I-TECH, in close partnership with voluntary medical male circumcision (VMMC) implementing partner, the Aurum Institute and technology partner, Medic, is conducting a five-year study funded by the National Institutes of Health to further evidence on the efficiency, safety, and scalability of two-way text-based (2wT) follow-up for VMMC services.
2wT is SMS-based telehealth, providing direct patient to provider communication that improves the quality of post-operative VMMC care. A daily educational message is sent to each participant, requesting a response to report potential complications. 2wT allows the nurse to triage men to care when needed or desired while supporting most men to heal independently at home. 2wT-based follow-up dramatically reduces unnecessary post-operative visits, saving patient and provider costs, while improving patient care quality through swift identification and referral for potential adverse events. In South Africa, the 2wT intervention benefits were similar across routine VMMC programs in both rural and urban settings.
On 18-19 May 2022, the International Training and Education Center for Health (I-TECH), in collaboration with the Programme National de Lutte Contre le Sida (PNLS; National AIDS Control Program) under the coordination of the General Directorate of Health, hosted its first national HIV prevention, care, and treatment quality improvement (QI) conference in Abidjan, Côte d’Ivoire. The conference brought together over 100 representatives from the Centers for Disease Control and Prevention, United States Agency for International Development, the Human Resources and Services Administration (HRSA), US President’s Emergency Plan for AIDS Relief (PEPFAR), and PEPFAR implementing partners from around the country to agree on a national approach to QI; update the national strategic plan for improving Quality, Health, and Safety; and learn about the unique QI approach being implemented by I-TECH through the Quality Improvement Solutions for Sustained Epidemic Control (QISSEC) program.
I-TECH QISSEC Project Director, Dr. Nathalie Krou Danho, describes the QISSEC approach at the National HIV QI Conference. Photo Credit: I-TECH
“This is an historic workshop. [There have been] many conversations and meetings with the PNLS/Ministry of Health and USG agencies [over the years] to gather all the stakeholders to harmonize QI interventions,” says Dr. Jean T. N’Guessan, QISSEC QI Consultant. “This national QI workshop was a success because the leadership was carried by the PNLS, the national Program to fight AIDS, and supported by I-TECH.”
The goal of the conference was to elevate QI practices on a national level and work with stakeholders to adopt and integrate the QISSEC QI approach into their own HIV prevention, care, and treatment programs to improve HIV services while identifying and addressing gaps in care (e.g., viral load monitoring, antiretroviral therapy uptake).
“In Côte d’Ivoire, all hospitals—both public and private—are required to implement continuous quality improvement for all care and services, which can lead to a one-size-fits-all approach to QI,” explains Dr. Nathalie Krou Danho, I-TECH QISSEC Project Director. “This workshop made it possible for us to identify gaps in national standards for the prevention, care, support, and treatment of HIV infection, while also providing an effective QI framework that helps clarify the roles and responsibilities of the stakeholders implementing QI initiatives across the country.”
QI interventions are often applied unilaterally across all sites regardless of analysis of the sites’ specific needs, but I-TECH’s approach tailors each QI intervention and related activities to the needs of the site according to self-identified gaps by the sites. This approach allows sites to be involved in each step of the process, reinforces skills and knowledge, and ultimately creates a sustainable approach to QI. By using the QISSEC approach, HIV programs around Côte d’Ivoire will be able to align their QI work and substantially improve HIV services, while also fulfilling PEPFAR priorities and targets.
“Since I-TECH’s approach works in collaboration with all levels (national, district, and site) of the health system pyramid, we are able to coach sites to develop a QI plan based on the identified gaps, implement it, as well as monitor and evaluate it,” says Dr. Nathalie Krou Danho. “Through data analysis of MER indicators and SIMS data, the approach takes into account the organizational improvement of the quality and the services offered to the patients.”
The QISSEC project, a five-year cooperative agreement with HRSA under PEPFAR, works with local partners to implement customized site-level QI interventions using patient-centered approaches in clinics to ensure a facility-owned and locally led response to the persistent challenges seen in HIV prevention, care, and treatment programs (e.g., HIV testing, retention, suppression, PrEP, TB prevention) and support Côte d’Ivoire in reaching the UNAIDS 95-95-95 targets. The project has initially been focused on 60 priority sites throughout the country but plans to expand to Abidjan’s 75 high-impact sites next year, bringing the total number of sites to 101.
“The QISSEC project aims to strengthen ownership of continuous QI at all levels of the health system pyramid,” says Dr. Nathalie Krou Danho. “To do this, I-TECH collaborates with all national stakeholders, including PEPFAR implementing partners and civil society organizations who can help motivate beneficiaries to take part in QI efforts and extend its QI approach to the community.”
I-TECH’S WORK IN CÔTE D’IVOIRE IS SUPPORTED BY THE HEALTH RESOURCES AND SERVICES ADMINISTRATION (HRSA) OF THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS) UNDER 1 U1NOA45176-01-00 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.
The International AIDS Society (IAS) virtually hosted their 23rd International AIDS conference (AIDS 2020: Virtual) on 6-10 July 2020. The AIDS 2020: Virtual theme was resilience, to celebrate and acknowledge the strength of the HIV community and the significant advances in treatment, while also addressing gaps in treatment, prevention, and care.
Representatives from the International Training and Education Center for Health (I-TECH) virtually presented the following posters with accompanying audio recordings:
Malango Msukwa, BSc, MPHc, I-TECH Malawi Monitoring, Evaluation, and Data Manager, received a scholarship from IAS to attend AIDS 2020: Virtual and presented a late-breaker e-poster on a study that evaluated the uptake of a new HIV surveillance system and described which populations have continued HIV transmission titled, “Characterizing recent infections among persons with new HIV-1 diagnoses in Malawi.”
In addition to the I-TECH representatives presenting their posters, representatives from the Centers for Disease Control and Prevention (CDC) and Health Alliance International (HAI) also presented data from I-TECH programs in Malawi and Mozambique.
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.
Zim-TTECH staff supports Kowoyo Clinic in Goromonzi District, Mashonaland East Province, Zimbabwe. Photo credit: Macpherson Photographers.
The International Training and Education Center for Health (I-TECH) has transitioned another office to an autonomous entity. The Zimbabwe Technical Assistance, Training and Education Center for Health (Zim-TTECH) was officially launched on April 1, 2020, as a locally registered health trust. Zim-TTECH is the administrative and managing partner for the two existing I-TECH CDC/PEPFAR funded grants in Zimbabwe, each grant having a consortium of local partners:
ZimPAAC (Zimbabwe Partnership to Accelerate AIDS Control) is a partnership between Zim-TTECH, Africaid, Pangaea Zimbabwe AIDS Trust, and I-TECH. ZimPAAC collaborates with the Ministry of Health and Child Care (MoHCC) on context-appropriate health interventions to improve access to, as well as strengthen the quality of HIV prevention, treatment, care, and support services. ZimPAAC provides services at 373 facilities in 17 districts.
ZAZIC is a partnership between Zim-TTECH, I-TECH, and two local implementing partners—Zimbabwe Association of Church Related Hospitals (ZACH) and Zimbabwe Community Health Intervention Research Project (ZiCHIRe). ZAZIC supports voluntary medical male circumcision (VMMC) services at 38 static facilities in 13 districts.
“The transition from an I-TECH country office to a fully fledged independent local organization is exciting,” states Dr. Batsirai Makunike-Chikwinya, Zim-TTECH’s Executive Director. “Zim-TTECH is committed to continue to provide high-quality support to the MoHCC and to the health sector as a whole. Special thanks go to management and staff of both I-TECH/UW [University of Washington] and UZCHS-CTRC [University of Zimbabwe College of Health Sciences Clinical Trials Research Centre], who played pivotal roles during this transition.”
I-TECH has worked in Zimbabwe since 2003, collaborating with the MoHCC and other partners to improve clinical services and strengthen health systems. “It is a pleasure to support the launch of Zim-TTECH, which is the right next step toward country ownership and, importantly, recognizes the high level of skill and professionalism of the prior I-TECH country office and now Zim-TTECH team,” remarks Dr. Scott Barnhart.
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.
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.
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.
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.
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.
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.
