Achieving HIV/AIDS Goals with Technology

TL;DR

As the world moves towards a more digitized and connected healthcare system, there is a huge opportunity to leverage emerging and digital technologies in low-resource settings to help clinicians with decision making and administrative tasks, connect data across facilities, and improve overall health outcomes. Care and Treatment Centers (CTCs) face challenges at the point of care that can be improved with digital health solutions.

Elsa's platform for CTCs is an open-source tool used at the point of care that empowers clinicians to make more data-driven decisions and improves health outcomes for people living with HIV (PLHIV). The platform is currently being used by all of the CTCs in Meru District in Northern Tanzania. If you're interested in collaborating together or contributing to this work, we would love to have you join our community!

Ending the Epidemic - What's Standing in The Way?

Billions of dollars a year is spent on HIV/AIDS programming globally. And while we are getting closer to ending the epidemic, we still aren't there. By 2020, only 8 countries countries had achieved the 90-90-90 goals (Eswatini, Switzerland, Rwanda, Qatar, Botswana, Slovenia, Uganda, and Malawi), there were 1.5 million new HIV infections globally in 2021, and the COVID-19 pandemic disrupted HIV/AIDS care and showed us how fragile many of the healthcare systems are around the world.

Now, don't get me wrong, this is an incredibly complex issue.  The challenge with HIV/AIDS is both a biological and sociological one; ending the epidemic requires that multiple disciplines come together to address the challenges that limit our ability to achieve an AIDS free generation - from testing to treatment to community-driven stigma. (This WHO article provides some useful insight.) Tanzania, for example, has made impressive strides towards achieving epidemic control with a multi-pronged approach that includes clinical improvements, community-based prevention strategies, digital health, behavior change, national campaigns, "boots-on-the-ground" community health work, enhanced supply chains.... the whole nine yards. And while this has effectively reduced the prevalence of HIV (from 7% in 2003 to 4.6% in 2018) and improved outcomes for people living with AIDS, there are still challenges at the point of care. People living with HIV (PLHIV) frequently drop out and miss appointments, broken supply chains affect when and where medication is available, and clinicians are often burdened by unnecessary administrative work.

Point of Care Challenges

Care and Treatment Centers (CTCs), which serve as the backbone for HIV care in Tanzania, utilize both digital and analog systems during clinic visits to track patient information, document medication changes, order tests, etc. Although a big improvement over paper-based systems, the digital systems used are not connected across facilities. They primarily serve as data collection tools, which is awesome for storing and managing large amounts of data, and horrible for offering automated, real-time insights into care outcomes, patient behavior, etc.

One place where this disconnection affects care is when patients attend clinic and pick up their medication at a facility other than the one where they are registered. For example,  if a patient is registered at Facility A, but picks up their medication at Facility B, the clinicians at Facility A are likely to consider that patient "missing" after 3 days or "lost to follow up" after 28 days. The only way for a clinician at Facility A to know that the patient went somewhere else is if they were informed by the patient or they spend a lot of time calling other facilities (ugh, administrative burden). In Tanzania, there are even policies put in place to prevent patients from going to a different facility more than two times without formally transferring - a process (with good intentions) that just adds more barriers to accessing HIV care.

We see that there is a big opportunity here to improve the HIV care cascade with point-of-care technologies that support clinicians, impact client health outcomes, and help countries achieve the 95-95-95 goals.

How We Bring Decision Support to CTC Clinicians

At Elsa Health, we have been working with CTCs in Northern Tanzania to build tools that address some of the challenges we saw while developing decision support technologies for healthcare.

The Elsa Health Platform for CTCs is an open-source digital tool that allows for management and real-time tracking of clients across facilities to improve care coordination, reduce administrative burden, and decrease dropouts.

With Elsa, clinicians are able to clearly see when and where their client has picked up medication or attended clinic, and can also predict a client’s risk of dropping out of their care plan, allowing for earlier, personalized, and more effective interventions to retain clients in care.

The platform also supports:

• Stock Management and Predictions. Clinicians are able to share stock information in real time with other facilities, including presence of expiring antiretroviral medication and medication requests, allowing for shared resources between co-located facilities with varying stock needs.
• Predictions for Risk of Non-Adherence and Drug Resistance. Elsa assesses a client’s risk of medication non-adherence and recommends possible interventions. The platform also assesses a client’s current risk of having drug resistance based on clinical, epidemiological, and social factors.
• Clinical Decision Support. Using client presentation (symptoms and signs), Elsa helps clinicians identify the likely cause of an illness and provides next steps recommendations. Clinicians also receive insights on viral load and CD4 counts over time.
• Reporting. Elsa generates facility and district-level reports for real-time visualization and data-driven decisions for both clinicians and District AIDS Control Coordinators.

Ensuring Facilities are Connected

The whole platform operates on a distributed network, where each facility serves as a node in the overall network and stores its own data. You can check this out here. We'll write another blog post all about this awesome technology. But in short, each node in the network can get access to data from the other nodes as it is made available (through synchronization). This approach provides significantly more data privacy and works offline.

Sounds Awesome, But Do Clinicians Use It?

Yes, they do!

Elsa for CTCs is currently deployed in all nine of the CTCs in Meru District in Northern Tanzania. Thirteen clinicians use the platform during their clinic visits; the platform has registered around 1,000 clients and supports clinicians with tracking patients across facilities, evaluating their risk of non-adherence or dropout, and gaining insights about symptoms and disease progression. Additionally, clinicians are able to document antiretroviral stock and view real-time medication availability from other facilities.

How This Makes a Difference

The ultimate goal of the innovation is to support achievement towards the HIV/AIDS 95-95-95 goals through the use of digital tools that facilitate data sharing between facilities, optimize clinical decision making, and streamline supply chain management for antiretroviral medication.

Clinicians, PLHIV, and district leadership all get distinct benefits:

• Care and Treatment Center Clinicians: The fact that real time data sharing between facilities is not available in current systems makes it difficult for clinicians to provide truly comprehensive and quality care. Elsa helps clinicians in tracking clients to ensure treatment continuity/ retention, and also provides insights and predictive analytics for better services.
• PLHIV: Current digital solutions do not provide the clinical impact and utility needed to improve health outcomes for PLHIV. Through optimized decisions and client-centered supply chains, client health is improved and care becomes more flexible.
• AIDS Control Coordinators & Health Stakeholders: It is well known that HIMS systems are not real time, contain high amounts of missing data, and require a lot of manual data collection and reporting effort. Elsa provides real time access to actionable information collected from connected devices on the ground - something that does not currently exist.

What's Next?

We're currently scaling the use of Elsa to other Care and Treatment Centers in surrounding districts in Northern Tanzania. This makes the platform more valuable to clinicians and increases the impact for clients. As we generate more evidence and scale the solution, we will seek integration opportunities with national systems (CTC2/3).

If you're interested in collaborating with us to improve, deploy, and/or scale this technology, we'd love to chat about how to make that possible!

If you're a clinician or a developer and are interested in contributing to this work, we would love to have you join our community! Clinical friends can contribute through our Open Health Platform. Technical friends can see our open source code and documentation on Github here and here.