections on Her Visit to the Mdjobe Clinic 
December 2006
Cathy Green recently made a trip to the Mdjobe Clinic with its senior nurse to learn about the extraordinary effort one woman has made towards the fight against HIV/AIDS.
 
We drive for one-and-a-half hours down a dirt track to get to the Mdjobe Clinic. Along the way, we pick up two ladies laden down with large duffle bags. They are standing by the roadside hoping for a lift. It is not advisable to pick up hitchhikers in South Africa; car-jacking is rife. But I’m accompanied by a wise, senior nurse who was born in this district. I take my lead from her.
 
We arrive at the clinic and the crowded waiting area falls silent as we walk in. I attempt a poorly pronounced Xhosa greeting and it seems to break the ice. There are a few giggles and some sheepish responses.
 
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 The Mdjobe Clinic
 
We are here to visit Sister Kumalo, one of only two qualified nurses who run the primary health care clinic that meets the immediate health needs of this rural community. Sister Kumalo is an extraordinary woman. Soon after becoming involved in a learning community, supported by the Institute for Healthcare Improvement and the Regional Training Center, she committed to finding ways in which her HIV-positive clients could get access to the drugs they needed to improve their health. 
 
Justin Yarrow, IHI's Project Manager based in Johannesburg, recently visited a mobile HIV testing center located in a busy shopping mall to better understand the HIV testing experience. The following entry recounts his reflections.
 
Who would you disclose to if you were HIV positive? What would their response be? What is your plan for remaining negative? What will you do if your result is positive? These are not questions that you normally answer on a trip to the mall, but in a country with a lot of malls and young at-risk citizens, innovative mobile voluntary counseling and testing (VCT) centers bring these questions into the heart of South African's favorite destination.
Deputy Health Minister Nozizwe Madlala-Routledge takes an HIV test near her home in KwaZulu-Natal, South Africa
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Designed to de-stigmatize the testing process, give people a way of knowing their status, and raise awareness for the ~90% of South Africans who are HIV negative, the initiative was advertised on the coolest radio stations, and those who got tested were guaranteed free entry to what promised to be a raging music concert. I can't attest to the concert, but, in a chic Levi's branded tent, I felt the fear of the unknown test results and developed my own answers to those questions. The results can be measured in the numbers tested — it must have been thousands, but I was more heartened by the teenage guy in the waiting area whom I overheard talking to his mom. He said he was there to get tested because he just wanted to know his status. The tap, as we say, is open, flooding the country with 500,000 people who need ARVs each and every year. Approaches like this will, hopefully, and eventually, slow it down to the barest of trickles.
 
 
Lloyd Provost's Visit (Part 3)  July 2006
A continuation of observations by Lloyd Provost, an Improvement Advisor for IHI’s work in South Africa and Malawi, on his site visits in South Africa’s Eastern Cape. 
 
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This morning I met Michele Youngleson and Darshna Bhatt to review the IHI improvement project in the Western Cape. Darshna has been working with Michele since May 2006 and this is her last week in Cape Town. She had just completed a study of HIV care for patients in the TB clinic at Ikhwezi which indicated that about 70% of the TB patients were HIV positive. About 60 of the 200 TB patients need to be on ARV treatment and another 40 need to be tested. Darshna’s analysis could lead to a pilot project to eliminate this backlog at Ikhwezi and then spread of the approach to all the other TB clinics in the Heldeberg Basin. We drove north to the beautiful Hottentots Mountains and visited the Sir Lowry’s Pass Clinic. There we met with Sister Jacoba and Julia, one of the counselors for the HIV/AIDS programs. Michele led the discussion, planning a series of PDSA cycles to better utilize the patient registries and improve follow-up on the PMTCT and VCT programs in the clinic.
 
We next drove to Somerset West and met with Elsie, the coordinator of the HIV counselors from the Philippi Trust. The workload for counseling from the ARV program has created a substantial strain on counselor resources.
 
Elsie had just completed an innovative PDSA cycle on refocusing the ARV counseling from an emotional to a more cognitive approach. In addition to better meeting the client’s needs, this approach could reduce the workload for counselors. Elsie and Michele planned a series of PDSAs to follow up this initial test with two other counselors. They also developed PDSAs to test group counseling sessions in two different contexts.
 
Next we visited with Paul Nkurunziza, Manager for HIV Care in Cape Town. Part of the complexity of this Western Cape project is the overlap in authority and resources from national, provincial, district, regional, city, and metro authorities; Michele has become very adept at navigating among these organizations. Darshna presented the results of her work in the TB clinic and then Michele approached Paul to accelerate getting all TB patients tested and on ARVs, when appropriate. Paul pointed out that a key part of IHI’s contribution has been getting health care workers to believe they can improve.
 
Lloyd Provost's Visit (Part 2)  July 2006
A continuation of observations by Lloyd Provost, an Improvement Advisor for IHI’s work in South Africa and Malawi, on his site visits in South Africa’s Eastern Cape.
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After a restful evening at one of Umtata’s nicest B&Bs, we stopped by our local partner’s (RTC, Research Training Center) office to finalize plans for the day’s improvement team meeting. This monthly meeting is a collaboration of representatives from about 12 district clinics focusing on improving HIV/AIDS related services.

With IHI’s coaching over a year ago, the group agreed on a goal of getting at least 1,500 clients on ARVs by December 2006. Currently there are 565 individuals on ART, so the group is very motivated to identify changes they need to test to accelerate the rate of getting new patients on treatment during the next 6 months.
 
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Using the process map the group had previously prepared, Alicia and Cathy led a discussion on the time delays at each step in the identification and preparation process. For about half of the clinics, the current bottleneck is prepared clients who wait 2-7 weeks to see a doctor before they can get their ARV prescription; this extreme shortage of doctors is something the group is going to have to address.
 
Since currently only 19 children in the district are on ARVs, Dr. Ola from RTC joined the meeting to give a presentation on speeding up the process to get kids on ARVs. After the meeting we headed to the Umtata airport to catch flights to Cape Town.
 
Lloyd Provost's Visit (Part 1)  July 2006
Lloyd Provost, an Improvement Advisor for IHI’s work in South Africa and Malawi, visited Cathy Green on her site visits in South Africa’s Eastern Cape. For three days of his journey he recorded these blog entries.
 
This morning I joined Cathy Green on a 6:15 AM flight from Johannesburg to Umtata in the Eastern Cape. We were met at the airport by Alicia Siphambo, a project manager for our local partner’s Regional Training Center. I don’t normally think of South Africa as cold, but it is winter here and the Avis attendant had to “de-ice” our car.
 
Our first meeting was about an hour’s drive to St. Lucy’s Hospital, where we met with the ward nurses to discuss counseling of all patients coming to the hospital about AIDS testing. Currently all the TB patients would be counseled and tested (about 80% testing positive), but in some of the other areas (outpatient and general wards) this was not always being done. Cathy and Alicia led a dialogue about the issues and opportunities and each of the nurses talked about plans to increase “VCT” (voluntary counseling and testing) for all the patients in their ward. They designed a data collection strategy to see the impact of their efforts by next month.
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In the afternoon, we drove to Nessie Knight Hospital for a meeting planned with the feeder clinics to the hospital. Because of lack of coordination, only one of the clinics was able to attend the session. Since nurses from all parts of the office showed up for the meeting, Cathy seized the opportunity to have a broader discussion of HIV/AIDS-related services, focusing on speeding up the counseling/preparation phase. The average length of stay at the hospital has gone from 4 days to 19 days because of the number of patients with HIV. Currently all patients in the hospital are counseled about testing for HIV/AIDS and more than 80% agree to be tested. Issues about follow-up testing arose and some of the nurses agreed to test the use of the registry to initiate reminders for follow up.
 
Mhlontlo Update from Pierre  January 2006
The Mhlontlo District collaborative continues to gather strength. It’s a testament to Nupe's coaching of local clinics that this has continued despite his departure from South Africa in December. We are hoping to find a project manager to consolidate this project as well as start up 2 adjacent District collaboratives, and to train local project managers to sustain the systems improvement initiative. This week, I traveled to 2 remote clinics and was struck by the ingenuity of the health care staff in overcoming obstacles to care, and by the hardship and determination of the patients trying to get care. Here are 2 examples.
 
One of the District's principle innovators, Sr. Mbegeni at the door of her benchmark clinic in Mhlontlo DistrictPhoto_MhlontloDistrict.jpg
 
Obtaining a CD4 blood count is a major stumbling block to efficient workup and referral of HIV positive patients who may need ART. Many clinics are not serviced by regular transport to pick up samples and there is no reliable way to get results. At Shawbury clinic, the nurse in charge, Sister Mbegeni has a devised a plan whereby she draws blood for CD4 counts on all HIV positive clients, gives the blood to the clients, who then pay for their own transport to take the sample to the Qumbu lab on that day. She then sends a letter along with the next set of clients over subsequent weeks to the Qumbu lab, requesting blood results from previous clients. These "patient couriers" then bring back results of fellow patients to the clinics. She has a 100% success rate with this system, average turn around for CD4 results is 2 weeks! The tragedy is that these clients are desperately poor and are paying exorbitant transport costs, just to personally take their blood sample to the lab.
 
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 The dirt road that leads to the Mbogotwana clinic (top right).
Note the pedestrian at the bend in the road on the left.
 
The determination of these patients to get treatment despite poverty and lack of transport is extraordinary to observe. A major focus of the project is to get HIV/AIDS care into local clinics so that clients don’t have to use expensive taxis to get to the central clinics. But even getting care in local clinics is not easy. The second clinic I visited is accessible only by a rutted dirt road, serviced occasionally by taxis. Sister Hoza of the Mbogotwana clinic says the great majority of her clients arrive on foot, many of who will walk several miles to get to the clinic.