Table 1

Changes made to improve the sequence of care steps for highly active antiretroviral treatment (HAART) initiation

System failures identified	Changes
Early identification and referral for HAART initiation
Limited number of patients testing, stigma and lack of information or misinformation about HIV/testing, lack of time for individual counselling, loss of patients after testing not returning for CD4 count results or wellness care, patient bumping around system leading to patient loss, initiation sites turning patients away for not having correct tests/results at appointment	Case finding and HIV testing All PHC sites provide HIV testing Triage system introduced to increase patient flow and opportunities for testing^* HIV educational health talks provided in general waiting areas^* Group counselling, couples counselling^* Engagement with traditional healers to increase referrals of those with signs/symptoms of HIV to the clinics^* Cross-referrals of patients from TB, family planning, STI clinics for HIV testing^* New longitudinal patient registers added to track TB/HIV integration HIV testing campaigns outside clinic in local community; integrated with community health days and wellness checks HIV counsellors placed at each service site Integration of HIV services into all services and rooms—all staff effort Provider initiated testing and counselling^* CD4 count testing Bundling HIV test with CD4 count test on same day, same location in rapid sequence^* Start of wellness care at PHC sites for patients who are HIV positive not yet eligible for HAART to keep them in care Patient files marked with barcode signalling need for repeat CD4 testing^* Patient collection of CD4 results Fast track queue for those collecting results^* Results from lab faxed to clinic; decreased results turnaround time from lab to clinic^* Client counselling on importance of knowing CD4 results^* Improved documentation of patient contact information for follow-up^* Communication to ensure increased patient confidentiality^* Patient follow-up reminder calls to collect results Referral for HAART Standardized up-referral^† forms provide clarity for patient and staff, include all test results and necessary next steps^* Relationship building between PHC and initiation site staff to increase communication and minimise patient loss^* Patient follow-up workers call patients to remind them of appointments Improved documentation of patients received from PHC site to identify missing patients^*
HAART initiation and chronic care
Misinformation about treatment and adherence, long waiting times leading to patient loss, missed appointments and poor retention, overcrowding, long time from diagnosis to treatment, loss of patients with low CD4 counts	Health Information talks in waiting area on initiation, medication, side effects and adherence^* Creation of referral forms and standard procedures^* Patient flow analysis leading to changes in booking and better patient flow (eliminating unnecessary steps)^* Fast tracking initiation of patients with low CD4 counts^* 2 months' supply of medication is provided to patients with stable disease to decrease congestion, unnecessary wait time and free up staff time to initiate new patients^* System of triage to improve patient flow^* Patient tracing phone calls after missed appointments Pharmacy automated dispensing system Down-referral^‡ of patients with stable disease on HAART back to their local PHCs to be managed by nurses

↵* Denotes changes that require no additional resources (equipment, supplies, staff, etc.); can be implemented through better use of existing resources.
↵† Up-referral defined as referring a patient to a higher level of care (ie, from PHC to secondary/tertiary initiation site for more specialised treatment).
↵‡ Down-referral defined as referring a patient to a lower level of care requiring less specialisation (ie, from initiation site to PHC for nurse management).
CHC, community health centre; HAART, highly active antiretroviral treatment; PHC, primary healthcare clinic; STI, sexually transmitted infection; TB, tuberculosis.