BACKGROUND: The 2015 Malawi Population-based HIV Impact Assessment found that Malawi is approaching the UNAIDS 95-95-95 goals. Achieving and maintaining epidemic control will require tailored prevention interventions and integrated testing models, identifying new infections to interrupt HIV transmission. Malawi has established a recent (i.e. within last 12 months) HIV infection surveillance system, integrating a rapid test for recent infection (RTRI) into routine HIV testing services (HTS), beginning at 23 facilities in Blantyre district. To monitor fidelity of recent infection surveillance, we implemented a continuous quality improvement (CQI) approach through routine monitoring visits.
DESCRIPTION: CQI processes are based on the Plan-Do-Study-Act (PDSA) model. CQI comprises a range of activities, including tracking performance, assessing indicators against standards (e.g. SOPs), prioritizing challenges/gaps, conducting root cause analyses (RCAs), developing action plans, testing interventions, and monitoring effectiveness. Using a CQI checklist, we assessed six key service delivery areas: staff, procedures, data, recruitment, physical facility, and supplies. We collected data using tablet-based Open Data Kit during monthly site visits and displayed data in real-time on color-coded scorecards and dashboards for use by stakeholders at facility and above-site levels. RCAs and action plans were developed with site-level CQI teams at underperforming facilities.
LESSONS LEARNED: From May-October 2019, we conducted 176 CQI visits and 218 RCAs, identifying 14 unique root causes, including: minimal/insufficient training (41%), stock issues (16%), low staff motivation (12%), client refusal (11%), and poor facility coordination (6%). CQI teams developed action plans addressing challenges, including training/re-training, strengthening supply chains, mentoring, and developing staff schedules. Quickly identified and implemented, these solutions improved both routine HTS and recent infection surveillance, leading to programmatic changes and sharing of best practices. At 30% of facilities (n=7), simple interventions like mentorship in eligibility and procedures yielded better recruitment and routine test kit delivery led to fewer stockouts.
CONCLUSIONS: As recent infection surveillance expands, key attention is required to ensure high-quality testing and data. CQI activities enable stakeholders to contextualize data to make informed public health decisions. Identifying and addressing challenges early, implementing teams can ensure accurate data to identify trends and suspected clusters of new infections and tailor appropriate public health responses to interrupt transmission.