Coaching visit at Gashikanwa health facility, Buye HD

Reaching an AIDS-Free Generation (RAFG) in Burundi

The Challenge

Burundi has achieved incredible progress in the fight against HIV/AIDS. Since 2010, new HIV infections and AIDS-related deaths have been cut in half, according to UNAIDS. Despite progress, Burundi remains one of the poorest countries in the world. Gaps in HIV service quality that constrain epidemic control include delays in linking new HIV-positive cases to antiretroviral therapy (ART) to minimize patient loss to follow-up, the need to improve ART retention and adherence, low access to viral load testing, and a low rate of viral load suppression.

Overview and Objectives

As a subcontractor to FHI 360, URC leads quality improvement (QI) activities and ensures QI is integrated into the overall program in the targeted provinces. The activity uses the science of QI to strengthen the service delivery system at the facility and community levels. QI is being applied to address systemic issues that affect the delivery of HIV services in order to meet the UNAID’s 90-90-90 goals.

The RAFG Activity’s objective is to scale up ART services for people living with HIV (PLHIV), beginning in five priority provinces in Burundi and now serving 14 provinces. By using an integrated, community-based approach in high-prevalence provinces, the project aims to contribute towards the Government of Burundi’s goal to achieve epidemic control nationally. To achieve the UNAIDS 90-90-90 goals in Burundi, RAFG focuses on:

  • Identifying HIV-positive men, women, and children through high quality, targeted HIV testing services and linking those who test positive to ART services;
  • Increasing ART coverage in men, women, and children living with HIV; and
  • Ensuring HIV-positive men, women, and children on ART are virally suppressed.

The FHI 360-led consortium is using the science of QI to strengthen the service delivery system at the facility and community levels. QI models are used to address the systemic issues that affect the delivery of HIV services so that the system of care for HIV patients achieves its expected performance along the 90-90-90 goals.

The RAFG activity is building the capacity of health district teams in the priority provinces to train and support facility-level QI teams to carry out continuous quality improvement (CQI) activities to optimize HIV testing services and improve yield. In addition, the Activity provides support at the national program level to develop an adequate and functional quality management system for care and treatment services.


  • In August 2018, the QI team developed a CQI plan aligned with the project work plan. The goal of the CQI plan is to provide a continuous formal process for HIV service providers to help them develop and implement plans to identify, seek opportunities, and progressively improve the quality of HIV services.
  • CQI orientation workshops were organized in the 14 supported provinces for health facility managers and quality improvement teams (QITs) and for health district and province health directors. Workshops aimed to orient participants on the concepts of improving the quality of HIV services to revitalize the functionality and activities of these QITs. Progress made in the implementation of the RAFG Activity is regularly monitored at the site level using the SIMS tool. The workshop provided an opportunity for participants to immerse themselves in and take ownership of information collected during SIMS visits.
  • In June 2019, the RAFG Activity convened a workshop to generate change ideas and solutions to improve the performance of the system of care for PLHIV. By scaling up best practices and implementing of new change ideas/solutions the Activity aimed to improve project performance in case-finding; initiate newly diagnosed patients on treatment; implement differentiated service delivery; TB screening and treatment; and viral load suppression among children.
  • RAFG developed a best practices package that shares lessons learned, strategies, and practices that contributed to the success and achievement of all 90/90/90 goals, including:
    • Accelerated screening of family members of PLHIV through active search of family members not yet tested;
    • Organization of visits for active notification of sexual contacts of PLHIV to offer HIV testing;
    • Adaptation of pre- and post-test counseling to the new “test and treat” approach;
    • Establishment and generalization of the appointment system to improve adherence, retention in care, and the quality of medical consultations for PLHIV on ARVs; and
    • Creating sample pretreatment sites to optimize viral load sampling campaigns.
  • In close collaboration with the Ministry of Health, through its National Program against AIDS and Sexually Transmitted Infections, the project organized a one-day workshop to share and validate the best practices document.
  • In September 2019, the project conducted a CQI assessment of HIV services offered in 36 project-supported sites within six provinces to measure the progress made in CQI of services provided to PLHIV and in meeting service standards in order to identify the performance gaps that will be addressed in the FY20 CQI plan. The CQI assessment found that 81% of the sites were scored ≥ 80% and 19% scored between 80 – 50%; only one site scored below 50%. Gaps in quality persist in the implementation of new strategies for test and treat, access to viral load testing, and viral load suppression.




Health Service Delivery, HIV/AIDS, Quality Health Systems, and Tuberculosis


Association Nationale de Soutien aux Séropositifs et malades du sida (ANSS), Croix-Rouge du Burundi, FHI 360, Réseau Burundais des Personnes Vivant avec le VIH/SIDA (RBP+), Service Yezu Mwiza (SYM), and Society for Women and AIDS in Africa (SWAA) Centre Nouvelle Espérance