IMPROVED ACCESS TO DATA LEADS TO TARGETED ACTION TO REDUCE STIS AT BANGWE HEALTH CENTER
Suzike Likumbo
Former STI Coordinator, Current QI Coordinator, Blantyre District
When she was Sexually Transmitted Infections (STI) coordinator in Blantyre, Malawi, clinical officer Suzike Likumbo became adept at handling public crises. She and her district health office (DHO) colleagues team have spent years battling an HIV epidemic which, at its peak in 2019, saw nearly 18% of Blantyre District’s residents living with the virus. People who contract STIs of any sort are significantly more at risk of contracting HIV. Not only are they engaging in risky sexual behaviors, but some STIs – such as genital ulcers – make the body inherently more vulnerable to HIV infection. “STI treatment is part of the HIV prevention package,” Likumbo explains. “90% of my work is linked to HIV.” But her ability to understand where those STIs were happening to inform responsive actions was limited by the lack of timely access to triangulated data.
Historically, data use in Blantyre was driven largely by donor reporting requirements and was fed to and analyzed at national level. Blantyre’s DHO coordinators had access to needed data on a delayed basis, often through paper-based reports that represented only a subset of data, limiting coordinators’ ability to triangulate key indicators and take data-informed actions. Such limited access to real time data meant that DHO technical coordinators spent hours at individual facilities, reviewing paper registers and hand calculating reporting results.
In 2020, Blantyre District began implementing the Blantyre Prevention Strategy (BPS) with one of its goals to support increased access and use of data to inform targeted HIV prevention services those most at risk for HIV infection and coordinated, rapid response to new HIV infections. By 2022 Malawi’s HIV rate, which had been falling for several years, was starting to plateau. It currently stands at 12.9% in Blantyre, and the district was struggling to make further progress on what was still a worryingly high infection rate. Likumbo’s team had been beset by a number of challenges as they struggled to respond to new STI outbreaks. “We were doing interventions, but there was a lack of coordination, and everyone – community-based organizations, private clinics, civil society organizations – was doing their own thing in terms of prevention delivery,” says Likumbo. “The system wasn’t coordinated or coherent.”
BPS has worked with the Blantyre DHO, city health team, facilities, community groups, and other HIV stakeholders to create an integrated local HIV management system under district leadership that operates in a coordinated fashion with, and able to leverages the capabilities of, multisectoral partners improving service delivery through linked public and private channels; supporting more responsive, effective, and efficient delivery channels; shares knowledge widely; accelerates the work of all partners through close partnership; and institutionalized to support quality service delivery and more effective introduction of new prevention products. With its strong focus on data use, improved coordination, and community engagement, BPS has given Likumbo and her team greater insights into the spread of STIs in her district, and has transformed the way they respond.
DATA-BASED DECISION MAKING TO
TARGET INTERVENTIONS
“BPS has brought about real data-based decisions,” she reports. “It all starts by looking at data in PALMS.” BPS worked with local and national data users to develop a data pipeline that brings together multiple previously fragmented data sources and the Prevention Adaptive Learning and Management System (PALMS). PALMS is a user-friendly data dashboard pipeline that presents existing that collates and triangulates that data for ease of access and improved decision making. It can be accessed on a computer, tablet, or smartphone. “PALMS helps us identify red flags and underperforming indicators, and everything else follows from that. Now we can meet as a district and see where we have a lot of STIs, then try to find out why. We are able to target our interventions.”
When Likumbo spotted a sudden rise in new STI infections at Bangwe Health Center in 2022, the spike was dramatic enough to cause alarm: the facility had registered 660 new STI cases in a quarter, nearly triple that of the previous quarter. “As a district, we got worried,” she says.
Figure: Total STI Diagnoses by Quarter at Bangwe Health Center (source: PALMS)
A COORDINATED APPROACH, GUIDED BY
COMMUNITY INSIGHTS
Prior to BPS, “We would go into the communities, but not consistently, and we wouldn’t get clear feedback from them,” she remembers. “And when you work in fragmented pieces with everyone doing their own thing, it’s complicated to even get data to see what is actually happening in the district. It was quite hectic and challenging.”
By bringing different HIV service providers together, explains Likumbo, BPS also enables the District Health Management Team to coordinate their response to rises in new infections more effectively. “When we have activities – say, a community mobilization campaign like a roadshow – we at the district go together with local organizations, implementing partners and private clinics,” she says. “We screen for STIs and provide management, HIV testing and linkage to care, antiretroviral therapy (ART) or prevention services like PrEP, depending on the results. We also provide condoms and give messages on HIV prevention.”
A CONTINUOUS FEEDBACK LOOP TO IMPROVE QUALITY AND DELIVERY OF HIV PREVENTION
These sorts of community-level insights create the kind of feedback loop that is key to delivering a more informed HIV response. For example, community insights that PrEP provision only at ARV clinics created a barrier to access informed change ideas raised through the BPS-supported Quality Improvement (QI) Collaborative, known as PrEPUP! The Bangwe QI team developed and tested different methods of distribution, which ultimately helped to increase PrEP uptake.
Figure: Total STI Diagnoses by Quarter at Bangwe Health Center (source: PALMS)
Civil society and community organizations also meet regularly with local health facilities to share information and provide feedback on interventions. These relationships enabled the district and Bangwe facility teams to identify the sources of new STI infections in the communities around Bangwe Health Center, and with remarkable precision. “We learned that specific new hotspots had been opened – certain bars, houses where sex workers were operating,” says Likumbo. “If we had been going into the communities on our own, we would never have got this information.”
In the case of Bangwe Health Center, the results of this new strategy were highly encouraging. Not only were Likumbo, the DHO, and Bangwe Health Center staff able to use newly available data to identify the steep rise in cases; they were also able to join with local private clinics, implementing partners, and community organizations to mount a coordinated and highly targeted response.
OUTCOMES
Thanks to these interventions, the rate of new STI infections in Bangwe quickly began to drop; in early 2023 the health facility reported only 222 new infections, down by two-thirds compared to six months before. PrEP one-month continuation rates also rose by over seven percent during the same period, from 23.1% to 30.4%.
Likumbo credits this success to the BPS approach, tools, and the training she has received. “Without it, we would not have been able to respond as promptly, and it wouldn’t have been as easy to come up with interventions,” she says. “Interventions used to take a top-down approach, and they weren’t as targeted. We are now working together.”
She hopes that other districts can benefit from the new approach she and her team have adopted in Blantyre. “We have tested this in Blantyre, we have seen that this is working”, she says. “Moving forward, this should inform the policies in Malawi. It should be replicated in other districts in the country, and even beyond.”
“BPS is a game-changer. It has really positively changed the way I do my work, the way I coordinate with others, the way I see data, the way I work with the community and with the health facilities”, adds Likumbo. “I feel empowered. It has really helped me a lot.”
