Reaching an AIDS-Free Generation (RAFG) in Burundi

The Challenge

Burundi has achieved incredible progress in the fight against HIV/AIDS. Since 2010, new HIV infections and AIDS-related deaths have been cut in half, according to UNAIDS.

Despite progress, Burundi remains one of the poorest countries in the world. Gaps in HIV service quality that constrain epidemic control include find new HIV-positive cases, continuity of treatment, the need to improve ART adherence, low access to viral load testing, and a low rate of viral load suppression among children and adolescent.

Overview and Objectives

As a subcontractor to FHI 360, URC leads quality improvement (QI) activities and ensures QI is integrated into the overall program in the targeted provinces. The Activity uses the science of QI to strengthen the service delivery system at the facility and community levels. QI is being applied to address systemic issues that affect the delivery of HIV services to meet the UNAID’s 95-95-95 goals.

The RAFG Activity’s objective is to scale up ART services for people living with HIV (PLHIV), beginning in five priority provinces in Burundi and now serving 10 provinces. By using an integrated, community-based approach in high-prevalence provinces, the project aims to contribute towards the Government of Burundi’s goal to achieve epidemic control nationally. To achieve the UNAIDS 95-95-95 goals in Burundi, RAFG focuses on:

• Identifying HIV-positive men, women, and children through high quality, targeted HIV testing services and linking those who test positive to ART services;
• Increasing ART coverage in men, women, and children living with HIV; and
• Ensuring HIV-positive men, women, and children on ART are virally suppressed.

The FHI 360-led consortium is using the science of QI to strengthen the service delivery system at the facility and community levels. QI models are used to address the systemic issues that affect the delivery of HIV services so that the system of care for HIV patients achieves its expected performance along the 95-95-95 goals.

The RAFG Activity is building the capacity of health district teams in the supported provinces to train and support facility-level QI teams to carry out continuous quality improvement (CQI) activities to optimize HIV testing services and improve yield through the implementation of index testing approach, enhance the enrollment of new HIV positives cases on ART treatment, reinforce the use of optimized ARV regimens to improve continuity of treatment and viral load suppressed. In addition, the RAFG Activity provides support at the national program level to develop an adequate and functional quality management system for care and treatment services.

Achievements

• The QI team developed annual CQI plans aligned with the project work plan and other gaps identified during assessments, regular supervision, and coaching visits. The goal of the CQI plan is to provide a continuous formal process to improve the quality of HIV services and to help health providers to identify gaps and area in need of improvements, find remediation actions, develop a QI plan and guide its implementation to progressively improve the quality of HIV services.
• During September 2021, the project conducted a CQI assessment of HIV services offered in 64 project supported sites within the 10 provinces to measure the progress made in CQI of services provided to PLHIV and in meeting service standards to identify the performance gaps that will be addressed the new CQI plan for FY22. The CQI assessment in FY21 found that 98.5% (63) sites evaluated scored ≥ 80% and 1.5% (1) site scored 78%, an improvement over the September 2019 CQI assessment which found that 81% of the sites were scored ≥ 80% and 19% scored between 80-50%; only one site scored below 50%.
• RAFG Activity conducted a Root Cause Analysis (RCA) associated to interruption-in-treatment (IIT) in seven sites located in Bujumbura Urban with a high number of IIT cases. Following the assessment, the RAFG Activity convened a workshop to generate change ideas and solutions to improve continuity of treatment in the seven sites.  Each site developed a CQI plan for RCA-IIT activities. Sites are implementing their CQI plans and the progress will be evaluated during Q4 FY22.  
• In line with USAID/PEPFAR guidance, RAFG QI staff conducted a Site Improvement Monitoring System (SIMS) reassessment in all 15 sites evaluated during Q4 FY21 to monitor progress obtained by implementing remediation plan set up after the initial SIMS assessment. All 15 sites obtained higher scores compared to the initial assessment.  
• RAFG technical staff provide support to the site QI teams through regularly coaching visits. These coaching visits focused on training for healthcare providers to strengthen and reinforce their capacities to implement WHO- and PEPFAR-recommended approaches and strategies for HIV epidemic control. Coaching visits support the ongoing, active implementation of CQI plans to address all identified challenges and assist QI team members to monitor performance progress.