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Expanding Two-Way Texting to Reduce Follow-Up Appointments for Male Circumcision Patients

Post categories: Caryl Feldacker Male Circumcision South Africa Zimbabwe
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This piece was first posted on the University of Washington Department of Global Health’s (DGH) website.

A new five-year research project will study two-way texting as a means of communication between healthcare providers and male circumcision (MC) patients in South Africa. It will build on previous research conducted in Zimbabwe.

Caryl Feldacker is the Principal Investigator (PI) on this RO1, which will support research through 2025. The multi-stage implementation science study is based out of the International Training and Education Center for Health (I-TECH), and will be implemented with Dr. Geoffrey Setswe, PI for South Africa partner, Aurum Institute, and with technology partner, Medic Mobile.

“Previous research shows that healthcare workers waste a lot of time and money reviewing MC clients without complications,” Feldacker said. “So, in partnership with Medic Mobile, we developed a two-way texting (2wT) system to identify and refer men with potential medical issues to in-person care while allowing the vast majority to opt-out of routine post-operative visits.”

Programs providing voluntary medical male circumcision (MC) in sub-Saharan Africa are struggling to meet the annual goal of 5 million MCs. However, chronic human and financial resource shortages threaten achievement of MC targets, reducing impact of this effective HIV prevention intervention. Although MC is safe with an adverse event (AE) rate of less than 2% , global MC guidelines require one or more in-person, post-operative visits within 14 days of MC for timely AE identification. With low AE rates, overstretched clinic staff likely waste invaluable resources conducting unnecessary routine reviews for MC clients without complications while men healing well needlessly pay for transport, miss work, and wait for reviews, discouraging MC uptake.

With this background, Dr. Feldacker’s prior randomized controlled trial (RCT) in Zimbabwe tested whether 2wT between patients and providers during the critical 13-day post-operative period (instead of routine in-person reviews) could ensure patient safety while reducing provider workload. 2wT safely reduced client visits by 85%, increased AE identification, and cut follow-up costs, suggesting that 2wT could make a dramatic difference in MC programs operating at scale. Plus, providers and patients found the 2wT follow-up approach highly usable and acceptable. “These daily text exchanges really empowered men to be partners in their healing process, creating a win-win for providers and patients.”

Read the entire story on the DGH website.

I-TECH Awarded Funding For COVID-19 Response and Activities

Post categories: COVID-19 HIV Care and Treatment Kenya Malawi
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Illustration of SARS-CoV-2, the virus that causes COVID-19. Image credit: CDC

Many of the International Training and Education Center for Health (I-TECH) country offices have received supplemental funding from the U.S. Centers for Disease Control and Prevention (CDC) or pivoted portions of current CDC funding to implement and support activities related to the global COVID-19 response, such as contact tracing efforts, provider education, vaccine preparedness, and infection prevention and control (IPC).

To date, I-TECH has received over $500,000 of new funding for IPC of COVID-19 in Kenya and Malawi, while several other offices have submitted proposals for additional funding.

CDC has also redirected $83,000 of I-TECH Tanzania’s funding to support training on COVID-19 case investigation and contact tracing teams specifically for field epidemiology and training program graduates and community health care workers.

“The funding and support that we have received from CDC will allow us to apply our decades of implementation knowledge and expertise from combating the HIV epidemic to the current global COVID-19 response,” says Ivonne Butler, MPH, Associate Center Director for I-TECH. “We look forward to working with other implementing partners and local ministries of health to provide comprehensive training, technical assistance, and learn from one another to effectively respond to this evolving pandemic.”

In addition to new funding and funding shifts, I-TECH has been invited by local governments and ministries of health to collaborate in their COVID-19 responses. So far, I-TECH has aided in the creation of standard operating procedures, contributed to public pandemic preparedness materials, and supported hospitals with COVID-19 IPC. Leveraging existing processes and programs — such as warm lines and distance learning platforms — has allowed I-TECH to rapidly respond to the emerging needs of health care workers and providers.

The newly established independent local Zimbabwe office, Zim-TTECH (Zimbabwe Technical Assistance, Training, and Education Center for Health), also received $579,000 for vaccine preparedness and disease prevention for the rapid scale-up and implementation of a SARS-CoV-2 vaccine (when available) as well as IPC triaging at 250 sites throughout the country.

Ensuring Continuity of HIV Care

I-TECH’s programs are now faced with the difficult task of ensuring the continuity of HIV care and treatment for people living with HIV (PLHIV) during the pandemic. Due to the COVID-19 pandemic, some countries are facing disruptions in antiretroviral therapy (ART) medication supply, an inability for PLHIV to pick up ART medication at pharmacies or hospitals, and a diverted focus from HIV testing due to lack of personal protective equipment and safety concerns.

“Our programs are committed to continuing to provide quality HIV care and treatment while maintaining a safe environment for those for staff and patients,” says Butler. “Our teams and programs have had to adapt and bring innovative delivery of uninterrupted HIV care and treatment services to people living with HIV. They have done an outstanding job in their rapid responses during this unprecedented time.”

Some examples of the innovative way teams are delivering HIV care during the COVID-19 pandemic is through text messaging as a way to reach PLHIV, coordinating community ART refill groups, educating and training providers via distance learning platforms, and using warm lines and WhatsApp to support providers.

I-TECH Ukraine Hosts First Index Testing Forum Following Launch of National Index Testing Program

Post categories: Index Testing/Partner Notification Ukraine
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Attendees brainstorm at the Index Testing Forum in Ukraine.
A group of forum attendees meet to brainstorm and discuss the index testing program. Photo credit: I-TECH Ukraine.

On December 18, 2019, I-TECH Ukraine facilitated its first forum on index testing, a key strategy used to identify and support HIV-positive individuals. Service providers, as well as representatives from the US Centers for Disease Control and Prevention (CDC) and the Public Health Center (PHC) of the Ministry of Health (MOH) of Ukraine, attended the forum and participated in discussions detailing the best ways to implement and adapt proven index testing methodologies in Ukraine.

I-TECH Ukraine rolled out its national program in October 2019, after shifting its programmatic focus to provide index testing development and quality assurance. The program was launched at 39 antiretroviral therapy (ART) clinics in 11 PEPFAR priority regions across the country.

The recent forum included a review of early program performance; identification of best practices that can be scaled up to improve index testing and partner notification performance; and solutions to key challenges that index testing providers are currently facing in Ukraine.

“The index testing strategy gives us all high hopes that we can reach out to the most affected groups of people living with HIV and identify many individuals in need of care much earlier than it happens currently in Ukraine,“ says Anna Shapoval, I-TECH Ukraine Country Representative. “As always, I-TECH is proud to build this new programming not just on the vast evidence and globally acknowledged best practices but also on the mountain of successful experiences in other countries where index testing programs have been initiated and implemented by I-TECH in previous years.”

To strengthen the programmatic response, the forum included a number of speakers and index testing subject matter experts. Dr. Serhii Riabokon, an infectious disease doctor in the PHC’s department of the coordination of treatment programs on HIV, viral hepatitis, and sexually transmitted infections, presented the current legal framework and the state of index testing program implementation in Ukraine. I-TECH’s program and evaluation teams also gave a brief overview of the program including the design as well as the successes and challenges to date. Four well-performing regional sites were also able to share the best practices they used during early program implementation.

Dr. Matthew Golden presents at the Index Testing Forum in Ukraine.
Dr. Matthew Golden shares his experiences in partner services implementation, scale up, and development around the world. Photo Credit: I-TECH Ukraine.

In addition to the index testing program-specific presentations, the forum also included presentations by experts who shared their valuable experiences in partner services implementation, scale-up, and development:

  • Matthew Golden, MD, MPH, Professor at the University of Washington (UW) Department of Medicine’s Division of Allergy and Infectious Diseases and I-TECH faculty member, reviewed the development and challenges of partner services programs around the world, as well as voiced practical recommendations for Ukrainian index testing advancement.
  • Nancy Puttkammer, PhD, MPH, I-TECH faculty and DIGI faculty lead, and Jason Beste, MD, MPH, I-TECH International Clinical Advisor, were on a panel discussion on the ways of overcoming key challenges in index testing implementation.

“A key part of the program is to ensure quality results,” says Shapoval, “and consistent and collaborative learning is paramount to building local capacity.”

December’s forum is just the first of planned, quarterly forums designed to further build local capacities around index testing and quality assurance.

THIS PROJECT IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER U91HA06801, THE INTERNATIONAL AIDS EDUCATION AND TRAINING CENTER (IAETC). THE CONTENT OF THIS POST IS THE AUTHOR’S AND SHOULD NOT BE CONSTRUED AS THE OFFICIAL POSITION OR POLICY OF, NOR SHOULD ANY ENDORSEMENTS BE INFERRED BY HRSA, HHS OR THE U.S. GOVERNMENT.

Expanding HIV Care and Treatment in Zimbabwe

Post categories: Cervical Cancer Differentiated Care Gender/Women & Girls Health Systems Strengthening HIV Care and Treatment Index Testing/Partner Notification Key Populations PrEP Stefan Wiktor Zimbabwe
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The ZimPAAC consortium collaborates with the Ministry of Health and Child Care (MoHCC) in Zimbabwe to meet the following primary HIV epidemic control objectives:

  • Diagnose 95% of all persons living with HIV through integrated testing
  • Ensure 95% of individuals diagnosed with HIV are initiated on antiretroviral therapy (ART), retained in care, and are virally suppressed using differentiated service delivery models

Using a Differentiated care model, a patient-centered model of service delivery designed to meet the diverse needs and expectations of all people living with HIV, ZimPAAC oversees activities such as:

  • facility and community-based HIV testing;
  • HIV self-testing, index case testing;
  • ART initiation; and
  • ART delivery through multi-month refills for stable patients, Family ART Refill Groups, and Community ART Refill Groups (CARGs). CARGs benefit group members—through decreasing health center visits, offering peer support, and allowing clients to take responsibility for their health—and staff, by decreasing workload and allowing greater time for patient care.
I-TECH Zimbabwe Care and Treatment Sites and Districts
A map of I-TECH’s Care and Treatment Sites and Districts in Zimbabwe.

In addition to differentiated service delivery, ZimPAAC conducts site-level mentoring at health facilities to strengthen health service delivery towards the “95-95-95” UNAIDS targets by improving patient linkages between HIV testing, initiation on treatment, and retention in care rates. This is accomplished in part by several hundred dedicated HIV testers and nurses who support ART initiation and management of opportunistic infections alongside MoHCC staff.

ZimPAAC also supports index testing through community linkages activities that help clients access HIV testing, especially sexual partners and biological children of existing HIV-positive clients who present to the health facilities. In an effort to improve index testing within MoHCC health facilities, ZimPAAC has implemented an assisted partner service model, known as Enhanced Index Case Testing. This program emphasizes reaching clients recently diagnosed with HIV and those whose blood tests show a high HIV viral load. Quality Improvement activities are a key part of ZimPAAC’s approach to improving outcomes for index testing. In 2019, a “change package” describing the interventions that have improved index testing was developed by ZimPAAC for national scale-up of the model.

ZimPAAC program activities also support retaining people living with HIV in care. Programs engage community linkage facilitators who work with facilities and communities to identify patients who have defaulted from treatment and return them to services.

In addition to HIV care and prevention for adults, ZimPAAC supports increased access to services for children and adolescents through Africaid’s community adolescent treatment supporters (CATS). CATS are HIV positive 18-to-24-year-olds trained to provide peer support, conduct demand-creation activities, build community engagement, and mobilize targeted HIV testing and outreach activities to bring services to this hard-to-reach group.

In addition to the first two objectives, ZimPAAC collaborates with MoHCC towards two additional objectives:

  • Strengthen and expand access to cervical cancer screening and treatment of precancerous cervical lesions among women living with HIV
  • Increase uptake of pre-exposure prophylaxis (PrEP) services through training, technical assistance and direct client support

In 2019, ZimPAAC began the expansion of cervical cancer screening for women living with HIV, beginning with a situational analysis to identify sites for implementation of a program serving women with visual inspection with acetic acid and cerviography.

Under the direction of PZAT, ZimPAAC also works closely with the MoHCC to support key-population-friendly programming in the public health sector facilities in Harare. PZAT supports health worker training at selected facilities and builds demand and knowledge of these services through community champions and engagement with vulnerable populations and advocacy and civil society organizations. PZAT also works to promote PrEP services for adolescent girls and young women in Mazowe district and among key populations in Harare.

Using Innovative Technology for Better Data in Zimbabwe

Post categories: eLearning/Distance Learning Health Information Systems Stefan Wiktor Zimbabwe
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The ZimPAAC consortium has supported high-quality health care worker (HCW) knowledge and skills in Zimbabwe with technologies such as applications with clinical resources for clinicians, tablet-based data collection, and self-study modules. Through the use of self-study courses, HCWs complete learning activities using case scenarios in either prevention of mother-to-child transmission client retention, HIV testing services for children and adolescents, or viral load testing. ZimPAAC also uses WhatsApp messaging groups as a training intervention during self-study for peer-to-peer learning and support. Tablet-based data collection has now become the norm for most sites.

ZimPAAC also continually works to strengthen its program monitoring systems, such as the deployment of TrainSMART as the national training database. Recently, ZimPAAC developed and introduced the ZimPAAC Data Improvement Plan (ZDIP)—a new system of electronic data collection tools that will improve reporting and give facility and district staff better access to data. The new digital forms in ZDIP offer built-in data quality checks, the ability to view graphs, and provides faster feedback to sites so they can use the data for facility-based improvements.

Reducing HIV through Voluntary Medical Male Circumcision in Zimbabwe

Post categories: Caryl Feldacker HIV and STI Prevention Male Circumcision Quality Improvement Scott Barnhart Zimbabwe
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Since 2013, the ZAZIC Consortium has been implementing Voluntary Medical Male Circumcision (VMMC) as part of a combination HIV prevention package approved by the Ministry of Health and Child Care (MoHCC) in Zimbabwe. Unlike other VMMC programs in the region, the ZAZIC model uses an integrated approach, blending local clinic staff supported by MOHCC with partner staff. The ZAZIC consortium supports:

  • Training using MoHCC approved curricula, health workers in the supported districts are trained on the surgical technique as well as on demand creation
  • Development and implementation of age appropriate demand creation strategies
  • Support service delivery in 13 districts from consent procedures to post-surgical care and linkage to other services
  • Comprehensive monitoring and evaluation including continuous quality improvement and operations research

From 2013-2018, ZAZIC performed over 300,000 VMMCs with a reported moderate and severe adverse event rate of 0.3%. The safety, flexibility, and pace of scale-up associated with the integrated VMMC model appears similar to vertical delivery with potential benefits of capacity building, sustainability and health system strengthening. Although more complicated than traditional approaches to program implementation, attention should be given to this country-led approach for its potential to spur positive health system changes, including building local ownership, capacity, and infrastructure for future public health programming. Over 80% of the circumcisions occur in outreach settings, an approach that ensures wide coverage and expanded services in hard-to-reach locations.

Two-Way Texting for Post-Operative VMMC Follow-Up RCT in Zimbabwe

Post categories: Caryl Feldacker Health Information Systems HIV Care and Treatment Male Circumcision Zimbabwe
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Voluntary medical male circumcision (VMMC) is considered safe and the vast majority of men heal without complication. However, guidelines require multiple follow-up visits, which can burden staff and facilities with clients who are typically healing well. With funding from the National Institutes of Health (NIH), ZAZIC recently conducted a prospective randomized control trial (RCT) to determine if two-way texting (2wT) was as safe as routine post-operative visits and if it reduced workload in two high-volume VMMC sites near Harare, Zimbabwe.

Image of the 2wT App used to support the study.

Both clients and providers felt satisfied with the 2wT system and felt it could be ready for scale. Many clients reported feeling confident, comfortable, satisfied, and safe with text follow-up. Importantly, clients felt that 2wT saved them time and money. Providers also noted 2wT saved them time, empowered their clients to engage in the healing process, and addressed gaps in MC service quality.

The results strongly suggest that 2wT is highly usable and acceptable for providers and patients. Men with concerns appeared confident and comfortable to receive guidance via text and providers noted that men engaged proactively in their healing.

It was recommended in the study that 2wT between providers and patients should be considered for future adaptation in other short-term care contexts. 2wT also appears far less expensive than active follow-up to improve patient safety: on average, post-VMMC follow-up under 2wT was $0.098 compared to $0.955 under routine care. 2wT was both less costly and more effective in identifying AEs relative to the expected rate of AEs.  As such, I-TECH aims to scale 2wT in further testing among rural clients and guardians to improve patient care at lower cost.

The trial is registered on ClinicalTrials.gov, trial NCT03119337, and activated on April 18, 2017. https://clinicaltrials.gov/ct2/show/NCT03119337. This RCT was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW010583.

Increasing VMMC Delivery and Safety in Zimbabwe

Post categories: Caryl Feldacker Male Circumcision Scott Barnhart Zimbabwe
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Employing modern medical male circumcision within traditional settings may increase patient safety and further male circumcision scale up efforts in Sub-Saharan Africa. ZAZIC established a successful, culturally sensitive, partnership with the VaRemba, an ethnic group in Zimbabwe that practices traditional male circumcision. The VaRemba Camp Collaborative (VCC) was created to provide safe, standardized male circumcisions and reduce adverse events (AEs) during traditional male circumcisions. ZAZIC supported the VCC by providing key MC commodities and transport to help ensure patient safety. In 2017, the VaRemba granted permission to ZAZIC doctors to provide oversight of MC procedures and post-operative treatment for all moderate and severe AEs within the Camp setting. Of the Camp residents, 98% chose medical male circumcision.

The multi-year, iterative cycle of meetings and trust building ultimately resulted in the successful VCC, a model that may be replicable for others trying to combine modern male circumcision and traditional practice.

Achieving Targets through Performance-Based Financing in Zimbabwe

Post categories: Caryl Feldacker Health Systems Strengthening Male Circumcision Quality Improvement Scott Barnhart Zimbabwe
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ZAZIC employs an innovative performance-based financing (PBF) system to speed progress towards ambitious voluntary medical male circumcision (VMMC) targets. The PBF schedule, which started at $25 USD and now varies from $6.50-$14 USD depending on the location and the circumcision team, is continually refined to set the program up for sustainable transition. The PBF is an incentive that is intended to encourage underpaid healthcare workers (HCWs) to remain in the public sector and to strengthen the public healthcare system. The majority of the incentive supports HCWs who perform VMMC alongside other routine services; a small portion supports province, district, and facility levels.

I-TECH conducted a qualitative study to assess the effect of the PBF on HCW motivation, satisfaction, and professional relationships. The study found that the PBF appreciably increased motivation among VMMC teams and helped improve facilities where VMMC services are provided. However, PBF appears to contribute to antagonism at the workplace and create divisiveness. To reduce workplace tension and improve the VMMC program, ZAZIC increased training of additional HCWs to share the PBF incentive more widely and strengthened integration of VMMC services into routine care.

Ensuring High-Quality Service Provision in Zimbabwe

Post categories: Caryl Feldacker Implementation Science Male Circumcision Scott Barnhart Zimbabwe
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Describing Adverse Events within VMMC Programs at Scale

I-TECH works diligently to review and revise procedures to identify, manage, and report adverse events (AEs). I-TECH’s previous publications on AEs reveal efforts to maintain high quality programming and emphasize patient safety alongside achievement of targets.

An evaluation published in the Journal of the International AIDS Society found that AEs were uncommon, with 0.3% of surgical and 1.2% of PrePex (a non-surgical VMMC device) clients experiencing a moderate or severe AE. However, the evaluation also found that younger clients were at greater risk of infection.

Increasing Understanding on the Timing and Type of AEs in Routine VMMC Programs at Scale

As VMMC expands in Sub-Saharan Africa, I-TECH works to ensure program quality matches efforts to increase program productivity. I-TECH ensures patient safety through patient follow-up to identify and treat AEs. The timing of routine follow-up visits in MC programs is designed to ensure patient safety by identifying, treating, and managing complications. Although routine follow-up timing may differ by country, in Zimbabwe, three follow-up visits are scheduled to ensure quality service provision and patient care: Visit 1 (Day 2); Visit 2 (Day 7); and, Visit 3 (Day 42).

I-TECH’s implementation science efforts use routine data collected from clients with AEs and has found that AEs followed distinct patterns over time. Using these findings, ZAZIC has been improving VMMC care by 1) improving counseling about MC complications following initial visits for clinicians, clients, and caregivers ; 2) distributing wound care pamphlets to clients and caregivers; and 3) emphasizing follow-up tracing for younger boys, ages 10-14, and their caregivers to provide additional targeted, post-operative counseling on AE prevention.

Increasing AE Ascertainment through Routine Quality Assurance Efforts

To further increase ascertainment of AEs, I-TECH recently conducted a quality improvement (QI) initiative to improve provider identification and reporting of AEs. ZAZIC Gold-Standard (GS) clinicians prospectively observed 100 post-MC follow-ups per site in tandem with facility-based MC providers to confirm and characterize AEs, providing mentoring in AE management when needed.

The QI data suggested that AEs may be higher and follow-up lower than reported and ZAZIC’s Quality Assurance Task Force is replicating this QA study in other sites; increasing training in AE identification, management, and documentation for clinical and data teams; and improving post-operative counseling for younger clients. Additional nurses and vehicles, especially in rural health clinics, are currently being trained and leveraged to further improve client follow-up and AE ascertainment.

Improving Data Quality

ZAZIC undertakes weekly, monthly, and quarterly data quality audits (DQA) to ensure data correctness and completeness. Intensive DQA processes were documented and availability and completeness of data collected before and after DQAs in several specific sites was assessed with the aim to determine the effect of this process on data quality. ZAZIC found that after the DQA, high record availability of over 98% was maintained and record availability increased. After the DQA, most sites improved significantly in data completeness and ZAZIC continues to emphasize data completeness to support high-quality program implementation and availability of reliable data for decision-making.