I-TECH builds local ownership and sustainability through collaborations throughout Zimbabwe. Under the CDC and PEPFAR awards, I-TECH has formed and leads two consortia – ZAZIC and ZimPAAC.
This piece was first posted on the University of Washington Department of Global Health’s website.
Voluntary medical male circumcision (VMMC) safely reduces the risk of female-to-male HIV transmission by up to 60%. Few men have any post-operative VMMC complication. However, current practice in Zimbabwe and throughout most of sub-Saharan Africa requires VMMC patients to return for multiple, in-person post-operative visits. With low complication rates, and severe healthcare worker shortages, these required visits are a burden for providers and patients — threatening achievement of critical HIV prevention targets. A two-way texting model studied by University of Washington researchers in Zimbabwe offers a new way to address this barrier by reducing provider workload while also safeguarding patient safety.
“These visits can be a barrier to male circumcision uptake and expansion in countries with severe health care worker shortages, as well as negatively impacting patients who needlessly pay for transport, miss work, and wait for unnecessary reviews,” said Principal Investigator Caryl Feldacker, PhD, MPH, at the International Training and Education Center for Health (I-TECH) in the University of Washington Department of Global Health.
The study included 721 VMMC patients in two locations in urban Zimbabwe. In the study, patients communicated directly with a health care worker through interactive text messaging for the critical 13 days post-VMMC, rather than returning for required in-person visits. By giving men the option to heal safely at home, or return to care when desired or if complications arose, the method dramatically reduced in-person visits by 85%. Texting also reduced follow-up costs by about one-third while improving the quality of care.
As compared to routine in-person care, the study yielded twice the number of reported complications. “This increased identification and reporting is a positive result that is likely attributable to improved counseling and men’s engagement in care. Through texting, men were empowered to observe their healing and report potential issues promptly, before they worsened,” said Feldacker.
Currently, most text-based health care efforts blast pre-defined messages to many people simultaneously, removing patients’ ability to communicate back with health care workers. In contrast, two-way texting between providers and patients provides interactive care, and the short time frame heightened participation: in the study, 93% of men responded to texts. Both providers and clients reported confidence in the texting option, feeling safe and highly recommending it for scale.
“With the current system, Zimbabwe could perform millions of unnecessary follow-up visits over the coming five years. The workload burden for health care workers and time lost for patients who are healing without complication is a significant burden for health care workers and clients alike,” said Feldacker. “Potential gains in efficiency and reduced costs through using two-way messaging are large.”
With funding from the U.S. Centers for Disease Control and Prevention (CDC), and in partnership with the Society for Family Health, the model will soon be tested in urban South Africa. The new, field-based research will further test two-way texting in a different geographical and patient context to better inform the model for adaptation and widespread scale-up.
Feldacker added that “while our findings are grounded in studies on male circumcision, our results are largely attributable to the methods rather than to a specific disease or condition.
“With minimal adaptation,” she continued, “two-way texting could streamline other post-operative care contexts or be re-configured for other similarly acute, episodic conditions where continuity of care within a short period is critical for patients, such as short-course TB treatment, post-operative healing, post-natal care or early childhood illnesses — diarrhea, pneumonia, malaria — laying the foundation for generalizing to other diseases and contexts.”
For more on the study, see the paper pre-published in the Journal of Acquired Immune Deficiency Syndromes (JAIDS):
The study was led by Caryl Feldacker, and co-investigators are Vernon Murenje (International Training and Education Center for Health (I-TECH), Harare, Zimbabwe); Mufuta Tshimanga (Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe); Scott Barnhart, Isaac Holeman, and Joseph B. Babigumira (Department of Global Health, University of Washington); Sinokuthemba Xaba (Ministry of Health and Child Care, Harare, Zimbabwe); and technology partner Medic Mobile (Nairobi, Kenya).
The Zimbabwe 2wT study was supported by the Fogarty International Center of the National Institutes of Health under Award Number R21TW010583.
I-TECH has developed extensive capacity and expertise in voluntary medical male circumcision (VMMC) program implementation and management by providing comprehensive VMMC services and/or technical assistance across Southern and Eastern Africa in Botswana, Malawi, Mozambique, Namibia, Tanzania, and Zimbabwe. Technical focus areas include health policy and guideline development, including early-infant male circumcision and piloting and evaluating devices; external and internal quality assurance; demand creation and community mobilization; training; and direct service delivery – all built on a strong foundation of monitoring, evaluation, and learning. Since 2011, I-TECH has directly provided more than 660,000 VMMCs with an adverse event rate of less than 2%.
I-TECH promotes an integrated model, consistent with the Global Health Initiative (GHI) Principles, and supports data-driven program implementation and management. By working closely with the Ministries of Health, local partners, and communities, I-TECH ensures implementations are country-owned and foster strong health systems and sustainable programs.
I-TECH’s quality improvement approach emphasizes ongoing assessments of program aims and operations. Country projects apply continuous quality improvement (CQI) strategies targeting both programmatic and management activities. Small-scale, practical Plan-Do-Study-Act (PDSA) cycles are used to construct improvement goals, test proposed changes, and implement adjustments, leading to increased quality of operations, service delivery, and care.
I-TECH’s monitoring and evaluation staff work to ensure the efficacy of health care training sessions and programs by applying their expertise in cost analysis, data collection, and measurement to rigorous evaluations of these interventions.
In addition to routine monitoring and evaluation (M&E) and continuous quality improvement (CQI), I-TECH designs and implements operations research (the application of research methodology to inform and improve program design and management) and special studies for both I-TECH country programs and our partners. These activities enable us to answer strategic questions concerning the selection and effectiveness of program interventions. The team analyzes and designs evidence-based solutions to increase relevance, access, and scope of HIV services.
Monitoring ongoing projects and programs allows for midstream corrections; key findings are communicated to managers and leaders to improve programmatic decision making. Results are disseminated through publication, when appropriate.
Additionally, I-TECH has significant capacity in the rapidly expanding field of health informatics for resource-limited clinical settings. I-TECH develops tools and systems—such as the Training System Monitoring and Reporting Tool (TrainSMART)—and provides technical assistance for electronic medical records, training management, and remote clinical diagnostic systems.
I-TECH specializes in developing appropriate research designs and methods for application in resource-limited settings, to get answers to research questions in real time. A university-based program, I-TECH draws from experts in qualitative and quantitative methods in a wide range of theoretical and practical disciplines, including health economics, anthropology, health sciences, medicine, and education.
The effective diagnosis, care, and treatment of infectious diseases require a skilled and motivated health care workforce, and sustainable systems to educate and train those workers. I-TECH uses a systemic approach to build the skills and knowledge of, and foster attitude changes in, health care staff and those who train and educate them.
The following model outlines I-TECH’s human resources for health-based approach to achieving comprehensive patient-centered care. Each component of the model, including a strong enabling environment, supports an optimized health workforce as the foundation of an effective service delivery system.
I-TECH has worked for almost twenty years to support health systems strengthening and the national response to the HIV epidemic in Malawi through significant contributions to the development of a robust health care workforce that provides high-quality HIV prevention, care, and treatment services.
In Malawi, I-TECH works through the secondment of well-qualified, experienced technical advisors (TAs) in the Ministry of Health (MOH) and other institutions to provide technical assistance for development and implementation of the national strategic plan led by the Government of Malawi (GOM). I-TECH TAs play an important role in ensuring timely national HIV/TB response by supporting prevention and control across the HIV care continuum. Additionally, I-TECH TAs support and facilitate surveillance and M&E for HIV/TB programs. This assistance enables the MOH to collect and manage up-to-date data to inform evidence-based decision-making by GOM and partners.
I-TECH technical assistance to Malawi MOH also covers the implementation of national surveillance systems to improve the generation of high-quality epidemiological data. Surveillance TAs work together with their GOM counterparts to improve storage and transportation conditions for lab samples, train staff in analysis of surveillance samples, and increase the functionality of surveillance systems to generate reliable and accurate data. The principal surveillance projects I-TECH TAs support in Malawi are Birth Defects Surveillance and HIV Recent Infection Surveillance. Most recently, I-TECH TAs have been placed at Public Health Institute of Malawi (PHIM) to support GOM with its emergency response to the COVID-19 pandemic.
Departments and units supported by I-TECH TAs include the National Tuberculosis Control Programme, Department of HIV and AIDS, Supply Chain of HIV Commodities, Monitoring and Evaluation of HIV Program Diagnostics, Reproductive Health Department, PHIM, National HIV Reference Laboratory, and the National Registration Bureau. I-TECH TAs also support clinical mentoring and M&E at Lighthouse Trust, a Center of Excellence for HIV care that was established in 2001.
Since 2009, the University of Washington’s International Training and Education Center for Health (I-TECH) has worked with the US Centers for Disease Control and Prevention and the Côte d’Ivoire Ministry of Health and Public Hygiene (MSHP) to strengthen laboratory information systems at the national and regional levels. I-TECH laboratory support to Côte d’Ivoire aims to develop and implement targeted interventions designed to support expanded use of laboratory information systems and their data for decision making. With I-TECH support, adoption of an open-source electronic laboratory information system (eLIS) has already resulted in improved efficiency and accuracy of laboratory data collection and reporting. Over 50 national, regional, and general hospital laboratories across Côte d’Ivoire have implemented eLIS systems.
In 2021, I-TECH began a five-year cooperative agreement with the United States Health Resources and Services Administration under the US President’s Emergency Plan for AIDS Relief (PEPFAR) to begin implementing the Quality Improvement (QI) Solutions for Sustained Epidemic Control (QISSEC) project, which aims to improve data quality and strengthen capacity to help close HIV-related service delivery gaps across clinics and communities throughout Côte d’Ivoire.
Current Program Highlights
Photo credit: Macpherson Photographers
There are an estimated 1.3 million people living with HIV/AIDS in Zimbabwe and the country is severely impacted by this disease. For the past 16 years, I-TECH has worked collaboratively with the Ministry of Health and Child Care (MoHCC) and other partners to strengthen the HIV response in Zimbabwe. I-TECH works together with local implementing partners and supports activities across the entire continuum of care from HIV prevention activities to HIV testing, immediate linkage to care and treatment services, management of opportunistic infections and retention in care and viral suppression.
In 2003, I-TECH began working in Zimbabwe by conducting an assessment of need and capacity for clinical and other HIV-related training in collaboration with Zimbabwe’s National AIDS and Tuberculosis Programs. With funding from HRSA, the US Centers for Disease Control and Prevention (CDC) and the US President’s Emergency Plan for AIDS Relief (PEPFAR), I-TECH provided a decade of technical support and assisted with the development of multiple training programs, evaluations, and laboratory systems strengthening.
In both 2013 and in 2018, CDC and PEPFAR awarded funding for I-TECH to continue and expand its work supporting the country’s HIV epidemic-control efforts through 2023.
In 2018, I-TECH Zimbabwe transitioned to the independent Zimbabwe Training, Technical Assistance and Education Center for Health (Zim-TTECH). Together, I-TECH and Zim-TTECH build local ownership and sustainability through collaborations throughout Zimbabwe. Under the CDC and PEPFAR awards, I-TECH and Zim-TTECH lead two consortia: ZAZIC and ZimPAAC.