1. What’s Next?
Practical Implementation
Lessons from the Partnership
for HIV-Free Survival
Emily A. Bobrow
Heather B. Davis
David K. Hales
MEASURE Evaluation
25 September 2019
Webinar

2. Partnership for HIV-Free Survival (PHFS)
• Innovative project designed to prevent and eliminate mother-
to-child transmission of HIV (PMTCT and eMTCT)
• Brought together proven practices from PMTCT, quality
improvement (QI), nutrition, and community outreach to
improve health outcomes for mothers living with HIV and their
HIV-exposed infants
• Supported by USAID and PEPFAR, PHFS was active
between 2012 and 2016 in six countries in sub-Saharan
Africa: Kenya, Lesotho, Mozambique, South Africa, Tanzania,
and Uganda

3. PHFS evaluations by
MEASURE Evaluation
• PHFS Legacy Evaluation Report
https://www.measureevaluation.org/resources/publications/tr-18-314
• Country-Specific Briefs
Kenya: https://www.measureevaluation.org/resources/publications/fs-18-251
Lesotho: https://www.measureevaluation.org/resources/publications/fs-18-250
Mozambique: https://www.measureevaluation.org/resources/publications/fs-18-293
South Africa: https://www.measureevaluation.org/resources/publications/fs-18-266
Tanzania: https://www.measureevaluation.org/resources/publications/fs-18-249
Uganda: https://www.measureevaluation.org/resources/publications/fs-18-255
• Outcome Evaluation of PHFS in Uganda

4. Intended users of the guide
• People who are keenly interested in improving the
performance of PMTCT/eMTCT programs and related
activities (e.g., retention in antiretroviral therapy
[ART])
• People with different expertise, including advocacy,
policy, planning, oversight, and implementation

5. Many combinations
• Conception of the guide originated from the PHFS
evaluations by MEASURE Evaluation
• PHFS approach was successful in many facilities
across the 6 PHFS countries, but not all approaches
were the same
• Explored how facilities were successful
• Conceptual image of a stew
o Baseline ingredients required
• Minimum number of baseline ingredients
o Recipes can differ
o Circumstances and availability of ingredients is important to consider
o Need to end up with a well-balanced, nourishing stew using your
winning recipe

7. “How-to” guide
• Practical information
• Designed to be flexible, so countries can identify and take
advantage of opportunities in their existing systems to shift
toward the PHFS approach
• Can take an incremental approach to implementation; not
required to do everything at once

8. Format of the “how-to” guide
• Key lessons from PHFS
o Short descriptions, definition of terms, tips
o Three main areas:
• Service delivery
• Quality improvement
• Community engagement
• Checklists
o Preparing to implement the PHFS approach
o Launching the PHFS approach
o Sustaining the PHFS approach
o Extending the PHFS approach

9. Key lessons from PHFS
1. Mother-baby pairs
2. Mother-baby clinics
3. Integrated services
4. Nutrition
5. Quality-improvement tools and techniques
6. Coaching and mentoring
7. Knowledge exchange
8. Community workers
9. Metrics and data sets

10. Mother-baby pairs
• What
o Mothers living with HIV and HIV-exposed infants are seen together at the
same appointment
• Why
o More efficient approach leading to better outcomes for mother and baby
• How
o One appointment for mother-baby pair
o Combined records
o Recommending joint appointments for as long as possible
o Continued dialogue with the mother

11. Mother-baby clinics
• What
o Mother-baby pairs are seen at designated mother-baby clinics
• Why
o Stigma reduction
o Less travel time and waiting time for mothers
o Establishment of relationships with peers including participation in formal
and informal support groups
o Health facility improvements in quality of care and support
• How
o Designated time and date—be consistent
o Possibly designated space for a mother-baby clinic

12. Integrated services
• What
o All relevant and/or required services are available to mother-baby pairs at
each visit to the mother-baby clinic
• Why
o Efficient and more-effective visits
o Better satisfaction contributing to better retention in care
• How
o Map how services are currently delivered
o Propose changes to integrate services

13. Nutrition—Breastfeeding
• What
o Changing breastfeeding beliefs and practices among mothers living with
HIV
• Why
o Benefits of breastfeeding for the baby and the mother are high
o Risk of transmitting HIV through breastmilk is extremely low when
mothers living with HIV are on ART
• How
o Health facility staff need to consistently communicate the current
breastfeeding recommendations

14. Nutrition Assessment,
Counseling and Support (NACS)
• What
o NACS activities, including breastfeeding practices, are available to
mother-baby pairs as a component of integrated services
• Why
o Pregnant women and mothers who are living with HIV and HIV-exposed
babies will have better health outcomes if they are properly nourished
• How
o Ensure NACS is an integral part of PMTCT programming
o Consider having a nutritionist at district level and at health facilities

15. Quality-improvement
Tools and techniques
• What
o Basic, facility-led quality improvement practices
• Why
o Improvement of facility performance and outcomes for mother-baby pairs
• How—specific tools and techniques
o QI teams
o Change ideas
o QI journals

16. Coaching and mentoring
• What
o Coaches and mentors provide regular support to frontline staff to
implement the overall PHFS approach, including QI activities
• Why
o Coaching has been shown to solidify PHFS-related outcomes through
supporting frontline staff to implement QI
o Coaches provide a level of quality control to the QI activities
• How
o Hands-on support and instruction to supplement training
o Work directly with frontline staff
o Consistent, frequent visits lead to success

17. Knowledge exchange
• What
o Frontline staff share knowledge and experience with colleagues at other
facilities, to learn from each other and continue to improve their program
• Why
o Efficient and cost-effective way to improve performance and outcomes
• How
o Formal knowledge exchange
• Quarterly review meetings
• Staff exchange visits
• Organized sessions with multiple facilities
• Webinars and conference calls
o Informal knowledge exchange
• Encouraging sharing ideas in day-to-day work environment

18. Community workers
• What
o Community workers, including peer mothers, conduct outreach work to
support retention in HIV care and treatment for mother-baby pairs.
• Why
o Creating and maintaining productive relationships with patients plays a
significant role in retention of mother-baby pairs
• How
o Capitalize on different cadres
• Community health workers, peer mother organizations, family support groups, support
groups for people living with HIV (PLHIV)
o Ensure community health workers have basic counseling skills
o Foster partnership between facility and community
o Tracing for loss to follow-up
o Develop a compensation plan for community health workers

19. Metrics and data sets
• What
o Appropriate and practical metrics and data sets to track and improve the
performance and outcomes of PMTCT programs
• Why
o Facility staff are invested in their own data and in making real-time
changes to improve services and retention
• How
o Identify metrics that will generate useful and useable data
o Frontline staff should be consulted on core metrics
o Revisit metrics over time to ensure relevance
• E.g., Tracking indicators with stable performance may not be needed, or a core
indicator like retention might be retained for quality assurance purposes

20. Additional considerations
• Reducing the burden of primary data collection
o Data collection is so cumbersome that it reduces the time for patient care
o 3 ways to reduce the burden
• Limit the number of indicators
• Streamline the process
• Increase staffing levels
• Leveraging the lessons and effectiveness of the PHFS approach
o Extending PHFS approaches to general ART centers could have a
positive effect on broader ART retention among PLHIV
• Potentially starting with mothers living with HIV transferring back to these centers at
the end of the PMTCT cycle

21. “How-to” guide
• Key lessons from PHFS
• Checklists
o Preparing to implement the PHFS approach
o Launching the PHFS approach
o Sustaining the PHFS approach
o Extending the PHFS approach

22. Checklist #1
1. Planning and approval
2. Site selection
3. Community partners
4. Technical assistance
5. Services
6. Quality improvement practices
7. Performance metrics and data sets
8. Coaches and mentors
9. Knowledge exchange
10.Tools and training
Preparing to launch the PHFS approach

23. Checklist #1
SITE SELECTION
 2.1. Develop a core set of selection criteria
 2.2. Use the criteria to identify facilities for PHFS
 2.3. Conduct a rapid assessment to determine
capacity and readiness/willingness
 2.4. Use the results to select facilities to implement
PHFS activities
 2.5. Work with managers and staff at the selected
facilities to plan the launch of the PHFS
approach
Preparing to launch the PHFS approach
EXAMPLE

24. Checklist #1
SITE SELECTION
 2.5. Work with managers and staff at the selected facilities to
plan the launch of the PHFS approach.
Issues to address include:
 An initial facility plan to identify where and when the mother-baby clinic
could operate
 A preliminary staffing plan that matches qualified and available staff with
different PHFS activities.
 A basic assessment of areas where technical assistance may be required
to effectively launch these activities (e.g., service delivery, QI,
counselling, community outreach, nutrition, data collection/quality/use)
 A basic budget to implement the PHFS approach, including any up-front
costs (e.g., facility refurbishment) and specific recurring costs that are not
covered by the facilities existing operating budget (e.g., funding for
outreach workers)
Preparing to launch the PHFS approach
EXAMPLE

25. Checklist #2
11. Human resources
12. Clinic logistics
13. Operations
14. Outreach education
15. Messaging
16. QI tools and techniques
Launching the PHFS approach

26. Checklist #2
OPERATIONS
 13.1. Designate PHFS clinic days and times
 13.2. Agree on mother-baby services
 13.3. Set up mother-baby pair appointment
system
 13.4. Set up mother-baby pair tracking system
 13.5. Set up a coordination system
• Ensure consistent and complementary information,
guidance, and support to mother-baby pairs
 13.6. Set up mother-baby pairs tracing system
 13.7. Establish a positive, patient-centered
atmosphere
Launching the PHFS approach–EXAMPLE

27. Checklist #2
OPERATIONS
 13.4. Set up a simple record keeping system that can
keep track of pairs, including the critical information for
both mothers and babies (e.g., height/length & weight,
growth monitoring, ART regimen, infant HIV test,
mother’s viral load testing)
• This system is likely to be an informal modification or workaround to
an existing record keeping system (e.g., patient cards and registers)
• Ensure staff have ready access to patient information for both mother
and babies at every appointment
Launching the PHFS approach–EXAMPLE

28. Checklist #3
17. Human resources
18. QI tools and techniques
19. Coaching and mentoring
20. Knowledge exchange
21. Patient input
Sustaining the PHFS approach

29. Checklist #3
HUMAN RESOURCES
 17.1. Assess integrated staffing plan for frontline workers
 17.2 Assess the knowledge and skills of frontline staff and their
managers
 17.3 Consult with frontline staff about their job satisfaction
• Workload
• Patient interactions
• Knowledge and skills
• Coaching and mentoring
• QI practices
• Management and compensation
Sustaining the PHFS approach–EXAMPLE

30. Checklist #3
 17.1. At least two times per year, assess the
integrated staffing plan for frontline workers,
including facility-based and community-based staff
 Talk directly with frontline workers about the strengths and
weaknesses of the staffing plan and possible ways to
improve the plan
 Consult with coaches and mentors about the strengths
and weaknesses of the staffing plan and possible ways to
improve it
 Use the basic QI tools and techniques to identify ways to
improve the staffing plan and the related issues
 Implement identified improvements
Sustaining the PHFS approach–EXAMPLE

31. Checklist #4
IDENTIFYING AND EXPLORING NEW OPPORTUNITIES
 22.1 Identify groups in health facilities implementing the PHFS
approach
 22.2 Discuss with managers and staff
 22.3 Plan for who will be involved and how
 22.4 Discuss how the approach will be adapted
 22.5 Ensure process is collaborative
 22.6 Review elements of the checklist that apply to this
effort
Extending the PHFS approach–EXAMPLE

32. Checklist #4
22.1. Identify departments, centers, and/or programs in health
facilities implementing the PHFS approach where the approach
could be adapted to improve performance and outcomes
 Consult with frontline staff who are using the PHFS approach about
departments, centers, and/or programs that could implement an adapted
version of the approach
 Initial assessment of these opportunities should be done at the facility level,
where frontline staff have the best perspective on where and how to adapt
the PHFS approach within their facility
 Existing management structures are likely to require facilities to get
agreement/sign-off from a higher level (e.g., district or above)
Extending the PHFS approach–EXAMPLE

33. Conclusion
• Designed to be flexible, so countries can identify and
take advantage of opportunities in their existing
systems to shift PMTCT programs toward the PHFS
approach
• Takes an incremental approach to implementation;
not required to do everything at once
• Practical information in two sections
• Key lessons from PHFS
• Checklists

34. This presentation was produced with the support of the United States Agency
for International Development (USAID) under the terms of MEASURE
Evaluation cooperative agreement AID-OAA-L-14-00004. MEASURE
Evaluation is implemented by the Carolina Population Center, University of
North Carolina at Chapel Hill in partnership with ICF International; John Snow,
Inc.; Management Sciences for Health; Palladium; and Tulane University.
Views expressed are not necessarily those of USAID or the United States
government.
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