Quality improvement collaborative approach to improving viral load suppression in the 15-24-year age group in four regions of Namibia, 2018-2020


BACKGROUND: Namibia's antiretroviral therapy (ART) program has been successful in achieving a high level of viral load suppression (VLS) of 91% (NAMPHIA, 2017). Sub-populations and geographic areas need approaches to reach optimal VLS. In August 2018, VLS in four high-burden HIV regions was 92% (n=2527) overall, but only 44% (n=407) among 15-24 years of age. We aimed to improve VLS in the 15-24 age group using a quality improvement collaborative (QIC) approach; a methodology that accelerates improvement where a performance gap is identified.
DESCRIPTION: Twenty-five ART healthcare facilities in Kavango, Omusati, Oshana and Oshikoto regions that provide care to almost 66,400 people living with HIV (PLHIV) were selected to participate. A team of three healthcare workers (ART nurse, data clerk and medical officer) per facility attended the inaugural QIC learning session on July 2018. Regional HIV mentors were trained as quality improvement (QI) coaches while the national QI coaches provided overall coordination and data management. Each facility set up a QI team and identified specific ideas to test using the model for improvement (Plan, Do, Study Act cycles). Facilities compiled and submitted monthly reports to the national level using an Excel template. VLS was defined as being active on ART with a viral load <1000 copies/mL.
LESSONS LEARNED: The key outcome was VLS in the 15-24 years age group improved from a baseline of 44% (n=407) in August 2018 to 74% by December 2020 (n=719). Change ideas that were successfully implemented in the 25 participating sites to improve adherence to ART, patient tracking and management included use of high VL registers (100% of the sites), enhanced adherence counselling (80%), multidisciplinary team management (72%), direct observation therapy (52%), use of pillboxes (32%), initiating and strengthening teen clubs (64%) and timely switch to working regimen (100%).
CONCLUSIONS: A QIC model applied with a dedicated team of healthcare workers and QI coaches led to the improvement in VLS in the 15-24 years age group. Facility level teamwork and QI learning sessions were critical to the success of the initiative. The QIC model may be used in other settings to optimize treatment outcomes for other indicators.