Improving care of HIV-infected breastfeeding mothers and their babies:

1. Improving care of HIV-infected breastfeeding mothers and their babies: Early results from the Partnership for HIV-free Survival Initiative in Uganda Tamara Nsubuga-Nyombi, URC IAS- Melbourne, Australia July 22nd, 2014

2. PHFS in Uganda

3. The Partnership for HIV-Free Survival

4. Retention of mother-baby pairs in care Changes Apr:Pairing of mothers and babies May 13: Merged EID and ART services at one service points and gave same appointment date Jun 13: Peer mothers involved in counseling mothers on appointment keeping Sep 13: Assigned EID focal person to pair cards and make phone calls to mothers Dec13: Set specific / separate day to see MB pairs At one low volume site ave. 93 pairs / mo May 13: Pairing of mothers and babies Jun 13: Peers escort MB pairs to the clinic Jul 13: Family support group meetings used to identify MB pairs and see them then Nov 13: ART and EID merged so MB pairs receive services in one area Mar 14: Phone calls to mothers At one high volume site ave. 170 pairs / mo

5. Mother-baby pairs who receive a standard package of care at routine visits Expert clients trained to do MUAC and assigned responsibility of assessing and nutrition counselling Mothers told about what services to expect so they can remind HW if they forget a service Merging of ART and EID services Learning session 2; new client flow chart developed Changes made at example site 20 clinics reporting 21 clinics reporting

6. Integrating the content and process of providing care Process of care How it is done: • Improve identification of mothers and babies • Improve retention in care • Provide routine services • Improve IYCF practices and adherence Content of care What is done: Guidelines on IYCF (e.g. all children should be exclusively breastfed for 6 months) Guidelines on Option B+ (all HIV positive mothers should be initiated on B+) Output/ outcome HIV-positive mothers on ART who are doing well Well nourished, HIV-free babies

7. Sequencing and simplifying the approach

8. Basics of Collaborative Improvement QI team representative Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care Collaborative-level sharing and synthesis of best practices Site-level summary Site-level testing of changes and analysis of results 8

9. Collaborative improvement model

10. Challenges and what we are learning Challenges: Not all HIV-positive mothers at the different entry points are identified; need to improve linkages and PICT 2-3 of 15 HIV-positive mothers do not consent to ART initiation immediately; health workers need to follow-up through phone calls What we are learning: Substantial effort has to be put into retaining mothers and their babies in care for 18 months The QI approach enables health workers apply the most effective and efficient changes to improve their work Having more entry points, involving the community and merging ART and EID services improves ART coverage, retention and quality of care

11. Acknowledgements The 22 PHFS demonstration sites The Ministry of Health, PEPFAR, and other partners in Uganda (TASO, JSI-SPRING, EGPAF-STAR SW) District quality improvement coaches Colleagues at USAID ASSIST For more information please contact: Dr. Humphrey Megere, Chief of Party, USAID ASSIST Project, URC Uganda hmegere@urc-chs.com