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Assessment of HIV Quality of Care in Cote d'Ivoire

Y-S Lin | N Livesley | D Nicholas | J Nguessan
Organization: USAID Health Care Improvement Project/URC

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

Region and Country: Cote d'Ivoire

Ministry of Health | PNPEC | ACONDA | CARE | EGPAF | ESTHER | ICAP

The assessment, conducted in July and August 2008, collected data from interviews with providers or heads of HIV services, as well as cohort data from medical records and registers used for prevention of mother-to-child transmission (PMTCT), voluntary counseling and testing (VCT), antiretroviral therapy (ART) and HIV care services.  The first cohort, made of patients already on ART, was defined as patients who had a documented ART initiation date in their medical records as of June 2007. The second cohort, the "pre-ART" cohort, consisted of patients who had tested HIV-positive, were in HIV care, but who had not initiated ART in the first three months of HIV care. A third cohort was drawn from PMTCT registers and consisted of prenatal care clients who had tested HIV-positive and for whom data might be available for a potential period of 18 months.

The assessment found that for both the pre-ART and the ART cohorts, adherence to standards of care during the initial visit at the assessed sites was good. It was better among ART patients compared to pre-ART patients, and generally better among children compared to adults. Basic HIV care standards of HIV typing, weighing, clinical staging, and CD4+ T cell count assessment were all performed in at least 65% of patients. Adherence to standards of care was lower in the second semester of care for both cohorts. A number of clinical activities that were not conducted during clinical visits represent low-effort opportunities for providing care, including clinical staging, weight-taking, and patient counseling.  Retention of patients in HIV care was found to be poor. Six months after initiating care, two out of three pre-ART patients and 45% of ART patients were lost to follow-up, comparing unfavorably with retention figures from other studies in the African context. While some sites worked with local groups providing community HIV care, coordination of this care was a challenge.

Reliance on information documented in medical records and registers limited this assessment, which was illustrated when medical record data for the ART cohort patients were compared with pharmacy data.



In discussing the findings with the Ministry of Health and stakeholders in Cote d'Ivoire, the following actions were recommended to be implemented as part of a collaborative approach to quality improvement:


§         Monitor a small number of quality indicators, especially indicators that track longitudinal care,
§         Improve documentation and information systems for efficient information retrieval,
§         Focus on addressing poor retention and medical record management, and
§         Promote shared learning of innovations in HIV care, including task shifting experiences.