Systems Analysis and Improvement Approach to optimize the pediatric and adolescent HIV Cascade (SAIA-PEDS): a pilot study

Abstract

Introduction Children and adolescents lag behind adults in achieving UNAIDS 95-95-95 targets for HIV testing, treatment, and viral suppression. The Systems Analysis and Improvement Approach (SAIA) is a multi-component implementation strategy previously shown to improve the HIV care cascade for pregnant women and infants. SAIA merits adaptation and testing to reduce gaps in the pediatric and adolescent HIV cascade. Methods We adapted the SAIA strategy components to be applicable to the pediatric and adolescent HIV care cascade (SAIA-PEDS) in Nairobi and western Kenya. We tested whether this SAIA-PEDS strategy improved HIV testing, linkage to care, antiretroviral treatment (ART), viral load (VL) testing, and viral load suppression for children and adolescents ages 0–24 years at 5 facilities. We conducted a pre-post analysis with 6 months pre- and 6 months post-implementation strategy (coupled with an interrupted time series sensitivity analysis) using abstracted routine program data to determine changes attributable to SAIA-PEDS. Results Baseline levels of HIV testing and care cascade indicators were heterogeneous between facilities. Per facility, the monthly average number of children/adolescents attending outpatient and inpatient services eligible for HIV testing was 842; on average, 253 received HIV testing services, 6 tested positive, 6 were linked to care, and 5 initiated ART. Among those on treatment at the facility, an average of 15 had a VL sample taken and 13 had suppressed VL results returned. Following the SAIA-PEDS training and mentorship, there was no substantial or significant change in the ratio of HIV testing (RR: 0.803 [95% CI: 0.420, 1.532]) and linkage to care (RR: 0.831 [95% CI: 0.546, 1.266]). The ratio of ART initiation increased substantially and trended towards significance (RR: 1.412 [95% CI: 0.999, 1.996]). There were significant and substantial improvements in the ratio of VL tests ordered (RR: 1.939 [95% CI: 1.230, 3.055]) but no substantial or significant change in the ratio of VL results suppressed (RR: 0.851 [95% CI: 0.554, 1.306]). Conclusions The piloted SAIA-PEDS implementation strategy was associated with increases in health system performance for indicators later in the HIV care cascade, but not for HIV testing and treatment indicators. This strategy merits further rigorous testing for effectiveness and sustainment.

The Systems Analysis and Improvement Approach: Data-driven Quality Improvement

“…To capture structured feedback and support consensus building, the investigators convened a panel of 23 implementation scientists, researchers, implementing team members and organizational stakeholders, all with direct experience implementing and/or evaluating SAIA. This panel included those experienced with SAIA's adaptation and application across a range of clinical areas (including PMTCT 6,11,12 , mental health 9 , hypertension 10 , family planning 8 , pediatric HIV 13 , cervical cancer, community-based naloxone distribution 17 , juvenile justice health care services, and malaria), and countries (Mozambique, Kenya, USA, Democratic Republic of the Congo), whose direct implementation experience made them well-suited to synthesize best practices and priorities for further adaptation and spread.…”

“…Broader conversation across clinical areas highlighted commonalities and differences, clarifying the essential SAIA components, as well as broader linkages of this multi-component strategy to Proctor's implementation outcomes. 19 Through consensus, the broader SAIA panel determined which Proctor implementation outcomes are effectively addressed through the use of the SAIA implementation strategy, a process that was informed by the published results of the various studies in peer reviewed journals [7][8][9]12,13,20,21 and conferences 17,22 as well as feedback from eld-based research teams. Implementation outcomes were considered for SAIA as a whole (not its individual components), as it is a multi-component strategy designed to be implemented holistically.…”

“…Over the last decade, there has been a steady rise in funded research to adapt SAIA to novel clinical areas and geographic settings, and a growing demonstration of its broader effectiveness across a range of public health settings. [8][9][10][11][12][13][14] To extend on this previously published research and ensure SAIA's success, its adaptation and implementation should be guided by conceptually clear implementation strategies. In this short report we comprehensively map the core components of the SAIA implementation strategy to the distinct strategies of the ERIC typology, specify each resultant ERIC implementation strategy according to Proctor's guidelines for specifying and reporting implementation strategies, and describe implementation outcomes that link to the multi-component SAIA strategy.…”

The Systems Analysis and Improvement Approach (SAIA): Specifying core components of an implementation strategy to optimize care cascades in public health

“…As pre-work, a smaller group of IS experts, engaged in the initial SAIA studies targeting the optimization of prevention of mother-to-child transmission of HIV (PMTCT) programs, convened to specify the components of the SAIA strategy (SAIA strategy meetings, cascade analysis, process mapping, CQI) and discuss the process by which the broader group of SAIA researchers would be engaged to both specify the SAIA core components and match relevant ERIC strategies to them. The broader SAIA research team included those with experience in SAIA adaptation and implementation across a range of clinical areas (including PMTCT(6,11,12), mental health (9), hypertension (10), family planning(8), pediatric HIV (13), cervical cancer, community-based naloxone distribution (14), juvenile justice health care services, and malaria), and countries (Mozambique, Kenya, USA, Democratic Republic of the Congo).…”

Scaling-up and scaling-out the Systems Analysis and Improvement Approach to optimize the hypertension diagnosis and care cascade for HIV infected individuals (SCALE SAIA-HTN): a stepped-wedge cluster randomized trial

“…During initial testing, SAIA was applied to optimize the prevention of mother-to-child transmission of HIV in three sub-Saharan African countries and demonstrated dramatic cascade improvements, as well as high penetration, acceptability, and feasible integration into routine service management activities [ 33 , 34 ]. SAIA has been adapted and applied to multiple care cascades in the USA and multiple countries in sub-Saharan Africa including but not limited to pediatric HIV testing [ 35 ], HIV testing in family planning services [ 36 ], cervical cancer screening and prevention [ 37 ], severe mental illness diagnosis and management [ 38 ], malaria diagnosis and treatment, and Naloxone distribution [ 39 ].…”