Return to care of children and adolescents living with HIV who missed their clinic visits or were lost to follow- up: a continuous quality improvement study in Uganda

Abstract

Background While the UNAIDS 95- 95- 95 targets have been met among adults, those for children and adolescents remain suboptimal. This study aimed to improve the return- to- care rates among children and adolescents living with HIV (CALHIV) who missed clinic appointments at a county- level rural health facility in eastern Uganda. Methods Between January 2023 and January 2024, we conducted a continuous quality improvement (CQI) study. A CQI committee was established through entry meetings and training, and quality of care gaps were identified through data reviews. We prioritised one gap for CQI through ranking, performed a root- cause analysis using a f ishbone diagram, and developed and ranked improvement changes using the impact- effort matrix. The improvement changes were implemented using Plan- Do- Study- Act cycles. The changes included (1) line listing CALHIV with missed appointments and following up via phone calls; (2) weekly data reviews to harmonise missed appointments and (3) assigning community health workers (CHWs) to trace and return CALHIV to care. We tracked and plotted the proportion of CALHIV returning to care over time to assess improvements. Results Before the implementation of CQI initiatives (August 2022–January 2023), the average return- to- care rate was 35% (baseline). Following the initiation of CQI in February 2023, the average return- to- care rate increased to 59% from February to May 2023 with the introduction of line listing (phase 1), to 69% from June to September 2023 with the implementation of weekly data reviews (phase 2), and to 88% from October 2023 to January 2024 with the involvement of CHWs (phase 3), ultimately reaching a peak of 100% in January 2024. Conclusion The CQI approach improved the return to care of CALHIV who missed clinic appointments, allowing access to optimal care and better health outcomes. These findings should serve as preliminary data for larger randomised studies.