New I-TECH Publication Shows Effectiveness of Index Testing Program in Ukraine

Posted on October 16, 2023October 30, 2023

Index testing is a is a key strategy to identify and support those most at risk of acquiring HIV.¹ Within the index testing framework, exposed contacts (i.e., sexual partners, biological children and anyone with whom a needle was shared) of an HIV-positive person (i.e., index client), are elicited and offered HIV testing services.

From 2019 to 2021, the I-TECH team in Ukraine provided increased technical assistance for 39 state healthcare facilities in 11 high HIV-burden regions to advance assisted partner notification/services and index testing.

In a recently published study in BMJ Open, the I-TECH team—along with representatives from the Public Health Center at the Ukrainian Ministry of Health—describe the success of this scaled program in index testing.

“Index case testing is crucial in reaching out to exposed contacts of individuals living with HIV, notifying them, and offering HIV testing,” said Anna Shapoval, I-TECH Ukraine Country Representative. “This approach is particularly important and effective in the context of Ukrainian national HIV response where, despite numerous successes, we still struggle to close HIV testing gap and reach out to people living with HIV earlier rather than later with proper treatment and support.”

I-TECH developed exhaustive standard operating procedures for index testing; thoroughly trained healthcare teams on the index testing algorithm; as well as provided consistent and regular methodological support as part of its index testing program.

The study includes clients enrolled in index testing services in 2020, who had with both recent (<6 months) and previously established (≥6 months) HIV diagnoses. Ukraine’s physician-led model involves a cascade of steps including voluntary informed consent, partner elicitation, selection of partner notification method and follow-up with clients to ensure partners are notified, tested for HIV, and linked to HIV prevention and treatment services, as needed.

“Ukraine’s index testing services were rolled out as a standard part of Ukraine’s HIV service package at the targeted governmental health facilities, and carried out by existing physicians,” said Alyona Ihnatiuk, Strategic Information Lead for I-TECH Ukraine and lead author of the study. “At each supported facility, one or two staff members were designated as focal persons for case management and follow-up. This integrated, physician-led model was streamlined to target index cases with both recent and established HIV diagnosis, to arrive at a high number of new cases of HIV identified.”

There were 976 new cases of HIV identified through the study period, representing a yield of 19.3%, and 1,408 people living with HIV (PLHIV) have been identified throughout the two-year index testing program.

Of 14,525 index clients offered index testing, 51.9% accepted, of whom 98.3% named at least one sexual partner, injection partner, or biological child. Clients named 8,448 unique partners; HIV case finding was highest among clients with recent HIV diagnosis and among people who inject drugs (PWID), and lower among clients with established HIV diagnosis. More than 90% of all partners with new HIV diagnoses were linked to care.

“The BMJ Open study confirms that comprehensive assisted partner notification services and index testing are highly effective in identifying people living with HIV,” says Ms. Shapoval, “as well as tracing previously diagnosed partners and supporting their linkage to care. I-TECH was honored to contribute to the design and implementation of this vital intervention in Ukraine early on and see it gradually rolled out across the country with multiple partners successfully implementing it now.”

Golden M, et al. Partner notification for sexually transmitted infections including HIV infection: an evidence-based assessment. Sexually transmitted diseases. 4th edn. McGraw-Hill; New York, NY: 2007.

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.

Ensuring High-Quality Service Provision in Zimbabwe

Caryl Feldacker Implementation Science Male Circumcision Scott Barnhart Zimbabwe

Posted on November 19, 2019May 10, 2021

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.

I-TECH Ukraine Initiates National Discussion on Performance-based Incentives Model in HIV

Ann Downer Best Practices Implementation Science Ukraine Uncategorized

Posted on May 9, 2019May 2, 2023

Participants of the national consultation on PBI model development discuss international best practices. Photo courtesy of I-TECH Ukraine.

In response to the need to quickly revitalize efforts to reach targets in Ukraine, CDC Ukraine has asked International Training and Education Center for Health (I-TECH) to support a performance-based incentive (PBI) model.

On March 28, 2019, I-TECH facilitated a high-level stakeholder workshop centered on PBI evidence and “best practices.” Participants from the U.S. Centers for Disease Control and Prevention (CDC) in Ukraine and the Public Health Center (PHC) of the Ministry of Health of Ukraine, and I-TECH gathered to discuss options for adapting proven methodologies to Ukraine’s HIV services.

PHC launched the model in December 2018 at five pilot sites across the country. In the pilot, monetary incentives were paid to individual doctors at the facilities to double efforts toward initiating new patients on ART.

PHC plans to expand the model to all 12 priority regions in the country. On the heels of COP ’19 discussions in South Africa, CDC Ukraine is looking for additional areas of the HIV cascade to which PBI could be applied to reach the FY2020 targets set by the U.S. Office of the Global AIDS Coordinator (OGAC).

The March meeting and the preceding preparatory meetings provided catalytic opportunities for identifying additional HIV services–including index partner testing, linkage to care, and loss-to-follow-up search–that could potentially benefit from the PBI model; discussing lessons learned from other PBI global initiatives; and utilizing evidence-based practices to design well-conceived and context-driven programs.

Marianne Holec, Senior Program Manager for I-TECH Zimbabwe’s voluntary medical male circumcision program; Efison Dhodho, Results-based Financing Health Specialist from the Programs Coordination Unit of the Ministry of Health of Zimbabwe; and Charbel El Bcheraoui, PhD, Assistant Professor at the Institute for Health Metrics and Evaluation (IHME) were keynote speakers at the event.

These working meetings resulted in meaningful exchanges between the guest speakers and Ukrainian experts about the successes (e.g., an increase in short-term achievement of targets and the opportunity to identify and target largest areas of need) and challenges (e.g., workplace friction, dissatisfaction with incentives, lack of teamwork, and reduced quality of care) of PBI implementation globally and in Ukraine to date.

Meeting participants appreciated the practical advice given by the guest speakers on designing effective, intentional, and sustainable PBI models for the longer term for HIV services. Experts advised developing a well-designed program that is adapted to local context; starting at a few sites and try different strategies to see what works best; gathering input from the providers as to what will work best; building in health competition between sites; and having a strong M&E framework.

With input from local stakeholders and international experts, I-TECH Ukraine has accepted the challenge of incorporating the key outcomes from the series of PBI meetings to structure the Ukrainian PBI model for HIV services. This narrative will include an outline of additional technical assistance required around its implementation.

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.

Laboratory Quality Stepwise Program in Cambodia

Cambodia Clinical Mentoring Health Systems Strengthening Human Resources for Health Implementation Science Laboratory Systems Leadership & Management Lucy Perrone Quality Improvement

Posted on March 26, 2019June 1, 2023

From September 2013 to September 2016, I-TECH conducted an implementation science research project to improve laboratory quality in Cambodia. The primary objective of the project was to implement a mentored laboratory quality stepwise implementation (LQSI) program to strengthen the quality and capacity of Cambodian hospital laboratories. As a result, target laboratories improved their operations in the areas of: biosafety, organization, personnel, equipment maintenance, purchasing and inventory, testing accuracy, process management, documentation and communication.

The project recruited and trained four laboratory technician to be mentors, training staff from 12 referral hospital laboratories in quality management systems (QMS), and reinforcing skills acquisition through in-person mentoring. Participating laboratories reported a 36% increase in quality management, 29% improvement in data management, and 25% improvement in specimen collection and handling. The laboratories established the foundational practices of a QMS, and the LQSI program has improved the recognition of the laboratory within the hospitals.

Aaron Katz

Aaron Katz is a principal lecturer emeritus of Health Services, Global Health (adjunct), and Law (adjunct) at the University of Washington School of Public Health where he teaches several graduate level courses in health policy. He also has an adjunct appointment at the University of Queensland (Australia) School of Public Health. Aaron has held numerous academic leadership positions, including his current role as faculty coordinator of the Health Systems and Policy Concentration of the Health Services Master of Public Health (MPH) program and was founding director of the Leadership, Policy, and Management track of the Global Health MPH program. He was director of the UW Health Policy Analysis Program from 1988 until 2003 and editor-in-chief of the School’s biannual journal, Northwest Public Health, from 1999 to 2008.

Aaron received the American Public Health Association’s Award for Excellence in November 2006 and the Outstanding Teaching Award from the UW School of Public Health in 2004. At the 2011 “State of Reform” Washington Health Policy Conference, Aaron received the Health Reform Leadership Award.

Aaron has developed a deep understanding of the U.S. health care system and its strengths and weaknesses during a career that has spanned 40 years and four “bouts” with health care reform. He has worked in health policy and planning in Washington state since 1978, serving as a health planner, policy and planning consultant, lobbyist, and political adviser. Aaron has directed numerous policy analysis and policy development projects for legislative bodies, state and local public agencies, and private sector clients, including work on health system reform, public health reform, managed care, rural access, HIV/AIDS, workers compensation, long term care, medical economics, and services for people with low incomes. Since 1999, Aaron has collaborated on policy development and advocacy projects with colleagues in various countries in southern Asia, sub-Saharan Africa, Latin America, and Japan.

Aaron has served as a peer reviewer of articles for the International Journal for Equity in Health, Health Affairs, Journal of Health Care for the Poor and Underserved, Global Health Action, and the American Journal of Public Health. He has served on numerous community boards, including the Washington State Budget and Policy Center, Northwest Health Law Advocates, Washington Physicians for Social Responsibility, and Health Alliance International.

Aaron received a bachelor of science degree from the University of Wisconsin – Madison in 1974 and a certificate [master] of public health degree from the University of Toronto in 1975.

Caryl Feldacker

Caryl Feldacker, PhD, MPH, has over 20 years of international experience focused on ensuring quality public health programming and rigorous program monitoring and evaluation (M&E), including more than ten years conducting HIV-related implementation science research in sub-Saharan Africa. Dr. Feldacker is the co-principal investigator (PI) on the International Training and Education Center for Health (I-TECH) Integrated Voluntary Medical Male Circumcision (VMMC) program in Zimbabwe. Her current research focuses on digital health solutions to improve the quality of patient care while reducing provider workload and program costs. She is PI for four National Institutes for Health (NIH) studies using interactive, two-way texting (2wT) between patients and providers to improve patient retention in care, provide post-operative telehealth, and improve data quality in Malawi, Zimbabwe, and South Africa. For each initiative, she partners closely with ministries of health and local partners with the aim of helping strengthen monitoring and evaluation (M&E) and research capacity for sustained improvement. Her digital health interventions employ the open-source Community Health Toolkit in collaboration with Medic.

Her broad implementation and research experience includes exploring trends in adverse events in VMMC programs; closing HIV service delivery gaps; strengthening routine data quality for accurate and timely reporting; task-shifting of healthcare workers; understanding patterns in loss-to-follow-up within routine HIV program settings; strengthening integration of family planning into HIV-related care; and expanding electronic medical record systems to provide integrated patient care.

Her current collaborations include partnerships with Lighthouse Trust (Lilongwe, Malawi); Aurum Institute and The Centre for HIV-AIDS Prevention Studies – CHAPS (South Africa); and Zimbabwe Technical Assistance, Training and Education Centre for Health – Zim-TTECH (Harare, Zimbabwe).

Dr. Feldacker is an Associate Professor in the Department of Global Health in the School of Public Health at the University of Washington (UW). In addition to her work with I-TECH, Dr. Feldacker is affiliated with the UW Global Center for Integrated Health of Women, Adolescents, and Children (GlobalWACh) where she aims to translate 2wT-based advantages for the postpartum care context.

Program Highlights

Expanding Two-Way Texting for Voluntary Medical Male Circumcision Clients in South Africa

I-TECH, in close partnership with voluntary medical male circumcision (VMMC) implementing partner, the Aurum Institute and technology partner, Medic, is ...
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Two-Way Texting for Post-Operative VMMC Follow-Up RCT in Zimbabwe

Voluntary medical male circumcision (VMMC) is considered safe and the vast majority of men heal without complication. However, guidelines require ...
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Reducing HIV through Voluntary Medical Male Circumcision in Zimbabwe

Since 2013, the ZAZIC Consortium has been implementing Voluntary Medical Male Circumcision (VMMC) as part of a combination HIV prevention ...
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Increasing VMMC Delivery and Safety in Zimbabwe

Employing modern medical male circumcision within traditional settings may increase patient safety and further male circumcision scale up efforts in ...
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Achieving Targets through Performance-Based Financing in Zimbabwe

ZAZIC employs an innovative performance-based financing (PBF) system to speed progress towards ambitious voluntary medical male circumcision (VMMC) targets. The ...
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I-TECH Shares Research at CUGH 2018

Haiti Health Information Systems HIV Care and Treatment Implementation Science Integrating Research and Practice Nancy Puttkammer Tanzania

Posted on March 14, 2018March 16, 2018

Logo courtesy of the Consortium of Universities for Global Health (CUGH): https://www.cugh.org/.

Representatives from the International Training and Education Center for Health (I-TECH) are headed to New York for the 9th Annual Consortium of Universities for Global Health (CUGH) Conference. The conference—held on March 16-18, with satellite sessions on March 15—will be co-hosted by Columbia University, Stellenbosch University, and the University of Peradeniya.

Featured speakers include Richard Horton, Editor of The Lancet, and Natalie Kanem, Deputy Executive Director of the United Nations Population Fund.

Building on the theme of “Health Disparities: A Time for Action,” staff and faculty from I-TECH will be presenting on the following topics:

King Holmes, MD, PhD, founding chair of the Department of Global Health and a co-Principal Investigator of I-TECH’s IAETC award, will join a morning plenary session and discussion about global health disparities. The discussion will be moderated by Director of the Fogarty International Center Roger Glass. Dr. Holmes will be joined for the discussion by Rose Leke, Gairdner Foundation Global Health Committee member and Emeritus Professor at Universite de Yaounde, and K. Srinath Reddy, President of the Public Health Foundation of India.
Kate Wilson, PhD, Clinical Assistant Professor, is presenting a poster titled “Evaluation of a New Field Epidemiology Training Program (FETP) Intermediate Course to Strengthen Public Health Preparedness in Tanzania.” The locally adapted course significantly improved trainee knowledge and skills in field epidemiology, and the evaluation also showed evidence of improvement in data quality and performance at trainees’ workplaces and districts.
Lindsay Mumm, MPA, Program Manager, is presenting a poster titled “Creating Relevant Change towards Reaching the UNAIDS 90-90-90 Target with High-Impact Leadership Training – Afya Bora Fellowship in Global Health Leadership.”

In addition to the research being shared at CUGH, I-TECH was represented earlier this month at the Conference on Retroviruses and Opportunistic Infections (CROI) in Boston. Nancy Puttkammer, PhD, MPH, presented a poster titled “Multi-Month Scripting (MMS) and Retention on HIV Antiretroviral Therapy (ART) in Haiti.” The retrospective study used data from the iSanté electronic medical record system in Haiti and found promising results that MMS for ART in virally suppressed patients improved retention and engagement in treatment.

About CUGH

The mission of CUGH is to build interdisciplinary collaborations and facilitates the sharing of knowledge to address global health challenges while promoting mutually beneficial, long-term partnerships between universities in resource-rich and resource-poor countries, developing human capital and strengthening institutions’ capabilities to address these challenges. Read more about CUGH: https://www.cugh.org/.

About CROI

Established in 1993, The Conference on Retroviruses and Opportunistic Infections (CROI) was provides a forum for scientists and clinical investigators to present, discuss, and critique their research. The goal of the conference is to provide a forum for researchers to translate their laboratory and clinical findings into tangible progress against the HIV pandemic. Read more about CROI: http://www.croiconference.org/.

Gabrielle O’Malley

Gabrielle O’Malley, MA, PHD, is I-TECH’S Director of Implementation Science. Dr. O’Malley has worked as an applied research and evaluation professional for over 25 years. Her experience includes a wide variety of international and domestic programs including child survival, private agricultural enterprise, medical education, community technology, reproductive health, HIV prevention (PrEP), and care and treatment as well as applied research for private industry. Her research interests include innovative practices for program evaluation and improvement, formative research, qualitative methods, and the relationship of gender and health.

Dr. O’Malley received her PhD from UW, an MA from Johns Hopkins University and a BA from Smith College.

Program Highlights

Birth Defects Surveillance in Malawi

Malawi is one of first countries in Southeast Africa to respond to the World Health Organization’s call for robust birth surveillance systems. Routine surveillance is essential for public health monitoring of pregnancy outcomes and birth defects, especially in high-HIV burden settings where women living with HIV initiate the use of ...
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Cervical Cancer Screening and Treatment in Namibia

I-TECH supported the Ministry of Health and Social Services in 2017 and 2018 in the development and dissemination of the national Cervical Cancer Prevention Guidelines including algorithms for screening, referral, and post cryotherapy instrument disinfection, and monitoring and evaluation tools ...
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COVID-19 Sentinel Surveillance in Malawi

Despite establishing COVID-19 monitoring measures within the existing routine national surveillance system and significant efforts to conduct testing, contact tracing, and case investigations, Government of Malawi institutions at both the national and district levels faced many challenges in mounting an effective response to the COVID-19 pandemic. The existing COVID-19 surveillance ...
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Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe women (DREAMS) in Namibia

In 2017, I-TECH began the DREAMS program in Khomas and Zambezi regions. The DREAMS program aims to reduce HIV infections among adolescent girls and young women (AGYW) through a core package of evidence-based interventions across health, education, and social sectors. At a safe space such as a school or community ...
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