Improving paediatric viral load coverage and suppression through scale-up of service quality assessments and viral load committees in Ndola District of Zambia

BACKGROUND: Despite notable progress toward reaching UNAIDS 90-90-90 targets in Zambia, paediatric HIV Viral Load testing Volume (VLV) and VL Suppression (VLS) remains suboptimal. Government data from Ndola District, Zambia showed that VLV and VLS for paediatrics (0-14 years) stood at 688 and 328/688 (48%) in quarter one (Q1) 2019, respectively, respectively. The Clinton Health Access Initiative (CHAI) works in partnership with the Zambia Ministry of Health (MoH) to accelerate testing and treatment coverage for children living with HIV.
DESCRIPTION: In Q2 2019, CHAI and MoH implemented paediatric Service Quality Assessments (SQAs), recommended in the MoH Quality Improvement and Assurance Guidelines for Health Workers in Zambia. This was done in 10 facilities in Ndola to comprehensively monitor performance against service delivery quality standards related to infrastructure, human resources, equipment, clinical practices, data documentation and commodities and supplies for the paediatric population. SQA roll out involved establishment and training of district- and facility-level multi-disciplinary teams to utilize the SQA tools, developing data dashboards to visualize real-time results and developing standard operating procedures.
LESSONS LEARNED: Baseline SQA findings revealed 3/10 (30%) facilities monitored VL according to national guidelines, 6/10 (60%) facilities documented receipt of adherence counselling, and 5/10 (50%) facilities had complete ART clinical teams with all members trained in paediatric HIV management. These findings prompted the establishment of district- and facility-level VL Committees to implement targeted remedial measures, including VL data audits and review meetings, coordinated sample management and referral, and targeted paediatric HIV clinical mentorship. A Welch's t-test was conducted on VL testing volumes and suppression following the intervention, finding a significant increase in paediatric VL testing volumes (668 vs 5,016 tests; p=0.0000001), and VLS (48% vs 84%; p=0.0000000001), from Q1 2019 to Q2 2020.
CONCLUSIONS: Scaling up comprehensive and structured quality improvement (QI) approaches such as SQAs and establishment of VL committees to implement targeted remedial measures resulted in major improvements in VLC and VLS among children 0-14; and can be important strategies to achieve Zambia's HIV epidemic control goals by 2030.