Improving rates of cotrimoxazole prophylaxis in resource-limited settings: implementation of a quality improvement approach

Abstract

Objective: To demonstrate the effectiveness of quality improvement methods to monitor and improve administration of cotrimoxazole (CTX) prophylaxis to improve health outcomes among adults living with HIV/AIDS in low resource countries.

Design: Program evaluation.

Setting: HIV/AIDS health care facilities in Uganda, Mozambique, Namibia and Haiti.

Intervention: Performance measures based on national guidelines are developed in each country. These may include CD4 monitoring, ART adherence and uptake of CTX prophylaxis. CTX prophylaxis is routinely selected, because it has been shown to reduce HIV-related morbidity and mortality. Patient records are sampled using a standard statistical table to achieve a minimum confidence interval of 90% with a spread of ±8% in participating clinics. If an electronic medical record is available, all patients are reviewed. Routine review of performance measures, usually every 6 months, is conducted to identify gaps in care. Improvement interventions are developed and implemented at health facilities, informed by performance results, and local/national public health priorities.

Main outcome measure: Median clinic rates of CTX prophylaxis.

Results: Median performance rates of CTX prophylaxis generally improved for adult HIV+ patients between 2006 and 2013 across countries, with median clinic rates higher than baseline at follow-up in 16 of 18 groups of clinics implementing CTX -focused improvement projects.

Conclusions: Quality management offers a data-driven method to improve the quality of HIV care in low resource countries. Application of improvement principles has been shown to be effective to increase the rates of CTX prophylaxis in national HIV programs in multiple countries.

Keywords: pepfar; performance measurement; quality improvement; quality management.