The use of HIV and AIDS-related information to track progress and design response efforts in Nepal is challenged by the two issues inherited in the current national system i.e., lack of mechanism to track people living with HIV (PLHIV) in spectrum of HIV care within and between districts, and reporting of aggregate level HIV care related data using DHIS 2 to the central level. This results in the double counting and reporting of repeat HIV testers including PLHIV which may under or overestimate the antiretroviral therapy (ART) initiation and ART coverage in the country. Considering the more extended period from generation of aggregated data to the provision of feedback also hinders timely correction of inaccurate data and incomplete reporting. Current aggregated data from ART centres also prevent us from identifying the bottlenecks in the spectrum of HIV care so-called HIV treatment continuum.
We developed a system between June and October 2017 to integrate following features in the existing system based on DHIS2: mobile health (mHealth), biometric app and DHIS2 Tracker. The DHIS2 Tracker Capture application is modified to accept information from the combination of the client side Biometrics app and the server side Biometrics app, in order to know the existence/non- existence of the patient in the system, and also the ability to search/modify the existing patient record at different ART sites using the fingerprint identification. To improve retention to care among PLHIV, Short Message Service (SMS) Application Programming Interface (API) integrated with DHIS2 to send SMS in Nepali to the PLHIV for key events such as: appointment reminders for medication pick-up, CD4 and Viral Load tests, early infant diagnosis testing and general awareness messages related to health check-up, partner testing, adherence messages and use of family planning methods. The patient referral functionality introduced in DHIS2 version 2.27 has been put into use to refer the patients from HTS to ART sites for confirmation testing, and from ART to another ART site for the continuation of treatment. The referral functionality is linked to incoming and outgoing queues via custom development to create a working list of the ART sites to understand which patients are being referred to their sites, and for which service. The geographic information system has been customised for mapping and analysing the data spatially on the map of Nepal.
We piloted developed system in three large ART centres in the capital city and addressed software bugs. Then after, the developed system rolled out in 15 ART and HTS centres situated at different districts, and the team at centre provided onsite coaching to counsellors about the application of developed system in HTS and ART centres. A comprehensive user’s manual was developed in Nepali to support health workers at district hospital or other users at a different level (district, province and national level) to use diverse features of system. We are still facing challenges to generate aggregate reports for importing in the instance of national health management information system. However, the developed system is successful to generate individual-level data of each patient from the HTS and ART centres, and that same information is available in real time at a different level for further analysis and response. Biometric app linked to DHIS 2 Tracker is also successful for deterministic record linkages such as linking pairs of records based on the specific identifiers of the patient between sites to avoid double counting. Considering the successful rollout, national centre under Ministry of Health planned to use developed system in all HTS (175) and ART centres (71) throughout the country in next two years.
Map of Nepal showing system (DHIS2 Tracker, mHealth and Biometric app) rolled out sites.