Phone-based patient screening for HIV Care and Treatment

1. Phone-based patient screening for HIV Care and Treatment

2. Problem Statement Project addresses two important programmatic challenges for continued ARV scale-up: (1) the severe shortage of physicians, nurses, and other trained health personnel in the face of the AIDS epidemic; and (2) the need to maintain high quality of care through rigorous use of standardized treatment protocols, such as the IMAI protocols, as patients are referred to more peripheral sites for diagnosis and treatment of AIDS related illness

3. Project Aim • The program aims to improve the efficiency and quality of HIV patient screening and increase the client capacity in HIV Care and Treatment Centers (CTC) by: • Introducing a mobile phone based system (e-CTC) that helps non-physician health workers in CTC centers to screen HIV clients during routine visits while following the MOH standards of care and guidelines • Can a triage algorithm be effective in screening HIV positive patients on ART ?

4. Objectives Objective 1: Adapt HIV patient screening protocols and software that had been previously used in South Africa trials for use in Tanzanian CTC sites. Objective 2: Pilot e-CTC and evaluate its ability to deliver standardized HIV patient screening in CTC clinics. Objective 3: Advocate for the adoption of guidelines or policy supporting HIV patient screening protocols and the use of e-CTC.

5. Study Description Funded by the Centers for Disease Control and Prevention, Tanzania Pwani region, Tanzania, two International Center for AIDS Program (ICAP) sites 992 patient encounters

6. Study Description Iterative design process -- mobile application was developed, tested and refined with continual feedback from health workers. Nurses enrolled and screened the client using the phone At the end of screening, the application determined client referral to doctor, counselor, and/or laboratory. All clients saw the clinicians for their regular visit after finishing screening The clinicians conducted their regular patient visit (without seeing nurse’s information) and filled out a paper doctor’s form to indicate his findings (including whether or not the patient needed to be seen)

7. Results: Comparing phone protocol with doctor “gold standard” Phone Referral YES NO YES NO Doctor Referral

8. Results: Comparing phone and nurse opinion against the doctor “gold standard” Phone vs. Nurse Referral YES NO YES NO Doctor Referral

9. Discussion Compared to the doctor, the algorithm proved to be highly sensitive, but less specific In other words, it over-referred 26 patients (2.6%) were missed who the doctor stated should have been seen/referred In total, 225 patients would have been correctly diverted by the nurses – that is almost 25% workload reduction for the doctor

10. Who are the 26? The 26 patients “missed” had a random distribution of ailments reported on the doctor’s form which were not reported on the phone, including: Eye problems Feeling unwell Weight loss Pain/numbness in feet or hands (4) Pregnancy Rash/sores on skin (4) Stomach pain/discomfort Pain/sores in mouth Backache Body itchy without rashes Dementia Frequent micturation Hypertension Swelling in the back of ear General body malaise

11. 26 – cont. In most cases the reason was something the nurse also asked about in the protocol, but apparently got a different answer In a few cases, there were rare conditions, such as dementia or swelling in the ear Some conditions may have been found due to the physical examination of the doctor, which the nurse did not do

12. Phone=silver standard? Interestingly, the phone did much better than the nurse’s judgment in referring patients the doctor agreed should be referred Thus, though a doctor or clinician examination is the gold standard, the protocol of the phone does effectively guide the nurse’s work Again, the phone protocol is more sensitive and less specific

13. Conclusions