Evaluation of quality of HIV clinical care in wollayta soddo Hospital

1. Evaluation of quality of HIV clinical care in wollayta soddo Hospital SNNP Regional state, Ethiopia Prepared by: Marshet We/yohanns Jimma may, 2009

2. Out lines • Introduction • Statement of the problem • Purpose of evaluation • Objective of the program • Program activities • Stage of development • Social context of the program • Logic model of the program • Stakeholder identification and analysis • Objective of evaluation • Evaluation question • Study Area and period • Study unit and Sampling unit

3. Out line cont.. • Sample size and sampling procedures • Focus of evaluation • Dimension of evaluation • Approach of evaluation • Designs of evaluation • Theoretical modal of evaluation • Inclusion and Exclusion criteria • Data collection procedures • Data management and Analysis • Limitation of the study • Report writing & dissemination plane • Result and Discussion • Conclusion& Recommendation • Reference

4. Introduction program evaluation is applied research used as part of the managerial process. • programs are evaluated basically because administrative decision have to be made and it is important to know (or to show) that our program are good programs.

5. statement of the problem • We are in the third decade of what has become the most important infectious disease epidemic (pandemic) in the last century. • UNAIDS fact sheet, estimated that, at end of 2007, 33.2 million people world wide were living with HIV/AIDS, 2.5 million become newly infected with HIV and 2.1 million lost their lives due to AIDS.

6. Statement cont... • According to the single point HIV prevalence estimate, SNNPR region is one of the areas with high prevalence and Incidence of HIV/AIDS. • The adult HIV/AIDS prevalence is estimated to be 1.5% with 0.2% Adult incidence.

7. statement cont… • To get the required out comes of HAART treatment care with standardized quality is mandatory . • Quality of care remains an area for improvement, despite the increased attention it has received in recent years.

8. Purpose of Evaluation formative evaluation was planed for this evaluation and its main purpose is: • Planning and management of the intervention which helps to improve the quality of HIV clinical care • Assist in an efficient allocation of resources • Report on the achievements of the intervention (i.e. accountability) • Ensure optimum use of its funds and other resources

9. General Objective of the HIV clinical service The objective of care and treatment program in Wolayta Soddo Hospital is : To improve the quality and length of life of PLWHA in Wolayta zone, by providing medical care and treatment service and thus contribute to the well being of their families and development of the country.

10. Program Activities • Preparation of ART clinic and establishing information system in the hospital • Training ART teams by communicating with the Regional Health bureau • Searching for and establishing a link with care and support group • Collecting necessary drugs and supplies from the regional health bureau • Provision of ART and pre ART chronic HIV care for eligible PLWHA • Conducting on site sensitization on ART and its referral system for staffs of health centers in the districts of wolayta zone.

11. Stage of development • Soddo hospital was started HIV clinical care program in June 2005. till the end of June 2008, There were 792 PLWHA gets pre ART care 985 AIDS patients started on ART

12. Logic model of the program The basic logic model components of this Evaluation Illustrates the connection between the planned activity and intended results. Resources: Program Activities: Out put: Out comes: Impact : Final Evaluation proposal Marshet word doc.doc

13. Stakeholder Identification& Analysis Stakeholders are individuals, groups, or organizations that tended to have significant interests on how well a program functions. Stakeholders are identified during evaluability assessment and proposal development.

14. Objectives of Evaluation General objectives The general objective of this study is to assess the quality of HIV clinical care provided by wollayta soddo hospital. Specific objectives • To assess HIV clinical practice compliance with the national guidelines. • To assess the Availability of human and material resources required to provide quality HIV clinical care in Wolayta Soddo hospital. • To assess adequacy of resources to provide HIV/AIDS clinical care in Wolayta Soddo hospital?

15. Evaluation Questions Evaluation Questions • Is the HIV clinical care provided by Wolayta Soddo hospital according to the national guideline? if not why? • Are there adequate resources to provide HIV clinical care in Wolayta Soddo Hospital?

16. Methods Study area and study period Wollayta zone is one of the biggest zones in SNNPR state. The total population living in the zone for the year 2008 is 1.7 million. In the zone there are 30 health center and 1 Government hospital, 1 private hospital and 1NGO hospital. Among these 21 health centers and the three hospitals are giving VCT services, ART services are given in 2 health centers and 2 hospitals. The study was conducted in wollayta soddo hospital The study pried was from December 1, 2008 – May 1, 2009 and data was collected from data was collected from December 1-20, 2008.

17. Methods cont… Target population All patients receiving chronic HIV care with or without ARV regimen In the hospital during the study period was target for this study. Study units and sampling unit. Adult patient with HIV who attend chronic HIV care and treatments was the sampling & study units for the study.

18. Methods cont… Sample size and Sampling Procedures Chart review Epi Info version 3.3.2 statcalc was used to calculate the required sample size. According to the hospital records, the total number of patients on chronic HIV care and treatment was 1777 The resulting sample size was 316 Were p. was the proportion of HIV patients who attends chronic HIV clinical care =50% C.I= 95%. Margin of errors = 5% The sample size for pre ART: 316* 792/1777 =141 The sample size for ART: 316*985/1777 =175

19. Methods cont… The study units was selected by using systematic random sampling. the first document was selected randomly by lottery system Expert interview The sample size for in depth interview was determined based on the adequacy of the information needed. (Using saturation sampling methods).

20. Methods cont… Focus of Evaluation This evaluation primarily focuses on measuring processes of quality of HIV clinical cares in wollayta soddo hospital Dimension of the evaluation This study uses 3 dimensions of evaluation. Availability Measures the presence of resources interims of infrastructure, equipment and supplies, and trained human in sufficient amount. Compliance This dimension helps to measure HIV clinical care practice in the hospital comparable to the national guide lines. Accommodation Measures the providers operation is organized in way that meet the constraints and preferences of the client.

21. Methods cont… Approach to evaluation The evaluation approach is formative evaluation because its purpose is to help form or shape the program to perform better. Design of evaluation Case study design was used for this study. The study was conducted through face to face interview, document review, and observational methods.

22. Figure 2 theoretical Modal of Evaluation Client Satisfaction Increased treatment compliance Increase service up-take Increase adherence to ARV Drugs Decrease loss to follow-up Accommodation Availabilityofresources Decrease drug resistance Reduction of HIV related morbidity and mortality Increase productivity Improved quality of service Compliancetoguideline Increase Service utilization

23. Data Collection Procedures Before the Data Collection, training was give to make the data collectors familiar with the information to be collected and to see the clarity of the different questionnaire The questionnaires was pre-tested for its reliability and validity before it is being used. In the Data Collection 5 Physicians 1 Pharmacy technician, 1 Laboratory technologist and 5 senior ART nurses was participated. To insure quality of data collection daily supervision was done by the P.E. • Availability of the necessary resources. • HIV clinical care compliance with the National guidelines • Expert Interview

24. Inclusion and Exclusion criteria Inclusion criteria for chart review All clients who have a minimum of two visits before the study period Exclusion criteria for chart review. Patients who have less than two visits before the study period. Patients who was lost to follow up and death are excluded from the study Inclusion criteria for expect interview. Experts who workers for more than 2 months on ART clinics

25. Data Management and analysis • The data collector was recruited out of the study health facility. • During data collection period data was rechecked every time at the end of each day. • After data collection & editing, quantitative data was entered and analyzed by using SPSS version 16. • Both descriptive and analytic statistical technique was used to describe the final findings • By identifying the thematic area of qualitative information, the data was analyzed manually .

26. Limitation of the study HIV clinical care offered to children is not evaluated by this study. Some service providers may not respond honestly. Some data collectors on observation check list may not feel the form honestly

27. Report writing and dissemination plan The final report of this evaluation will be commented by Jimma university research comity, then the report was distributed both in hard and electronic copy to all stakeholders and interesting organization. The copy of this evaluation report will also be submitted to Jimma University.

28. Results and discussion Availability Human resource • Implementation of Effective HIV clinical services is successful when staffs at program management level are trained • In Wollayta soddo Hospital, there were four MD, ten ART nurses, five laboratory technician and eight pharmacy technicians are trained in ART and all of them are working in HIV clinical care department. • Due to shortage of human power the four physicians have multiple responsibilities in addition to HIV clinical care. Compared to the national guideline the availability of trained human resource achievement resulted was 100 %.

29. Availability of OI and ART Drugs • Highly active antiretroviral therapy (HAART) can reduce the amount of HIV in some ones body and restore their immune system • The availability of OI drug in the hospital is found as expected. Among the required OI drugs, all are found to be available during the data collection period. This is the most heartening result seen in this evaluation and it has to be sustainable. • Regarding the availability of ART drugs only 50% of the drugs are available. when we observe the availability of ART drugs specifically, the resulting judgment criteria become fair.

30. Availability of OI and ART Drugs cont… • In HIV infected patients on HAART 80% to 90 % adherence has been associated with failure to complete viral Suppression in 50 % of patients. one of the factors associated with non – adherer to ART& OI drug is poor drug supply. • From this specific evaluation finding It is possible to hypothesize that, In Wollayta soddo Hospital patient’s on HIV clinical care are highly exposed for none adherence to ARV drugs due to stock outs of the drugs.

31. Number of rooms for ART SERVICES • Facilities infrastructure are required to be accredited before starting to provide ART service. • Regarding infrastructure for HIV clinical care: there were one examination, one separate counseling, one onsite pharmacy, one storage space and one specimen collection rooms are available. • According to the Judgment criteria, the availability of rooms for ART services Compared to the national guidelines found to be excellent (100%)

32. Number of rooms cont… • In similar evolutions study conducted in Addis Ababa, The physical set up compared with the national Guideline was found to be 80 % which is in adequate. • This study result was better when compared to the above evaluation findings.

33. Availability of Laboratory Services • The HIV clinical care department of the Hospital uses laboratory services from the laboratory departments of the hospital. • Some of the laboratory reagents for the service, which are not available include: Indian ink, BUN and cretinin. According to the above result the availability of Laboratory service in the hospital was judged as good (66.6%)

34. Availability of The necessary Laboratory and pharmacy supply and equipment The availability of laboratory and pharmacy supply and equipment was found as expected. Out of the 8 necessary Laboratory and pharmacy supplies and equipment recommended by the national guidelines, 6 of them are found functional. Hematology auto analyzer and clinical chemistry auto analyzer were not available in the Hospital. According to the judgment criteria, the result is found to be 75 % (Good).

35. Compliance to the National Guideline To assess compliance of clinical care for patients with HIV infection in Wollayta Soddo Hospital with the national treatment guideline, a total of 316 charts of patients attending HIV clinical care in the hospital were reviewed. Out of these 175 (55.3) were on ART and the rest 141 (44.6) were on pre ART HIV clinical care.

36. Socio demographic characteristics of study population for chart review • The mean age of the study population was found to be 30.6 years (SD + 8.2). More than half (57%) are between the age of 18 and 30 years. • The majority of the study population in the sample (37.9%) had primary school education about 26.5% were not able to read and write at all. only 1.9% completed college level education.

38. Socio demographic cont… • Marred make up significant proportion (49.2) of the sample, Followed by single 26.2 and widowed 17.4 percent. 6.9 percent of the study populations were divorced. • More than half of the study subjects (61.5%) were female and the rest are male. Table of socio demographic characteristics. final draft of Evaluation thesis marshet word doc.doc

39. Evaluation and follow up of HIV clinical care of the patients • To provide, continuum of HIV care at different level trained man power is an essential entity that needs to be strengthened and highly coordinated. • Accordingly Wollayta soddo Hospital has adequate trained man power and more than 96% of the patients are evaluated by trained physician. • Compared to the national guidelines this result is considered to be excellent and needs to be continued in the future.

40. Evaluation and follow up cont… • Patient monitoring and evaluation is an important part of high quality of patient care. • Out of 316 patients who have at least two follow up on HIV clinical care in the hospital,180(56.8%) of their clinical status was monitored on every visit for the last 6 months. • This shows that the proportion of clients whose clinical status is monitored every visit is judged to be faire. • which is not accepted according to the agreed up on evaluation parameters & by the national guideline so It needs argent correction.

42. Cotrimoxazol prophylactic therapy (CPT) and TB screening • Several clinical trails in Africa have shown the impact of CPT in reducing morbidity and mortality in PLWHA • Studies in West Africa suggest that Cotrimoxazol prophylaxis reduces the morbidity and mortality related with opportunistic infection specially patients with TB HIV Co infection.

43. CPT prophylactic cont… • According to the national TB /HIV implementation guideline criteria, in this evaluation study 91.6 % of the eligible Patients are prescribed with CPT prophylaxis therapy. • In similar evaluation study conducted in one referral Hospitals of the Amhara National Regional state, only 45.9% of eligible patients were taking Cotrimoxazol prophylaxis therapy. • The acivments of Wolayta soddo hospital with regard to this components of HIV care was found to be better when compared to the above study findings.

44. CPT prophylactic cont… • Based on TB/HIV implementation guideline, all HIV positive clients should be informed about the advantage of being screened for TB& they should under go screening for TB. • This evaluation finding identifies, in Wollayta soddo Hospital only 56.2% of the sampled HIV positive case are screened for TB which is far lower than the national TB/HIV implementation Guideline. This needs argent Correction.

45. ART and OI Adherence Counseling According to the national guidelines at least 95% adherences required for ART and OI regimen to be fully effective and avoid the emergence of resistant strains of the viruses. Accordingly this evaluation study revealed that adherence counseling and evaluation of adherence status was done for 52.7% & 88.5 % of patients respectively. Since Adherence counseling do have direct relation with adherence status of the patient the above result is not acceptable according to the agreed evaluation criteria.

46. ART and OI Adherence cont… • None adherence in patients on anti HIV/Therapy is the strongest predictor of failure to achieve viral suppression below the level of detection and faulty adherence to anti HIV drugs most often underlies treatment failure. • From this point of view the above evaluation findings needs urgent correction

47. Staging and follow up of patients with CD4 count Out of 316 patients included in this evaluation study CD4 count was performed at least once during the last 6 months for 173 (54.6) patients. This makes the proportion of patients who have CD4 counts at least once during the last 6 month to be judged as Fair. Wollayta soddo Hospital uses the WHO staging criteria for the follow up of disease progression in each patient.

48. Staging and follow up cont… According to this criterion, from a total of 316 patients who are on chronic HIV clinical care 239(75.4) of the patients are staged correctly, the rest 77 (24.6) are not staged correctly. This result concludes the proportion of patients who are correctly staged during there last visit to be judged as Good.

49. Initiation of ART treatment • From a total of 211 patients who are eligible for ART 174(82.4) of them are started ART, The rest 37(17.6) even thou they are eligible for ART they didn’t started ART with in 2 weeks of their eligibility time and they are not currently on ART. • After the initiation of the ART treatment 9 of the 10 patients declared that there health condition is being improved from time to time.

50. INITIATION OF ART TREATMENT • In similar study undergone in Amhara national region the result showed that only 76.8 % of eligible patients are started ART. • According to agreed evaluation criteria even thou this results is Judged to be very good, from the point of view of benefit gained by timely Initiation of ART treatment and the need for the result to be nearly 100 % this finding needs Improvement.