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PrEP Up! A quality improvement collaborative (QIC) to scale-up PrEP in health centers in Blantyre, Malawi

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BACKGROUND: Although Malawi continues to experience high numbers of new HIV infections, uptake of PrEP has been slow. In Blantyre, PrEP was introduced in 2020 as a pilot in drop-in centers (DICs) for key populations but was not being offered in health centers or hospitals where eligible people seek routine care. As part of the Blantyre Prevention Strategy, under the leadership of the Ministry of Health, with technical support from a consortium of partners, QIC was launched by the District Quality Improvement (QI) unit in 21 facilities in 2021, including 3 hospitals, 14 health centers and 4 DICs. A readiness assessment conducted in December 2020 showed that only 3 clients were on PrEP in hospitals and health centers, with 891 on PrEP in DICs. The initial focus of facility QI activities was to identify service entry points for assessing patients who would be PrEP-eligible for formal screening according to national guidelines, including HIV testing.
METHODS: Facilities apply standard QI tools for root cause analysis, process mapping and testing of team-identified changes through Plan-Do-Study-Act cycles. Coaching provided by a team of district health officers guided by expert QI mentors (MaiKhanda Trust) occurs both in-person and virtually. Nine basic indicators are measured monthly spanning from assessment to monitoring and continuity of care.
RESULTS: Early results from facilities show rapid increase of patients being assessed for PrEP, of eligible candidates screened. Monthly PrEP initiation jumped in hospitals and health centers from 36 in April to 249 in November 2021, with a total of 1042 people initiated over 8 months, with an additional 713 initiated in 4 drop-in centers. Redesign of clinic flow was the most common QI intervention which centralized HIV testing as the focal point for decision-making to offer ART as either treatment or PrEP. In larger facilities, PrEP teams were created, champions were identified to create demand in service areas, including STI, youth, ophthalmology and medical clinics. Educational talks and materials are also routinely made available in health center waiting areas.
CONCLUSIONS: Quality Improvement Collaboratives are an effective strategy to accelerate PrEP uptake in diverse facilities through integration into multiple service delivery points.