Decentralizing HIV care and TB screening in St. Petersburg, Russia

Improvement Topics: Antiretroviral therapy/ART/ARV, HIV-TB, HIV/AIDS basic care and support, Retention in care

Region and Country: Russia

The Report

Problem:

As in many large Russian cities, HIV/AIDS services in St Petersburg were traditionally relying on a specialized and well-equipped AIDS Center. However, the rapidly growing number of patients with HIV posed a serious challenge to this Center’s ability to respond adequately to patients’ needs. With a total of 29,100 patients identified with HIV in 2004, only 32% were able to receive basic HIV-related care. The expanded availability of ART starting in 2006 overwhelmed the Center’s ability to maintain its commitments. TB, a major HIV co-infection, is also on the rise and the number of co-infected patients in St. Petersburg increased from 287 in 2005 to 723 by mid-2009. The needs for expanded access to HIV care and the improvement of clinical outcomes for HIV patients are paramount elements of the city’s strategy for HIV/AIDS treatment and care.

Intervention:

USAID began supporing HIV/AIDS improvement activities in St. Petersburg n 2004, first under the Quality Assurance Project and later under the USAID Health Care Improvement Project (HCI). With support of the City health authorities, an interdisciplinary team of providers from the St. Petersburg AIDS Center and facilities in one district, Krasnogvardeisky, began participating in a national improvement collaborative involving teams in three other cities in Russia, to develop a model for decentralized delivery of HIV/AIDS treatment, care and support. Twenty-five facilities in St. Petersburg, including Krasnogvardeisky district polyclinics, TB and substance abuse treatment facilities, the City AIDS Center, and key NGOs representing PLWHA worked to analyze the system of HIV care, from patients’ entry into the system, all the way to the AIDS Center. In addition, quantitative data were collected to formulate a complete picture about barriers to HIV care. Although significant gaps were found in the lack of providers’ clinical skills and knowledge about HIV infection and its services, a large number of barriers were discovered in HIV care organization.

Representatives of the St. Petersburg pilot team worked to find ways to remove barriers to care and periodically met with teams from the other cities to share their results. Key changes introduced in Krasnogvardeisky district included:

· Creation of database on HIV-infected individuals residing within each polyclinic’s service area

· Developing clear procedures and forms to facilitate the exchange of information about HIV-infected patients between district polyclinics and the AIDS Center

· Greater involvement of HIV-infected individuals in care

· Issuance of reminders to patients to get medical follow-up care at their local polyclinic

· Processes were established to test HIV patients for TB through X-ray, microscopy and tuberculin as an integral part of the medical follow-up at polyclinics

· Design of referral forms and procedures to connect HIV patients referral with other health and non-health-related services

· Improvements to patient’s recording forms and reporting systems to facilitate coordination of care.

Key measures, such as the number of newly detected HIV patients registered for care, the number of registered HIV patients who received repeated medical follow-up at polyclinics, and the number of HIV patients tested for TB (including in polyclinics), were used by the team to track their progress.

Improved communication and coordination between infectious disease specialists in district-level polyclinics and the AIDS Center, implementation of a step-wise approach for engaging polyclinics in medical follow-up of HIV-positive patients, better tracking of HIV patients living within the area of each polyclinic’s service, and established cooperation between care providers and NGOs representing PLWHAs led to increased coverage of all HIV patients who received medical follow-up in polyclinics of Krasnogvardeisky District from 22% in 2004 to 51% in 2006. At the same time, the percentage of HIV-infected individuals who were registered for care reached 93% in 2006, up from 52% in 2004. The number of patients who were enrolled on ART has also increased from 12 in July 2005 to 82 in December 2006.

By late 2006, health authorities in St. Petersburg supported the innovations of the Krasnogvardeisky District and asked HCI to support the scale-up of improvements to the 17 other districts of the city. Since 2007, the tools designed by the Krasnogvardeisky team have been successfully scaled up through implementation of a city-wide improvement project that included inter-disciplinary teams of providers from 58 polyclinics, 19 TB dispensaries, the AIDS Center and NGOs acting in the area of HIV prevention and care. As part of the scale-up strategy, each district health department appointed a coach who oversaw each team’s progress and served as a focal person for communicating with HCI staff, who provided technical support. In most of the districts these coaches were selected from the head specialists or deputy heads of the district health departments. Coaches received a two-day basic training about teamwork, the quality improvement model, and the importance of measurement. On average, teams met every six weeks to review progress and participated in learning sessions organized by HCI twice a year in cooperation with the Chief Infectious Disease Specialist of the City Health Care Committee, City AIDS Center and City TB Dispensary. Another aspect of the scale-up was a training organized for all infectious disease specialists from polyclinics in St. Petersburg on clinical aspects of HIV care. Faculty of the City’s Medical Academy for Postgraduate Education delivered the training according to curricula designed with assistance from the American International Health Alliance.

Another important factor in the scale-up was the adoption in October 2007 of a Directive (official order) by the City Health Care Committee that required district authorities to secure funding to support or employ, if necessary, infectious disease specialists and nurses to provide medical follow-up for HIV patients, including those who receive ART.

Results:

By July 2008, registration of HIV-infected individuals in medical care in St. Petersburg reached 83%, up from 54% in 2006. At the same time, the proportion of HIV patients receiving medical follow-up at the polyclinic level (rather than at the City AIDS Center or City Infectious Disease Hospital) rose from 21% to 80%. This expansion of patients in care led to a significant increase in the number of patients who were enrolled on ART—from 1,113 in January 2007 to 2,390 in July 2008.

The number of HIV patients who received repeated medical follow-up in polyclinics also increased, from 465 in 2007 to 2,862 by the first quarter of 2009. .

As part of the expanded HIV services to polyclinics, the number of patients tested for TB also grew, due in large part to TB testing of HIV patients in polyclinics as part of routine medical check ups. Although the proportion of HIV patients tested for TB compared to the overall number of patients registered in care has only increased slightly (from 21% in 2007 to 32% in 2008), there has been a rapid increase in the coverage with TB testing of those HIV patients who came to polyclinics for their medical check-ups. In 2007, only 3% of TB patients were tested, a percentage that grew to 58% in 2008.

Lessons:

Extensive research and observation found that decentralizing HIV/AIDS care is essential for expanding access to HIV/AIDS services in Russia. It requires the implementation of multi-disciplinary team approaches, which allow for the linkage of services of various health sectors and providers in a way that engages them in finding local solutions to barriers to care. Reliance on existing system resources and the involvement of health authorities, as well as constant communication with them from the beginning, is crucial to achieve sustainability of new practices.