I was drawn to working in the field of child health during medical school. I felt a deep care and concern for this vulnerable age group and recognized that interventions during this time can be critical for the path that a child will follow into adulthood. A recent project has given me the space within my organization to be an advocate for pediatric and adolescent HIV program work in our area and further afield.
South Africa has made tremendous gains in its HIV care and treatment program over the last decade, supporting a considerable number of people to access life-saving treatment. There are, however, still many challenges in ensuring all people, including children and adolescents, can connect to care and support. A collaboration of passionate leaders in pediatric and adolescent HIV care in Johannesburg was formed to help tackle these gaps. The Paediatric and Adolescent Scale-Up Project, consisting of Department of Health (DoH) stakeholders and donor-funded implementation support partners, strives to ensure more children are tested for HIV and linked to the care and treatment they deserve.
Approaching hospitals to offer them support can feel quite daunting, as there are several complexities we face when compared to primary health care facilities. These include a variety of departments, managers, and reporting pathways; large numbers of patients; and high burden of disease and turnover. In HIV care, this means a higher number of HIV-exposed newborn deliveries, as well as significantly more HIV testing and care provided, than at primary care clinics. We had limited interaction with hospitals as a group in the past, and no easily accessible existing platforms was to build relationships, improve data management, and overcome identified gaps in clinical services.
The team engaged with the six hospitals offering care to children in Johannesburg through a new platform, the Hospital Forum. We prepared collaboratively for forum meetings, including data review, stakeholder engagement, and collection of best practices from the hospitals. We held three meetings in 2016 and a fourth the following year to tackle various gaps, including testing at birth for HIV-exposed newborns, linkage to care for HIV-positive infants, HIV testing in older children, treatment and follow-up, missed diagnostic opportunities, and completion of a routine data collection tool for HIV-positive children.
Each meeting followed a specific structure. We set the scene with a case presentation and data review – using these to identify major gaps – followed by a discussion to develop an understanding of current practice and root causes of these gaps. Then, we shared potential change ideas being used at some of the sites and selected change ideas and actions to be taken by each hospital. Between the meetings, the team led follow-up and support at the individual hospital level. At each meeting we then looked back on progress using routine data and feedback from the various hospital teams.
Creating a new platform where staff from the hospitals could meet, share common challenges, and learn from each other was key to building relationships between the hospitals as well as with the project staff. Members of the platform were able to see themselves as part of a bigger team and understand the mandate being given to them, which really helped to facilitate follow-up at the individual hospital level at a later stage.
The main challenge identified was data management. The key here was to break down the process into focus areas for each meeting, which made tackling the gaps more achievable. Gaps in to tackle identified gaps in care and data management. We thus came together to design, implement and review a hospital improvement strategy between July 2016 and July 2017. Our aim services were more challenging, as they related to limited human resources in some cases.
Despite the busy schedules of our stakeholders, meetings had excellent attendance, with only one hospital not represented on one occasion. We had a broad mix of departments and managers. Different hospitals had the opportunity to share change ideas, and others learned from these successes. This encouraged others at the meeting, giving them hope that change was possible. Hospitals gave feedback on progress and identified new gaps and change ideas. Reported birth HIV-PCR test uptake improved from 26 percent of at-risk births (August 2015 – March 2016) to 104 percent* (April 2016 – May 2017). The number of tests reported increased from a median of 89 per month prior to the forum to 1075 per month. Total tests for children ages 19 months to 14 years increased from 57 (April – June 2016) to 648 (April – June 2017). Data collection using the tool increased as well. Progress is still being made to ensure all hospitals report their HIV treatment data (currently 4 of 6 hospitals are reporting this), as well as to increase HIV testing uptake in outpatient settings.
The Hospital Forum created a platform in which relationships can be built between hospital representatives, DoH, and supporting partner organizations, who traditionally had limited interaction at this level. It has provided a way for hospitals to learn from each other and collaborate on unique and shared challenges, allowing teams to overcome these in their own settings. The idea was relatively simple to implement and well attended by a wide representation of stakeholders, and it has proven results.
The project as a whole has been an incredible opportunity to bring together people who have a passion for child health and improving outcomes of children and adolescents who are living with HIV. It has allowed us as individuals, as well as organizations, to focus in on this age group, and test out new strategies and ideas, in an environment where there are so many other priorities and needs that also need to be addressed.
We would recommend that other areas adapt or adopt this strategy to overcome common challenges relating to pediatric and adolescent HIV care at hospitals. Lessons we have drawn from this project include:
- Addressing different levels of health care services (e.g., hospital vs primary health care) in different platforms is useful to fully understand root causes and contexts, as well as to develop relevant change ideas.
- Sharing change ideas that were successful in similar settings helps to motivate teams.
- Close support on the ground level may need to be intensive to achieve desired outcomes.
Overall, the Paediatric and Adolescent Scale-Up Project has shown that teams can raise awareness and create change in pediatric and adolescent HIV care.
The initial results of this work were shared as an abstract at the 2018 IHI Africa Forum on Quality and Safety in Healthcare. Reserve your spot now for the 2020 conference.
*Note: This percentage is calculated using the number of tests administered and the number of live births to women who are HIV-positive. In some cases, there are issues with the reporting of the routine data element of births; for example, the birth of twins may be counted as one birth but two tests, and some babies transferred from other sites receive the test but are not counted in the number of births. As a result, the percentage here is slightly higher than 104 percent; if we had perfectly accurate numbers, the maximum (and the goal) would be 100 percent.
Dr. Carol Tait is Project Manager/Medical Officer of the Paediatric and Adolescent Scale-up Project at the Anova Health Institute in Johannesburg, South Africa.