1. USAID World Breastfeeding Week Webinar Series: Every day at 9-10AM EDT
July 31st : Barriers to Breastfeeding: Findings From a Systematic Review of Practices in 20 countries
August 1st: Working Together to Save Lives in Emergencies: Initiatives and Tools to Support Breastfeeding in Emergencies
August 2nd: The Global Partnership for HIV-Free Survival: Quality Improvement and Breastfeeding/ART Compliance
August 3rd: Human Milk Feeding for Small/Sick Newborns
August 4th: Revitalizing the Baby Friendly Hospital Initiative: Experiences from Malawi
For more information, visit:

2. ADDITIONAL RESOURCES
USAID Global Health:
USAID Multi-sectoral Nutrition Strategy:
Breastfeeding Symposium:
Breastfeeding Seminar:

3. The Global Partnership for HIV-Free Survival (PHFS): Quality Improvement and Breastfeeding / ART compliance World Breastfeeding Week Webinar Series | August 2, 2017
Amy F. Stern
Improvement Director
University Research Company
Tamara Nsubuga-Nyombi
Senior Improvement Advisor
University Research Company
Linda Kisaakye
Program Officer
Ministry of Health, Uganda

4. The PMTCT care spectrum
Non-pregnant:
Family planning (FP) counseling
Preconception Care
Partner HIV testing
Antepartum:
PITC in ANC
CD4 Testing
ART treatment or prophylaxis
Adherence support
Infant feeding (IF) counseling
Safe Motherhood Birth Preparedness
Intrapartum:
PITC in L&D
CD4 testing
ARV prophylaxis Safe Delivery
IF counseling
FP counseling
1-8 Weeks Post Partum:
Maternal postpartum follow-up
Enrollment into HIV care
ART treatment or prophylaxis during BF
Adherence support
2-6 Months Post Partum:
Repeat CD4 (6 months pp)
ART treatment or BF prophylaxis
6-9 Months Post Partum:
FP counseling IF counseling Adherence support
9-12 Months Post Partum:
ART treatment or BF prophylaxis FP counseling IF counseling Adherence support
12-18 Months Post Partum:
ART treatment FP counseling Adherence support Repeat CD4
PMTCT Maternal Care Spectrum from Pregnancy to 18 months Post Partum
Effective PMTCT includes a series of biomedical and psychosocial interventions administered throughout the reproductive life of the woman living with HIV

5. Drop of ARV uptake before and after delivery
38%
51%
Source: UNAIDS, UNICEF and WHO, 2013 Global AIDS Response

6. The Partnership for HIV-Free Survival
PHFS in six countries: Uganda, Tanzania, Kenya, Lesotho, Mozambique, South Africa
AIM: Decrease HIV transmission & improve nutrition, infant feeding
Deliberate focus on in-country and cross-country learning
Design for sustainability – country owned & led
ASSIST QI demonstration sites
Kenya - 16
Lesotho - 12
Tanzania - 30
Uganda - 22

7. The Partnership for HIV-Free Survival
Nutrition in 1st 1000 days (optimal infant feeding, nutrition and health practices)
Option B+ (effective ARVs to reduce HIV transmission)
HIV-free survival of infants born to HIV-infected mothers

8. Improvement approach Engages teams of providers and other staff
Focuses on client needs
Analyzes systems and processes
Empowers teams to make changes to improve outcomes
Guided by data to measure results
Peer-to-peer learning
Langley et al, 1999, The Improvement Guide

9. Basics of collaborative improvement
Multiple sites simultaneously testing changes, common indicators, peer learning about how to improve that area of care
QI team
representative
Collaborative-level sharing and synthesis of best practices
Site-level summary
Site-level testing of changes
and analysis of results 9

10. Applying improvement to achieve HIV-free survival
WHAT ARE WE TRYING TO ACHIEVE?
HIV-positive mothers who are alive and in care
Exposed infants who are HIV-free, alive and in care
Improve data system to identify areas for improvement
Improve retention of mother-baby pairs
Provide critical package of care at ROUTINE VISITS
Provide critical package of care at SPECIAL VISITS (6w PCR and results visit, 6 and 12m visit, 18m visit)

11. Retention of mother-baby pairs at baseline and end of intervention

12. So…WHAT HAPPENED TO THE IYCF?
Infant and young child feeding (IYCF) results
So…WHAT HAPPENED TO THE IYCF?

13. Defining a standard package of care to be given at each visit
Tally Sheet for Routine Visits
Mother’s ART
CTX/ NVP (baby< 6 weeks) given
IYCF counselling done? (Specify topic)
Nutrition assessment for mother and baby?
Appointment for next visit given and explained what will happen at next visit?

14. Percentage of HIV-positive mothers who receive IYCF counselling at each visit, 22 PHFS sites and 3 comparison sites, Uganda

15. Increasing adherence to IYCF practices, 22 sites, Uganda

16. Improving IYCF adherence at scale

17. Providing the standard package of care at scale

18. What we know now
Interpersonal relations are key
For mothers, patient-provider relations centered on quality education and counseling and motivating patients to remain in care. For many women, more counseling on how to maintain a healthy lifestyle and keep their babies HIV-free were important improvements in the quality of services.
For some mothers, the quality of services before the introduction of improvement methods was fine, but they were able to point out areas where there had been changes. One woman noted that while “services were fine and satisfactory”, changes included providing counseling at every visit, and providing both mother and baby medications at the same visit.
Mothers are able to describe the changes in quality
Improved and more frequent education on treatment adherence and feeding practices was also noted as a valuable change. For many women, more counseling on how to maintain a healthy lifestyle and keep their babies HIV-free was an important improvement in the quality of services

19. Sustaining improvement at the national level
National evaluation of the MBCP found:
90% of facilities were providing services as per guidelines.
Consistency in services reported and actual services received by mothers.
Health education, IYCF counselling and ARV refills were almost universal in all facilities.

20. Improving processes can improve outcomes

21. In summary, the key lessons learned
Robust data system
Retain mother-baby pairs in care
Provide a standard package of care
Early initiation on ART
Empower mothers and create supportive systems

22. Acknowledgements The support of the American people through USAID
Tim Quick, USAID
U.S. President’s Emergency Plan for AIDS Relief
WHO and UNICEF
PHFS partners IHI, FANTA and LIFT
Country implementing partners
USAID ASSIST project staff and MOH counterparts in Uganda

23. For more information about PHFS quality improvement
Amy Stern: Anisa Ismail: Tim Quick:
To view the PHFS learning platform, visit: