The Botswana Combination Prevention Project (BCPP) Data Linkage Tool

What was the problem?

Data management systems that support individual-level patient tracking are often neither affordable nor easy to implement. However, being able to track patients at the individual level can facilitate timely and accurate HIV service delivery to those in need. For example, real-time follow of antiretroviral treatment (ART) patients who have not picked up their medications reduces the amount of time an ART patient is without medication.

Researchers in a large-scale, PEPFAR-funded project in Botswana (known as the Botswana Combination Prevention Project, or BCPP), needed to follow project participants over time, using an electronic platform, in order to measure the impact of offered HIV services. That is, researchers needed data demonstrating that persons diagnosed with HIV were linked to treatment, initiated and retained on ART, and are virally suppressed in a timely and efficient manner. As such, the requirements of the electronic tracking system included:

  • Trace persons who tested positive for HIV, but did not initiate ART (i.e., persons who were lost to follow up)

  • Monitor individuals through the clinical cascade, from HIV testing through viral suppression

  • Uniquely identify persons (either through unique identifiers (UIDs) or another approach)

  • Monitor movement of persons across communities and geographic spaces

  • Record age and sex at the individual level

The investigators undertook an extensive search to identify and purchase an affordable data management system that supported individual patient tracking over time. However, they were not successful in finding a system that met their needs. As a result, the Botswana Harvard AIDS Institute Partnership developed a system rather than purchasing one.

What is the tool?

The flexible, affordable open-source data management system supported the longitudinal tracking of patients on an individual basis for the duration of the project.

Key steps in building the data linkage system included:

  1. Data Security

    Key elements to ensure data security include a firewall, hash keys to ensure encrypted data cannot be unencrypted, user logins, physical security and access, and routine data back-up measures.

  2. Data Quality

    Tablets have built-in validation tools to limit errors (e.g., invalid, implausible numbers). Staff are also trained to review data for completeness and errors.

  3. Confidentiality of Data

    Data were ‘hashed’ or encrypted to protect the privacy of patients in this project. As a result, data became “unusable, unreadable, or indecipherable” when unauthorized persons attempted to view the data. An Omang, the Botswana national identification card for citizenship, UID was encrypted with a one-way hash prior to being transferred to the project server. When there was consent, or a waiver of consent, from the client to extract identifiable data from the clinic medical record systems (electronic and web-based), clinic data were linked with HIV testing data using the ‘hashed’ Omang.

  4. Costing

    The average costs for establishing the project’s infrastructure for the 30 communities was $14,394 per community (total = $431,815). The annual bandwidth and maintenance cost for each of the three communities where this was implemented was $4,974 (total = $14,922). The project bought 18 laptops in 2016 to replace agency laptops at the project sites. The cost was $20,625, or $1,146 per laptop for the 18 Dell Latitude 3470 laptops purchased. Estimates for the total cost of the equipment used for the database hardware were as follows:  $5,500 for Ubuntu server, $1,200 for tape backup and $3,500 for UPS for a total of $10,200.  Please note, with typical information technology systems, the standard replacement cycle for hardware is approximately every 3 years.  The annual cost to maintain the hardware and network is $28,000/year.

 Figure 1. BCPP Data Linkage System

Figure 1. BCPP Data Linkage System

How to Use the System:

After BCPP research assistants completed their daily data entry of patient level data collected at the community level, they reported to BCPP ‘base operation village’ trailers (i.e., their main community-based headquarters). The research assistants’ laptops automatically connected to the secure Wi-Fi when in 15 meters range. Data were synchronized, uploaded, and transmitted to the server at the Botswana Harvard AIDS Institute Partnership offices.

Complete details on this data linkage approach can be found at: https://aids.harvard.edu/after-the-capture/#more-6903. Countries can access the BCPP data management system (Python modules) at GitHub (https://github.com/botswana-harvard).

Key Outcomes:

This BCPP data linkage management system facilitated the rapid examination of the effects of HIV clinical interventions on timely patient-level linkage to treatment, retention, and viral suppression rates; and follow-up of patients within 24 hours as opposed to months later.

 Figure 2. Flow of information from the first test of HIV to cleaning and analyzing the data.

Figure 2. Flow of information from the first test of HIV to cleaning and analyzing the data.

TB Preventive Treatment (TPT) Implementation Tools

what is the problem?

TB Preventive Therapy (TPT) should be given to any person living with HIV in a country with high burdens of both diseases. It is logistically and financially practicable, and is considered a routine standard for HIV care and treatment. In many countries with high dual burdens, TPT is recommended and included in national guidelines. However, it has not been well-implemented or widely scaled up in most countries. There are many different reasons for this, including clinician concerns about adverse events or engendering drug resistance, or programmatic concerns about administrative leadership and procurement.

what is the tool?

These tools are a fairly comprehensive set of response/aids intended to address the many different concerns or obstacles that HIV programs may face when scaling up TPT. They constitute a library that programs may select from and adapt as needed to fit the local context. The following graphic lists the tools and indicates where in the planning and execution each might be useful:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Partner Engagement - In-Person Meetings Ongoing Training Monitoring (Program Indicators) Monitoring (Program Indicators)

Human Resources for Health Staffing Allocation Tool

WHAT iS THE PROBLEM?

To achieve the UNAIDS 95-95-95 targets, health facilities and community-based HIV service delivery points need to provide efficient, effective, and high-quality services to ensure that people living with HIV (PLHIV) know their status, receive antiretroviral therapy (ART), and achieve and main viral suppression. A key resource to achieve this goal, among other system factors, is the health workforce. Most low- and middle-income countries, though, experience many challenges when it comes to producing an adequate health workforce. These include, misallocation of new health workers, shortages of available health workers, and limited productivity and performance of the existing health workforce. Each of the 3 toolkits below address one of the above stated challenges, and can be used individually or in conjunction with one another.

What is the tool?

Tool 1: A Guide for Efficient and Equitable HRH Staffing Allocation

The Government of Tanzania committed to gradually increasing the number of health care workers hired annually; however, insufficient funding has been a fundamental constraint for meeting this commitment. This tool has helped Tanzania to strategically focus on improving the efficient allocation of health workers to increase service coverage and improve outcomes.

In Oct 2014, Tanzania mandated the use of the WHO Workload Indicators of Staffing Needs (WISN) to build data driven HR plans. The method determines how many health workers of a particular type are required to cope with the workload of a given health facility, and assesses the workload pressure of the health workers in that facility Concurrently, USG funded the development of a Priority Optimization and Allocation Tool (POA) that takes WISN results and prioritizes health worker allocation based on strategic priorities, budget, and supply constraints. After assisting with implementation in seven regions, USG and partners realized the approach was unsustainable and unrealistic; it required manual data collection at each facility because many of the indicators were not accessible through the Health Management Information System (HMIS).  

USG, through a PEPFAR supported private-public partnership, conducted a sensitivity analysis of WISN indicators and defined a subset that (1) comprised the majority of health worker time, and (2) could be found in the existing HMIS. The simplified WISN + POA methodology identifies the number of HRH needed at facilities based on their current performance, and prioritizes the highest burden facilities; thereby promoting equity of HRH allocation in a resource limited setting.

Tool 2: Estimating and Optimizing Human Resource Needs

Service providers have identified differentiated service delivery (DSD) models for clinically stable clients to provide HIV services through a client-centered approach that simplifies and adapts services across the HIV continuum of care. Differentiated care can reduce the burden on the health system and utilize available human resources more efficiently and effectively. This tool is a means to help plan for implementation of differenced care models based on HIV client caseload and the use of task sharing to increase efficiency among existing and proposed staff

The tool is intended for facility managers (site-level) and program planners (above-site, e.g., district, provincial, regional or national) to estimate and/or optimize human resource needs for different DSD scenarios, including:

  • Staffing needs for implementing one or a combination of HIV service delivery models.

  • Efficient ART task distribution among existing health workers to implement various DSD models.

  • Configuration of DSD and task-shifting/sharing (reassigning tasks from one health worker cadre/type to another) to reduce human resource imbalances (excesses or gaps).

  • Organization of site-level services to meet daily client needs: infrastructure, work hours and staffing.

Outputs from the tool enable users to make informed decisions for maximizing the use of the available workforce and to generate evidence for the need for additional human resources where appropriate.

Tool 3: Optimizing Health Worker Performance and Productivity

This toolkit focuses on workforce influences, as these are often the least understood and addressed. The toolkit provides a rapid, step-by-step process for addressing site-level, workforce-related barriers that contribute to HIV service delivery gaps. It also outlines additional tools that can be used to support further analysis and identify potential workforce interventions, many of which promote data use and quality improvement techniques.

The tools help:

  • Collect workforce-specific data and general data for analysis.

  • Analyze the underlying causes of the most common workforce problems observed in HIV service delivery programs, including health worker competency gaps, low staff engagement, poor allocation of tasks among staff, and inefficient workflow.

  • Identify interventions to address the causes of workforce problems.

  • Support intervention monitoring.

Case study examples highlight how the steps and tools can be applied throughout the toolkit.

The toolkit is accompanied by a slide deck and facilitator’s guide that can be customized and used by program leads to train colleagues and scale its use. 

additional resources

Tool 1

Standard Presentation on Simplified WISN Plus POA (ppt)

Tool 2

DSD-HRH Tool One-Pager (pdf)

DSD-HRH Tool User Guide (pdf)

DSD-HRH Tool User Guide, French (pdf)

ART-FTE Estimation Tool (xls)

ART-FTE Estimation Tool, French (xls)

Tool 3

Optimizing Health Worker Performance and Productivity to Achieve the 95 -95 -95 Targets: A Toolkit (pdf)

Toolkit Slides (ppt)

Facilitator Guide (pdf)

Improved Monitoring of the Key Population Cascade: The Need for Use of Customized Indicators

What is the problem?

Specialized non-governmental organizations (NGOs) frequently provide testing and prevention services for key populations (KPs). However, HIV care and treatment are typically only accessible via government facilities. NGOs, then, act as the mechanism to link KPs to HIV testing and treatment services. Existing monitoring and evaluation (M&E) frameworks do not enable NGOs to measure and report these linkage services. As a result, it is difficult to track progress toward epidemic control among key populations.

What is the tool?

LINKAGES, which is the largest global project dedicated to key populations, created by PEPFAR and the U.S. Agency for International Development (USAID), introduced a set of standardized, custom indicators for the KP clinical cascade in 2017. These new indicators were created with the intention of improving monitoring of the non-clinical activities conducted by NGOs in their engagement with KPs.

The Peer Navigator Enrollment Frontline Tool  (doc) is used at the point of enrollment in services to track client characteristics and history, services rendered, and health outcomes (including reporting on the customized indicators described in the below Customized Indicator Reference Sheet). 

Selection of New Indicators: These indicators were developed because MER indicators often do not represent the full package of services provided by KP programs. The list was generated by key staff from PEPFAR, USAID, and LINKAGES based on common gaps described in MER guidance and input was also requested from selected country teams and civil society partners. These new indicators are:

  • HTS_LINK

  • TX_LINK_NEW

  • TX_LINK_RETURN

  • COMM_SUPP_RET

See the Customized Indicator Reference Sheet (pdf).

Integrating New Indicators into Reporting Process: Minimal effort is required for the data collection required by these indicators. Dara are collected at the NGO/community level as the interventions described are conducted by non-clinical staff. One required input for the implementation of these indicators is the update of data collection forms to include the indicators for the NGOs.

Once proven useful for measuring NGO activities with KPs, larger-scale rollout can occur and these indicators can be integrated into the national reporting system. Minor edits and additions to existing strategic information tools will be needed.

Expected Outcomes: The expected outcomes of using these new indicators include: capturing information about KPs missed by MER indicators, closer monitoring of NGO activities and achievements, and identifying gaps in the services offered to KPs. The use of KP-specific custom indicators will more accurately track the number of KPs living with HIV (KPLHIV) that PEPFAR supports, as well.

Graphs demonstrating the gaps in existing data coverage, which Customized Indicators aim to fill.

Expedited Biobehavioral Surveys and Data Availability

What is the problem?

Data is necessary for targeted service delivery. Key population (KP) programs need relevant and timely data about KPs—sex workers, men who have sex with men, transgender individuals, people who inject drugs, and people in prison and other closed settings—engaged and not engaged in services in order to target their services. Biobehavioral surveys (BBS) provide population-based information about KP risk behaviors, HIV prevalence and, importantly, the 90-90-90 cascade to inform service provision and policy. The time BBSs take to plan, implement, and make available the results for remediated actions, is a major limitation to their utility.

What is the tool? 

These tools aim to make BBS planning, implementation, and results provision efficient and timely.

1.       Key factors and interventions to consider for timely and successful implementation of the BBS are summarized in the Technical Considerations Fast Tracking Quality Key Population Biobehavioral Surveys (doc).

2.       Data management and cleaning for a BBS survey can take upwards of three months. It is therefore essential to begin these processes during data collection. This also allows problems to be addressed in near real-time and means that data analysis can begin soon after the end of data collection. The Priority Results Table (doc) is a minimum set of variables whose results should be shared with key stakeholders within two months of the end of data collection. The survey team should collaborate with stakeholders to identify context-specific modifications to the Priority Results Table, including of response categories and additional priority variables.

3.       The sample size and thus duration of BBS implementation can heavily influence the budget. The WHO Blue Book (external link) offers a budget template for costing BBS. As the bulk of the budget is associated with implementation, expediting BBS does not necessarily result in substantial cost savings as survey duration may remain unchanged.

Examples of outcomes related to use of BBS data: BBS data can be used to advocate for, and inform, the development of a Ministry of Health key populations policy and provide new insight into areas where key populations congregate. For example, a BBS in South Sudan revealed additional areas where service providers can find sex workers, through the geospatial mapping component of BBS. In Papua New Guinea, early release of BBS data prompted the use of social-network methods for reaching and testing KPs.

Additional Resources:

WHO BBS Survey Guidelines for Populations at Risk for HIV: Supplementary Materials (pdf)

 

Index and Partner Notification Testing Toolkit

What is the problem?

Index testing and partner notification is a core intervention used to efficiently and effectively identify HIV-positive individuals. However, tools that helped ensure index testing programs were implemented with appropriate quality, scale, and fidelity were not readily available.

What is the tool?

The following Job Aids (ppt) lists 6 recommended steps to follow when implementing the Index and Partner Notification Testing Toolkit. These are:

Step 1: Use  Talking Points & Scripts for Index Testing Services (doc) to introduce partner/family testing to the index client and complete the Index Client Information Form (page 1 of Tools for Documenting & Monitoring Partner Notification Services (doc)).

Step 2: Use the Partner/Child Elicitation Form (page 2 of Tools for Documenting & Monitoring Partner Notification Services (doc)) to record partner(s)' names and contact information.

Step 3: Use the Partner Information Form (pages 3-4 of Tools for Documenting & Monitoring Partner Notification Services (doc)) to document results of IPV screening and preferred partner notification method and/or child testing method.

Step 4: Determine preferred method of partner notification: client referral; contact referral; provider referral; or dual referral. Additional tips and scripts for the referral processes can be found in Patient Information & Handouts (doc).

Step 5: Contact all named partners using the preferred approach.

Step 6: Record partner notification outcomes on the Outcome of Testing Forms (pages 5-6 of Tools for Documenting & Monitoring Partner Notification Services (doc)).

Step 7: Provide appropriate services for children and seroconcordant/discordant partners based on HIV status.

All forms and documents listed above, along with other useful handouts, can be found in the Index Testing Handouts (doc).

Additional information regarding this toolkit and helpful case studies can be found in Partner & Family-Based Index Case Testing SOP Slides (ppt) and Case Studies for Index Testing (doc). Also, the following spreadsheets can be used when implementing Index and Partner Notification Testing: