Abstract
There have been a range of quality improvement (QI) and quality assurance initiatives in low- and middle-income countries to improve antiretroviral therapy (ART) treatment outcomes for people living with HIV. To date, these initiatives have not been systematically assessed and little is known about how effective, cost-effective, or sustainable these strategies are in improving clinical outcomes. We conducted a systematic review adhering to PRISMA guidelines (PROSPERO ID: CRD42017071848), searching PubMed, MEDLINE, Embase, Web of Science, and the Cochrane database of controlled trials for articles reporting on the effectiveness of QI and quality assurance initiatives in HIV programs in low- and middle-income countries in relation to ART uptake, retention in care, adherence, viral load suppression, mortality, and other outcomes including cost-effectiveness and long-term sustainability. One thousand eight hundred sixty articles were found, of which 29 were included. QI approaches were categorized as follows: (1) health system approaches using QI methods; (2) QI learning networks including collaboratives; (3) standard-based methods that use QI tools to improve performance gaps; and (4) campaigns using QI methods. The greatest improvements were seen in ART uptake [median increase of 14.0%; interquartile range (IQR) -9.0 to 29.3], adherence [median increase of 22.0% (IQR -7.0 to 25.0)], and viral load suppression [median increase 26.0% (IQR -8.0 to 26.0)]. QI interventions can be effective in improving clinical outcomes; however, there was significant variability, making it challenging to identify which aspects of interventions lead to clinical improvements. Standardizing reporting and assessment of QI initiatives is needed, supported by national quality policies and directorates, and robust research.
Highlights
Considerable strides have been made in the scale-up of antiretroviral therapy (ART) in low- and middle-income countries (LMICs)
We conducted a sensitivity analysis to examine the increase in ART uptake in pregnant women compared with the general patient population across the evidence, identifying that the median percentage increase in patients initiating ART in programs focused on prevention of mother-to-child transmission (PMTCT) was 19.0% (IQR 13.5–40.5) compared with 13.0% (IQR 4.5–29.3) for programs directed at the general population (Table 1), this was not statistically significant
This study reported on outcomes related to ART uptake among HIV-infected pregnant women and cost, finding that monthly referrals for ART rose from 78.7 [95% confidence interval (CI): 69 to 89] individuals to 188.2, whilst monthly ART initiation concurrently rose from 20.7 individuals to 123.8, with much smaller increases in the control district (39–55 initiations per month)
Summary
Considerable strides have been made in the scale-up of antiretroviral therapy (ART) in low- and middle-income countries (LMICs). In LMICs with the highest burden of HIV, coordinated action is urgently needed to achieve global targets, so 90% of all PLHIV know their status, 90% of those diagnosed as HIV positive start ART, and 90% of all people receiving ART have durable viral suppression.[3]. There have been a range of quality improvement (QI) and quality assurance initiatives in low- and middle-income countries to improve antiretroviral therapy (ART) treatment outcomes for people living with HIV. To date, these initiatives have not been systematically assessed and little is known about how effective, cost-effective, or sustainable these strategies are in improving clinical outcomes
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