No abstract

HIV-related stigma and discrimination (S&D) in healthcare settings represents a potent barrier to achieving global aims to end the HIV epidemic, particularly in Southeast Asia (Cambodia, Lao People’s Democratic Republic, Thailand and Vietnam). Evidence-based approaches for measuring and reducing S&D in healthcare settings exist, but their incorporation into routine practice remains limited, in part due to a lack of attention to how unique organisational practices—beyond the knowledge and attitudes of individuals—may abet and reinforce S&D. Application of a quality improvement (QI) approach in which facilities leverage routine measurement of S&D among healthcare workers and people living with HIV, team-based learning, root cause analysis, and tests of change offers a novel means through which to address S&D in local contexts and develop interventions to address individual-level and organisation-level drivers of S&D. To support the adoption of a QI approach to S&D reduction, the Southeast Asia Stigma Reduction QI Learning Network was launched with Ministries of Health from Cambodia, Lao PDR, Thailand and Vietnam, to co-develop strategies for implementing QI activities in participating facilities. Since the inception of Network activities in 2017, Ministry-led QI activities to address S&D have been implemented in 83 facilities and 29 provinces across participating countries. Moreover, 27 strategies and interventions have been tested to date and are being evaluated for scale up by participating facilities, spanning multiple drivers and organisational domains. Lessons learned through Network activities offer national-level and facility-level HIV programmes best practices for implementing a QI approach to S&D reduction.

Introduction-Most successfully resuscitated cardiac arrest patients do not survive to hospital discharge. Many have withdrawal of life sustaining therapy (WLST) as a result of the perception of poor neurologic prognosis. The characteristics of these patients and differences in their postarrest care are largely unknown.

Background Hypertension (HTN) is highly prevalent among people with HIV (PWH) in Namibia, but screening and treatment for HTN are not routinely offered as part of HIV care delivery. We report the implementation of a quality improvement collaborative (QIC) to accelerate integration of HTN and HIV care within public-sector health facilities in Namibia. Methods Twenty-four facilities participated in the QIC with the aim of increasing HTN screening and treatment among adult PWH (>15 years). HTN was defined according to national treatment guidelines (i.e., systolic blood pressure >140 and/or diastolic blood pressure >90 across three measurements and at least two occasions), and decisions regarding initiation of treatment were made by physicians only. Teams from participating hospitals used quality improvement methods, monthly measurement of performance indicators, and small-scale tests of change to implement contextually tailored interventions. Coaching of sites was performed on a monthly basis by clinical officers with expertise in QI and HIV, and sites were convened as part of learning sessions to facilitate diffusion of effective interventions. Results Between March 2017 and March 2018, hypertension screening occurred as part of 183,043 (86%) clinical encounters at participating facilities. Among 1,759 PWH newly diagnosed with HTN, 992 (56%) were initiated on first-line treatment. Rates of treatment initiation were higher in facilities with an on-site physician (61%) compared to those without one (51%). During the QIC, facility teams identified fourteen interventions to improve HTN screening and treatment. Among barriers to implementation, teams pointed to malfunctions of blood pressure machines and stock outs of antihypertensive medications as common challenges. Conclusions Implementation of a QIC provided a structured approach for integrating HTN and HIV services across 24 high-volume facilities in Namibia. As rates of HTN treatment remained low despite ongoing facility-level changes, policy-level interventions—such as task sharing and supply chain strengthening—should be pursued to further improve delivery of HTN care among PWH beyond initial screening.