AIDS 2012: Turning the Tide Together

More than 25,000 health professionals, activists, global and community leaders, and people living with HIV will gather in Washington, DC, next week to take part in the XIX International AIDS Conference. Conference attendees will share the latest news and research in working towards a world with zero HIV infections and zero AIDS-related deaths, a goal reflected in the conference theme “Turning the Tide Together” and The Washington D.C. Declaration to end the AIDS epidemic. 

For those who work on the frontlines of HIV care, reaching this goal involves addressing a host of underlying factors at each level of a complex and multifaceted system. Just two of these factors are: 1) how to ensure that every patient who needs care gets it and 2) how to evaluate the care provided.

Health care facilities collect and report large amounts of data to fulfill multiple requests from donors and to report to their district/regional and national offices. Donors and technical partners use these data to make funding decisions. Yet the data often does not provide enough meaningful information to assess the quality of HIV services. Assessing quality, or how well HIV programs perform, is vital for all health system levels. With such knowledge, country governments can make informed decisions about national HIV strategies; facilities can address gaps in their HIV services; and donors can measure the impact of their programs and gain insight for making funding decisions.

To strengthen this capacity within countries, the Office of the Global AIDS Coordinator (OGAC), the US Agency for International Development (USAID), and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (Global Fund) asked the USAID Health Care Improvement Project (HCI) to develop an approach to yield meaningful information about the quality of HIV services for users at multiple levels of the health system. 

Together with the Global Fund, HCI developed an approach that uses 16 proposed HIV program quality criteria (QC). The QC relate to five HIV service delivery areas: testing and counseling, care and treatment, prevention of mother-to-child transmission (PMTCT), tuberculosis/HIV (TB/HIV); and harm reduction. Global technical partner organizations, such as the Joint United Nations Programme on HIV and AIDS (UNAIDS) and the World Health Organization (WHO), participated in defining the QC and in identifying existing mechanisms to measure the criteria. 

The QC are designed to be general enough to allow country programs flexibility in evaluating the quality of program performance for reporting and improvement purposes, without restricting countries to indicators that may not all be applicable or feasible in their context. HCI field tested the QC approach in five countries representing different types of HIV epidemics: three in Africa and one each in Eurasia and Southeast Asia. The three African countries were in East Africa, West Africa, and Southern Africa.

A Feasible Approach

Countries should be able to report on the QC if the data are available in the facilities. However, field test findings indicated that this was not always the case. Facilities fulfill reporting requirements by gathering numerator data (the volume of patients who received a service). Country governments collect these data at the national level, compile it, and calculate national coverage using population estimates as the denominators. As a result, little to no denominator data (patients eligible to receive a service) are being tracked or used at the facility level. This means that facilities, government agencies, and donors often have an incomplete picture of what is actually happening on the ground and whether services are reaching everyone who needs them. 

In addition to an absence of meaningful data, many facilities were not using the data they did have to assess their performance and improve their HIV services. Of 35 facilities visited during the field test, data collectors noted three where staff members used quality improvement methods, such as analysis and use of data, to make and track changes to address facility needs and client services. 

Overall, national officials, providers, and facility staff interviewed found the QC to be "very useful" or "useful" for all service delivery areas, with the exception of the harm reduction QC proposed for drug treatment programs. This encouraging finding supports using the QC to produce the data vital for improvement and informing decision-making so that facility staff can track their progress, and performance data can be shared with donors to monitor program performance and spread lessons learned and success stories. 

Ultimately, improved data use and information about services will lead to fewer gaps in care, stronger links between services, and better health outcomes – all necessary components in "Turning the Tide Together.”

Amy Stern is the Senior QI Advisor for Indicators for HCI; Rhea Bright is a QI Specialist for HCI; and Sarah Whitmarsh is Communications Specialist for URC.

Data collectors interview a key informant at the regional level.
Data collectors interview a key informant at the regional level.
July 19, 2012