Improving STI/HIV passive partner notification using quality improvement methods in Malawi

Abstract

Introduction Human Immunodeficiency Virus (HIV) and other curable Sexually Transmitted Infections (STIs) constitute a large public health burden world-wide. The control of HIV and STIs is incomplete if sexual partners of individuals with HIV and STIs are not identified and treated. The proportion of sexual partners that present to health facilities for screening and treatment is low in the sub-Saharan African (SSA) region. A recent study in Malawi reported a sexual partner referral proportion of 24% through passive partner notification. Several other approaches to partner notification (PN) have been shown to be feasible, acceptable and cost-effective for SSA. However, passive PN is widely used as the standard of care (SOC) and is the most preferred approach for resource-limited settings including Malawi. The low proportion of sexual partner referral points to the need to improve the efficiency and effectiveness of the SOC method of PN in order to realize a better yield of sexual partners in Malawi and SSA. Methods A pre- and post-intervention quasi-experimental study was conducted at Bwaila STI Unit (BSU) in Lilongwe Malawi from January to June 2017. At baseline, we estimated the proportion of sexual partner referral and identified health system-related factors that influenced PN at BSU through interviews with health workers and clinic observations. Based on the baseline findings, a three-prong intervention was designed through expert consultation and implemented with a quality improvement (QI) team using the model for improvement (MFI). The intervention included: early start time of the clinic; shortening of the group health talk and expedited clinic flow for sexual partners. Each intervention was tested twice through 1-week long test cycles and then combined into one package and tested twice. Process data were collected and monitored using run charts. We used run charts to assess for non-random signals of change in the PN process and assessed for a 10%

increase in the sexual partner referral proportion between the pre- and post-intervention periods at 95% power and at α=0.05. Results At baseline, the proportion of sexual partner referral was 15.6%. Experts included BSU staff, research staff and Ministry of Health officials who were involved in the selection of interventions based on findings from the interviews and clinic observations. The QI team consisted of the investigator, a nurse-in-charge, a counselor, a clinic receptionist and a clinic aide who championed implementation of the intervention. In the post intervention period, we assessed 267 patient records. The median age was 29 years and 56% were female. Out of the three interventions, the team managed to shorten the duration of the group health talks from 56 minutes to less than 40 minutes and expedited the clinic flow for partners by reducing the duration of clinic stay by 45 minutes. However, the target clinic start time of 08:00 hours was not achieved. The post-intervention proportion of sexual partner referral was 21.4% representing a statistically significant increase of 37% (P=0.04). There was an upward trend in data points on the run chart which was indicative of a non-random signal of improvement in the proportion of sexual partners. Discussion Our results demonstrate that passive PN can be successfully improved through use of the model for improvement in Malawi and suggest that our intervention was highly effective at increasing the proportion of sexual partner referral. However, despite this increase, the proportion of sexual partner referral remains suboptimal. More effort is required to increase the proportion of sexual partner referral in Malawi.