Improving Early Infant Diagnosis for HIV-Exposed Infants: Quality Improvement Strategies from a Near-Miss Case.

Early infant diagnosis of HIV remains a major challenge in developing countries, resultantly reducing the life expectancy of HIV-infected infants. This often results from loss of follow-up and provider and mothers’ gaps in knowledge. A QIP in Uganda revealed that the rates of HIV testing can be significantly improved if providers are adequately trained and if the mothers are followed up effectively. This paper will explore a case of a late infant diagnosis that eventually resulted in mortality, and adapt recommendations from the Northern Uganda QIP to propose possible solutions to prevent similar mortalities.

1)     Introduction

My patient is a 5-month-old male infant who was brought to our facility with symptoms suggestive of pneumonia. After a week on antibiotics with little improvement, we became suspicious of other etiologies. Initially, the mother denied a positive HIV status despite being diagnosed with the disease during pregnancy. This led to a delay in treatment before the infant's HIV infection was confirmed. I chose this case because it highlights a major problem of missed diagnosis of HIV-infected infants due to mothers’ loss of follow-up because of knowledge gaps and stigma associated with disclosing the diagnosis (Mpinganjira et al., 2020; Watt et al., 2019) 

Three- Stage Diagnosis

a)     Clinical Diagnosis

The infant was brought to the hospital by his mother after developing fevers, tachypnea, and refusal to breastfeed. On examination, the baby was lethargic, and the vitals were as follows: spo2 85%, temperature 38.5oC, RR 75 breaths/min, PR 180b/min. On examination, he had mild pallor, lower chest wall indrawing, nasal flaring, and suprasternal retractions with no crepitations on auscultation.

The notable findings of the investigations were as follows.

·       FHG: WBC 5*10^9/L, Hb 7.0 g/dl, platelets 160*10^3/ μL

·       UECs: Normal

·       Urinalysis: Normal.

·       TB LAM test- negative

·       ESR 20 (<20)

·       Chest X-ray – Left lung opacities.

Diagnosis- Severe Bacterial Pneumonia with microcytic hypochromic anemia

Differentials- Pulmonary Tuberculosis, Pneumocystis carinii pneumonia (PCP).

Management:

Ø  Benzylpenicillin 50,000IU/kg QID

Ø  Gentamycin 7.5mg/kg OD

Ø  Paracetamol 120mg TDS

Ø  Transfusion 124 ml of whole blood.

Ø  Oxygen supplementation with CPAP.

The patient deteriorated, and he was referred to a tertiary facility.

b)    Individual Diagnosis

Ideas- The mother believed that her baby had pneumonia that would resolve upon treatment. She was not aware that failure to disclose her HIV status could affect her baby’s management.

Concerns- She initially rejected blood transfusion because of the fear of blood-borne infections. She was also concerned by out-of-pocket expenses related to the treatment.

Expectations- At first, the mother was optimistic, but as he deteriorated, she became more anxious and eventually resigned to the possibility of his death, which unfortunately occurred a few days after the referral.

c)     Community Context

The mother was married to a middle-aged man from a low socioeconomic setting. She was diagnosed with HIV during the pregnancy but was lost to follow-up. The infant’s disease occurred because he was infected with HIV and developed opportunistic Pneumocystis carinii pneumonia (PCP) that failed to respond to conventional antibiotics (Lala, 2023).

2)     Quality Improvement Project

·       “Quality Improvement Interventions for Early HIV Infant Diagnosis in Northeastern Uganda.”- Izudi et al., (2016).

I chose Izudi et al., (2016) is a quality improvement project done in Kaabong Hospital in Uganda. A background analysis revealed that only 20% of HIV-exposed infants at the hospital received an HIV DNA PCR test at 6 weeks. A root cause revealed that many HIV-positive mothers did not receive adequate education concerning the need to test their infants, while others were lost to follow-up. Besides, many healthcare providers had knowledge gaps about the need for timely testing for HIV- exposed infants. The project aimed to improve the percentage of DNA-PCR testing by 8 weeks among HIV-exposed infants born at the hospital from 20% to 100% within 20 months to enable early diagnosis and treatment.

The baseline measurements were derived from the abstraction of records on early infant diagnosis. Some of the proposed interventions included the introduction of continuous medical education (CMEs) for relevant health workers and the integration of lab testing services for HIV follow-up clinics. They would also use expert patients with HIV to track those lost to follow-up. The outcome measure for the project was the percentage of HIV-exposed infants who would test by 8 weeks. Unfortunately, the paper does not adequately expound on process and balancing measures. The percentage of health workers who attend CMEs would have been a reasonable process measure, while the cost implications of the additional testing would have been a good balancing measure. These changes were implemented through the PDSA cycle, which enabled the hospital to meet the outlined goal in 20 months.

The advantage of the abstraction of baseline data from manual records is that it enabled the stakeholders to assess the practicability of different interventions and prioritize the most effica

cious ones. A potential flaw of this approach is that it relied on manual forms that were possibly prone to human errors. Educating health workers about the need and timing of testing was a relatively easy, cheap, and effective intervention. The representation of the data through line graphs also allowed stakeholders to visualize the trends and enabled them to appreciate the potency of the changes. Using HIV-positive mothers to encourage newly diagnosed women in the community was a rational way of promoting follow-up (Tenthani et al., 2012). This approach, however, could raise concerns about the cost implications of training them and potential breaches of confidentiality for mothers who may not be willing for their diagnoses to be shared with these mothers. 

3)     QIP in My Setting

A similar project can be implemented at Chogoria Hospital, Kenya, using eHealth prompts, provider education, and mother-to-mother psychological care (Okusanya et al., 2022).

        PDSA Cycle

a)     Plan

The main aim of the project will be to ensure that, over 12 months, the percentage of HIV-exposed infants followed up at the hospital who receive a diagnostic PCR test by 7 weeks will increase from an estimated 40 to 100 percent (Ghadrshenas et al., 2013). This will be done by conducting a seminar and regular CMEs to educate frontline clinicians and lab technicians about the necessity of these tests. Our hospital’s electronic system can also be optimized to prompt providers about scheduled PCR tests and send short mail services (SMS) to mothers to these infants about clinic appointments (Okusanya et al., 2022). Older HIV-infected mothers will also be paired with newly diagnosed ones to offer psychological support and encourage follow-up (Okusanya et al., 2022). A potential disadvantage of these strategies is that they could be less efficacious for infants who do not enter the health system through the prevention of mother-to-child transmission (PMTC) program (Ghadrshenas et al., 2013). Clinical judgment will still be necessary to facilitate the testing of infants with unexplained malnutrition, recurring infections, or those who do not adequately respond to antibiotic therapy (Munthali et al., 2017).

b)     Do

Two hospital staff members from each department will be first trained, eHealth prompts will be sent to them, and SMSs will be sent to the newly diagnosed mothers. Two older HIV-positive mothers will be tasked to follow up with those who miss allocated visits despite the SMS. This will be done over a period of 4 weeks to assess the practicality of the interventions.

c)     Study

After the initial implementation, the outcome measures (the percentage of HIV-exposed infants who receive a PCR test by 7 weeks), balancing measures (the cost implications of interventions), and process measures (the number of health workers who attend CMEs and their post-training quiz scores and compared to pre-session ones) will be assessed and analyzed (Ciaranello et al., 2011).

d)     Act

If the assessed measures are satisfactory, the project will be implemented on a larger scale. Minor alterations will likely be made to the project to make it most suitable for the setting. Another PDSA cycle will be initiated with adopted changes.

Stakeholder Analysis

	Low Interest	High Interest
High Power	·       Hospital Administration ·       Local government health officials	·       Doctors ·       Laboratory scientists
Low Power	·       General Public ·       Hospital support staff	·       IT technicians ·       Nurses ·       Social workers ·       Patients

Table 1: The power and interest analysis of stakeholders.

I will create a QIP team that will have a representative from each of these categories.

High Power High Interest

 Two representatives will be chosen from each group to manage the QIP team (Boaz et al., 2018). I will communicate with them directly and explain the advantages of early infant diagnosis in improving the life expectancy of HIV-infected infants from 2 to 64 years (Ciaranello et al., 2011). I will also explain the urgency of the intervention by referring to the specific cases and near misses from the hospital (Ghadrshenas et al., 2013).

High Power, Low Interest

I will request a meeting with the hospital management and the local government’s Department of Health to explain the possible cost implications and contrast them with the profound advantages the project could have for the hospital and county.

High Interest, Low Power

I will choose a representative from among them to facilitate communication and involvement in decision-making. A line graph will be pinned on the noticeboard to inform them regularly about the progress.

Low Interest, Low Power

I will request them to express their views through direct messages or an anonymous suggestion box.

Conclusion

Early infant diagnosis of HIV remains a major challenge in developing countries, resultantly reducing the life expectancy of HIV-infected infants. This often results from loss of follow-up and provider and mothers’ gaps in knowledge. A QIP in Uganda revealed that the rates of HIV testing can be significantly improved if providers are adequately trained and if the mothers are followed up effectively. A similar project can be implemented in my setting with minor modifications to enhance the timely diagnosis of infected infants.

References

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Ciaranello, A. L., Park, J.-E., Ramirez-Avila, L., Freedberg, K. A., Walensky, R. P., & Leroy, V. (2011). Early infant HIV-1 diagnosis programs in resource-limited settings: opportunities for improved outcomes and more cost-effective interventions. BMC Medicine. [Online] 9 (1), 59–59.

Ghadrshenas, A., Ben Amor, Y., Chang, J., Dale, H., Sherman, G., Vojnov, L., Young, P., & Yogev, R. (2013). Improved access to early infant diagnosis is a critical part of a child-centric prevention of mother-to-child transmission agenda. AIDS (London). [Online] 27 Suppl 2 (Supplement 2), S197–S205.

Izudi, J., Akot, A., Kisitu, G. P., Amuge, P., & Kekitiinwa, A. (2016). Quality Improvement Interventions for Early HIV Infant Diagnosis in Northeastern Uganda. BioMed Research International. [Online] 20165625364–5625368.

Lala, M. M. (2023) The “Pulmonary Diseases Spectrum” in HIV Infected Children. Indian Journal of Tuberculosis. [Online] 70 Suppl 1S49–S58.

Mpinganjira, S., Tchereni, T., Gunda, A., & Mwapasa, V. (2020). Factors associated with loss-to-follow-up of HIV-positive mothers and their infants enrolled in HIV care clinic: A qualitative study. BMC Public Health. [Online] 20 (1), 298–298.

Okusanya, B., Kimaru, L. J., Mantina, N., Gerald, L. B., Pettygrove, S., Taren, D., & Ehiri, J. (2022). Interventions to increase early infant diagnosis of HIV infection: A systematic review and meta-analysis. PloS one. [Online] 17 (2), e0258863–e0258863.

Tenthani, L., Cataldo, F., Chan, A. K., Bedell, R., Martiniuk, A. L., & van Lettow, M. (2012). Involving expert patients in antiretroviral treatment provision in a tertiary referral hospital HIV clinic in Malawi. BMC Health Services Research. [Online] 12 (1), 140–140.

Munthali, T., Chabala, C., Chama, E., Mugode, R., Kapata, N., Musonda, P., & Michelo, C. (2017). Tuberculosis caseload in children with severe acute malnutrition related with high hospital based mortality in Lusaka, Zambia. BMC research notes. [Online] 10 (1), 206–206.Tuberculosis caseload in children with severe acute malnutrition related with high hospital based mortality in Lusaka, Zambia. BMC Research Notes. [Online] 10 (1), 206–206.

Watt, M. H., Cichowitz, C., Kisigo, G., Minja, L., Knettel, B. A., Knippler, E. T., Ngocho, J., Manavalan, P., & Mmbaga, B. T. (2019). Predictors of postpartum HIV Care Engagement for Women Enrolled in Prevention of Mother-to-Child Transmission (PMTCT) programs in Tanzania. AIDS Care. [Online] 31 (6), 687–698.