Background
On-time pill pick-up: % of patients with 100% on-time drug pick-up during the first 12 months of ART or during a specified time period Retention in care: % of patients retained in care 12 months after ART initiation Drug stockout: % of months with any day(s) of stock out of any routinely dispensed ARV drug Prescribing practices: % of ART prescriptions congruent with national/international guidelines Viral load suppression: % of patients with viral load < 1000 copies/mL 12 months after ART initiation |
Methods
Sample
Recruitment and interview procedures
1. Please describe the methods this facility uses to monitor HIV drug resistance for the pediatric population. a. What challenges, if any, have you experienced using these methods to monitor drug resistance? b. What are the positive aspects of using these methods to monitor drug resistance? 2. How effective has any of these drug resistance monitoring systems been in identifying possible drug resistance in the pediatric population? 3. Please describe any standards and procedures regarding conducting pill counts with pediatric ART patients at this facility. a. What challenges or barriers does this facility experience regarding conducting pill counts with pediatric ART patients? b. How can these barriers or challenges be addressed? 4. Please describe any standards and procedures regarding the conduct of adherence counseling with pediatric ART patients at this facility. a. What challenges or barriers does this facility experience regarding conducting adherence counseling with pediatric ART patients? b. How can these barriers or challenges be addressed? 5. Please describe any standards and procedures for tracking or tracing pediatric ART patients who miss appointments and drug pickups at this facility. a. What challenges or barriers does this facility experience regarding tracking or tracing ART patients? What about among the pediatric ART patients? b. How can these barriers or challenges be addressed? 6. Does this facility have the equipment and qualified staff to conduct viral load testing? If yes, a. Please describe any challenges or barriers to conducting routine viral load testing at this facility. b. In your opinion, how can these barriers or challenges be addressed? c. What works best in conducting routing viral load testing? If no, a. Please describe the procedures regarding viral load testing with pediatric patients? b. What challenges or barriers does this facility encounter with viral load testing? c. In your opinion, how can these barriers or challenges be addressed? d. What works best in conducting routing viral load testing? 7. Please describe how the current facility practices regarding pill counts, adherence counseling, and/or patient tracing may affect the quality of records needed for pediatric ART monitoring at this facility. 8. Overall, are the ART medical and pharmaceutical records at this facility well-maintained, or are there some gaps in recording the necessary information? a. Please describe any factors or challenges to maintaining complete and up-to-date ART records. 9. What interventions would you recommend to improve routine EWI monitoring at your facility? |
Analyses
Ethical approval
Results
Theme |
%
|
---|---|
On-time pill pick-up | |
Facility level
| |
Inappropriate forms to record pediatric information. | 39.1 |
Variable use of pill count to assess adherence. | 34.7 |
Staff shortages and inadequate adherence counseling skills | 47.8 |
Patient level
| |
Non-disclosure of HIV status to the child hinders adherence | 69.6 |
Stigma hinders adherence | 30.4 |
Retention in care | |
Facility level
| |
Lay providers require support | 82.6 |
A need for a national tracking system and tracking policies | 21.7 |
Patient level
| |
Guardians pose a challenge to pediatric retention in care | 52.2 |
Viral load suppression | |
Facility level
| |
Systemic issues prohibited viral load measurement | 95.7 |
On-time pill pick-up
Facility level
Inappropriate forms to record pediatric information
The spaces provided are not adequate. For example, on the space of the drug that I am prescribing for the client, there is no space to prescribe the dosage. It’s only the type of drug but the dosage is not there…. [I] wish that it had enough adequate space for us to include the drug dosage. (Provincial hospital, MoH managed)
For the pediatric population I thought we would have an extra blue card, a different one designed for them because some of the information here is not meant for the pediatrics. (Provincial hospital, County government managed)
Variable use of pill count to assess adherence
We don’t have anywhere to record those pill counts, we haven’t put measures on how to put pill counts on records. (Health center, County government managed)
Our main challenge as I had told you earlier is most of the population, especially from 5-14 [years old]…is still schooling…. That time for schooling, you only see the caretaker coming or the treatment supporter coming to collect the drugs for the child, while this child was supposed to visit. Yeah, so mainly the challenge we are getting especially where the clients are concerned the failure to visit the clinic in time. (District hospital, FBO managed)
Staff shortages and inadequate adherence counseling skills
Our facility workload is very large, even though we need more time to counsel, sometimes we shorten our counseling period because we have other patients who are waiting to be seen…. So at least when we deal with the staffing issues we will have dealt with the challenge. (Health center, County government managed)
We make sure that everything is documented by the end of the day, but sometimes, the workload is too much for us, we find that we have so much to do at the end of the day…. We need more staff, record officers, we are doing work which is not ours, it’s for records, filling the files, tracking the clients. (District hospital, County government managed)
Okay, the peer educators can show you the record where they capture the adherence counseling and also the patient’s file has everything. In the file there is a form for adherence counseling. (Health center, County government managed)
Respondent: The counseling is done by trained personnel on adherence counseling. We also have PLP taking the clients through adherence counseling.
Moderator: What is PLP?
Respondent: That is people living positive.
Moderator: Okay, they also do the counseling for…
Respondent: Adherence because we have trained them. (Provincial hospital, MoH managed)
The main adherence counseling is done by the nurse, because we require a professional to do the enrolment as we empower the client with adequate information on care and treatment and everywhere else adherence continues because the clinician will talk about it, the peer educator will talk about it, the records person will talk about it, the pharmacist, the nutritionist the same and the like, it’s for each…. Adherence counseling is done on every visit and we reinforce it especially where we identify a gap. (Provincial hospital, County government managed)
We have our records office being managed by our qualified health information records officer. She has all the registers with her, the daily activity register. She is the one who manages the diary, she manages the ART register and after every activity, she sits down to go through the day’s work, identify where the gaps are and they compare their results with the peer educators who have also been asked to monitor all the clients booked for the day’s work. Then they bring their data together to see whether there is any data remaining so the records are well kept in the records office. (Provincial hospital, County government managed)
Patient level
Non-disclosure of HIV status to the child hinders adherence
So I think pediatrics is a challenge on adherence. Then the other problem with the pediatrics is disclosure because you question why: “Why am I taking? What are these for?” Most too often than not they won’t tell them they are taking drugs for HIV. Like the caregivers, they won’t tell them the truth that they are taking them for the HIV disease so they would take and take and sometimes they get tired of taking and say “I won’t take again...” till you explain to them why they are taking. We have even had teenagers taking ARVs and don’t know they are taking ARVs. (Provincial hospital, County government managed)
The issues, especially if they are not disclosed, parents have not disclosed, so it’s a problem, they refuse to come back. They are as if they don’t want to take the drugs because the parents have not explained to them why they are taking drugs. They say why are they taking drugs and others are not taking. So we get them into groups and explain to them why they are taking drugs and we involve their parents, that is why we are able to retain them in here. (District hospital, County government managed)
When the child is ten years, we like including them as early as possible. So they are able to understand. Ten years I am imagining it’s a child in class four, so this is a child who is able to understand. So we help them understand the importance of taking the medicine and we assist them in knowing how many they are supposed to take and we involve them in the counting so that they can appreciate how they need to take their drugs and what I expect the next time they come over. (Provincial hospital, County government managed)
Stigma hinders adherence
Our adolescents, they experience a lot of challenges when they go to school…. The environment at school may be hostile and he will abandon treatment. How to access the dormitory is a problem. How to take their medication because…it may be during class time is a problem. So you find that they keep the drug until they feel they are free, that is when they take the drugs. So it has led to drug resistance in children. (Provincial hospital, County government managed)
For the pediatric patients, we also have some groups, pediatric support group. We have children support groups, when we also follow them and talk to them, so that they can be able to interact together with those who are positive and those who are not. (District hospital, County government managed)
Retention in care
Facility level
Lay health workers require support
The volunteer who works here is conversant with most of the clients that come from the area that she comes from…. Or she is able to know somebody who comes from an area that is nearer one of the clients so we are able to track them that way. (Sub-district hospital, Country government managed)
If they don’t come, we call volunteers or the community health worker to follow them. We also have the SMS system, we send them an SMS daily. (District hospital, County government managed)
It all amounts to financial support. For the follow up, we will need financial support. One, they need airtime. Two, in terms of motorcycles or vehicles, they will need fuel. (Teaching/referral hospital, MoH managed)
Some of those patients don’t have phone numbers and there is no money provided for physical tracing. So, when they don’t have a phone and don’t come, we just wait for them. We don’t trace them physically. (Sub-district hospital, County government managed)
A need for a national tracking system and tracking policies
How do I do a follow up? How am I covered with the policy, in case anything happens to me there? Is this policy designed in a way to protect me? …you could go somewhere you find [gangs], you find them armed with knives, so is there anything to show if I go there and anything happens? So the guidelines [would] really assist, …the guidelines should come officially in this manner so that you can just put it there… even when clients come you can point out to the client and say, you see what the government says in this and this. (Health center, Country government managed)
Clients on transit are a challenge and those are the things we experience as a facility, if NASCOP had a mechanism like a national ID card such that all clients who are enrolled to care and treatment are able to be tracked at one point, it will help us. (Provincial hospital, County government managed)
Patient level
Guardians pose a challenge to pediatric retention in care
Getting the relative’s contact becomes hard because whoever has been the treatment support sometimes when you call back they say they do not know the child, or the child went with other relatives. They do not know how the child is fairing on, so it becomes hard because they hand over from one person to another. (Provincial hospital, County government managed)
The father is there but he is not cooperative because when I asked the child to be accompanied by him, he doesn’t come. I have never seen him…. The other relatives are not near. He only stays with the father and the mother is not there. She passed on. (District hospital, FBO managed)
For the pediatric, we try to have several phone numbers on how we can reach them. If we can have two or three caregivers who stay with the child, if at all we are not able to reach one, we can try the other one. (Sub-district hospital, County government managed)
Maybe community—identifying other people who can be able to support the child outside that person who comes with the child. Addressing the family as a whole so that when one person is not there, the others can be able to sit in for the main one, and also involving the child quite early and making the child understand the importance of drug adherence. (Provincial hospital, County government managed)
Viral load suppression
Systemic issues prohibited viral load measurement
CD4 we did not have that much of the challenge. The turnaround time was short, we would get the results even in a week’s time. But for viral load the turnaround time is very long. The thing is that by the time I bleed until I get my results, even 2/3 months can go by. So that is not appropriate because you need to have results as soon as possible so that we can make decisions as soon as we wish to. (Provincial hospital, County government managed)
Provide a viral load machine…and also have continuous supply of filter papers or what is required for the viral loads to be done so that we can be able to meet our targets. (Provincial hospital, MoH managed)
Yes, erratic supply also demotivates the client actually. You come today and you are told it’s not there; you come next time you are told it’s not there, so you will not bother again and just forget about it. (Provincial hospital, MoH managed)