Uganda’s “EID Systems Strengthening” model produces significant gains in testing, linkage, and retention of HIV-exposed and infected infants: An impact evaluation

PLOS ONE RESEARCH ARTICLE Uganda’s “EID Systems Strengthening” model produces significant gains in testing, linkage, and retention of HIV-exposed and infected infants: An impact evaluation Charles Kiyaga1, Vijay Narayan ID2*, Ian McConnell2, Peter Elyanu1, Linda Nabitaka Kisaakye1, Eleanor Joseph2, Adeodata Kekitiinwa3, Jeff Grosz2 a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Ministry of Health AIDS Control Programme, Kampala, Uganda, 2 Clinton Health Access Initiative, Kampala, Uganda, 3 Baylor College of Medicine, Kampala, Uganda * Abstract OPEN ACCESS Introduction Citation: Kiyaga C, Narayan V, McConnell I, Elyanu P, Kisaakye LN, Joseph E, et al. (2021) Uganda’s “EID Systems Strengthening” model produces significant gains in testing, linkage, and retention of HIV-exposed and infected infants: An impact evaluation. PLoS ONE 16(2): e0246546. https://doi. org/10.1371/journal.pone.0246546 A review of Uganda’s HIV Early Infant Diagnosis (EID) program in 2010 revealed poor retention outcomes for HIV-exposed infants (HEI) after testing. The review informed development of the ‘EID Systems Strengthening’ model: a set of integrated initiatives at health facilities to improve testing, retention, and clinical care of HIV-exposed and infected infants. The program model was piloted at several facilities and later scaled countrywide. This mixed-methods study evaluates the program’s impact and assesses its implementation. Editor: Julie AE Nelson, University of North Carolina at Chapel Hill, UNITED STATES Methods Received: August 30, 2020 Accepted: January 20, 2021 Published: February 4, 2021 Copyright: © 2021 Kiyaga et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper and its Supporting Information files. Funding: The authors received no specific funding for this work. Competing interests: The authors declare they have no competing interests. Abbreviations: HEI, HIV-Exposed Infant; HIV+, HIV-Positive; ART, Antiretroviral Therapy; EID, We conducted a retrospective cohort study at 12 health facilities in Uganda, comprising all HEI tested by DNA PCR from June 2011 to May 2014 (n = 707). Cohort data were collected manually at the health facilities and analyzed. To assess impact, retention outcomes were statistically compared to the baseline study’s cohort outcomes. We conducted a cross-sectional qualitative assessment of program implementation through 1) structured clinic observation and 2) key informant interviews with health workers, district officials, NGO technical managers, and EID trainers (n = 51). Results The evaluation cohort comprised 707 HEI (67 HIV+). The baseline study cohort contained 1268 HEI (244 HIV+). Among infants testing HIV+, retention in care at an ART clinic increased from 23% (57/244) to 66% (44/67) (p < .0001). Initiation of HIV+ infants on ART increased from 36% (27/75) to 92% (46/50) (p < .0001). HEI receiving 1st PCR results increased from 57% (718/1268) to 73% (518/707) (p < .0001). Among breastfeeding HEI with negative 1st PCR, 55% (192/352) received a confirmatory PCR test, a substantial increase from baseline period. Testing coverage improved significantly: HIV+ pregnant women who brought their infants for testing after birth increased from 18% (67/367) to 52% PLOS ONE | https://doi.org/10.1371/journal.pone.0246546 February 4, 2021 1 / 20 PLOS ONE Early Infant Diagnosis (of HIV); DBS, Dried Blood Spots; DNA, Deoxyribonucleic Acid; PCR, Polymerase Chain Reaction; ANC, Antenatal Clinic; PNC, Postnatal Clinic; OPD, Outpatient Department; MOH, Ministry of Health (of Uganda); CHAI, Clinton Health Access Initiative; HW, Health Worker; MUAC, Mid-upper Arm Circumference; PMTCT, Prevention of Mother-to-Child Transmission (of HIV); NGO, Non-governmental Organization; PEPFAR: (United States) President’s Emergency Plan for AIDS Relief; KI, Key Informant; DHO, District Health Officer; QI, Quality Improvement; SMS, Short Message System; POC, Point of Care. Impact of novel EID service delivery model on retention of HIV-exposed and infected infants in Uganda (175/334) (p < .0001). HEI were tested younger: mean age at DBS test decreased from 6.96 to 4.21 months (p < .0001). Clinical care for HEI was provided more consistently. Implementation fidelity was strong for most program components. The strongest contributory interventions were establishment of ‘EID Care Points’, integration of clinical care, longitudinal patient tracking, and regular health worker mentorship. Gaps included limited follow up of lost infants, inconsistent buy-in/ownership of health facility management, and challenges sustaining health worker motivation. Discussion Uganda’s ‘EID Systems Strengthening’ model has produced significant gains in testing and retention of HEI and HIV+ infants, yet the country still faces major challenges. The 3 core concepts of Uganda’s model are applicable to any country: establish a central service point for HEI, equip it to provide high-quality care and tracking, and develop systems to link HEI to the service point. Uganda’s experience has shown the importance of intensively targeting systemic bottlenecks to HEI retention at facility level, a necessary complement to deploying rapidly scalable technologies and other higher-level initiatives. Introduction Despite tremendous progress over the past decade, 150,000 children were newly infected with HIV in 2019, with 126,000 of them in sub-Saharan Africa [1]. In Uganda, over 90,000 HIVexposed infants (HEI) are born yearly and 5,000 new children are infected with HIV [2]. To survive, HIV-positive (HIV+) infants must be diagnosed and started early on anti-retroviral therapy (ART) [3, 4]. Disease progression is rapid: if infected infants are not started on ART, 35% will likely die by their first birthday and over 50% by age two [5–7]. Early Infant Diagnosis (EID) is a complex, multi-step process (Fig 1). In Uganda, Dried Blood Spot (DBS) samples are obtained from HEI at health facilities from 6 weeks of age. The DBS samples are transported to a specialized reference lab and tested by DNA Polymerase Chain Reaction (PCR) [8]. The PCR results are then sent back to the health facility and given to the HEI’s caregiver. If negative, a 2nd confirmatory PCR is done after cessation of breastfeeding [9]. Established by Uganda’s Ministry of Health (MOH) in 2007, the National EID Program rapidly scaled up testing of HEI. However, little was known about outcomes of HEI after testing. In 2010, the MOH and Clinton Health Access Initiative (CHAI) conducted a program review at 7 health facilities: a retrospective cohort analysis of tested HEI at 3 hospitals, and qualitative assessment at all 7 facilities [10]. Here we briefly highlight several key findi (...truncated)