Community-based HIV counseling and testing (HCT) programs serve as a means for identifying early, new HIV-positive clients and linking them to treatment, care and support programs. At the same time, they serve as an opportunity to collect socio-behavioral indices of clients that are testing for HIV on a national scale [1–5]. The data collected can then be used to suggest the predisposing factors that may be associated with clients who turn out positive within a geographical area of interest. Knowledge gained from such data is a rich resource for designing evidence-based interventions to tackle the continuous spread of the HIV/AIDS epidemic within that geographical area. Although Nigeria has developed a national HCT client intake form that can serve these purposes, our observation of ongoing projects and the lack of a national guideline on the utilization of data on risk factors suggest that data generated from these encounters is not being put to optimal use for collective/geographical behavioral risk assessment and action . Such a nationally mandated tool if applied as the basis of a national surveillance system would have been the perfect fit for studies of association between HIV status and socio-behavioral factors. However, owing to various factors, such a significant data collection system remains a dream of those who proposed these tools. Yet, the country depends on the less reliable intermittent sentinel surveillance and demographic surveys to estimate the prevalence of HIV and to identify the behavioral factors associated with HIV in its population.
This article is written to share the experiences obtained from implementing an electronic database for archiving records generated from the client intake forms in the field and for automating monthly analysis and report preparation. We hope that this experience will influence policy makers and will set the stage for a possible routine surveillance system for HIV risk factors from HCT data in the future.
In 2009, the nongovernmental organization Pro-Health International received from the US Centers for Disease Control and Prevention (CDC) Nigeria a grant to implement the HCT Expansion Plan for Nasarawa and Plateau States (HEPNAP). Following the award, staff and volunteer HCT officers drawn from target communities were trained by members of the national HCT technical working group (TWG) on the national guidelines for implementing and monitoring HCT projects. After the startup workshop, the project was rolled out in target communities. As expected with any new project, various problems were encountered in implementing and monitoring the project activities. These problems were progressively identified and methods on how these problems were addressed are described in this article.
The core methodology was iterative planning and quality audits. Several brainstorming sessions were held to identify collectively the weak points in the project's activities. The task team responsible for this activity was made up of the HEPNAP project management team, the volunteer HCT officers at the health facilities and the managers of partner health facilities. The brainstorming sessions were organized in a roll over fashion in which new ideas were implemented, evaluated and the results reintroduced into new brainstorming sessions [7,8]. The sessions were facilitated by a member of the project management team and minutes of the sessions were documented by another team member. Issues identified were subjectively assessed by the task team members on their level of importance and tackled according to the agreed level of importance. Quality audits also revealed incomplete data collection forms and loss of records during transfer from the field sites to the project management office. The team progressively developed and deployed a comprehensive system to capture all the information required according to the national guidelines. We also incorporated new organizational processes to improve the performance of our project through the application of stringent protocols. Some of the processes developed include processes for the retrieval and transfer of client intake forms from the field locations to the project management office. In addition, we developed the HEPNAP management information system (MIS). This system was designed to archive data from the client intake forms and to generate reports that are used to measure the performance of the counselors as well as report to CDC, our main funding partner, and the health ministry at the local, state and federal levels. The HEPNAP MIS is a Microsoft Access 2007-based database application, which mirrors the data of the HCT client intake form and located on a computer at the HEPNAP project office. Training of volunteer counselors on the processes for the completion of the different HCT forms had already been given at the inception workshop of the project by the HCT TWG team. However, on-site mentoring was continued afterwards by HEPNAP project officers. National, Presidents Emergency Plan for AIDS Relief (PEPFAR) and organizational indicators were incorporated in designing the reporting module of the HEPNAP MIS. Some of the indicators that were built into the system include the following: the number of people who received counseling and testing services and received their results disaggregated by sex, age, test result and the type of counseling (individual or couple) that was received . A manual for the use of this database was drafted by the developer and shared among members of the project management team. They also received training on the basic operations of the system.
Results and discussion
The brainstorming sessions and the quality audits identified several weaknesses in our processes as the program evolved. The challenges identified ranged from issues with the distribution of rapid test kits (RTKs) to the various facilities that were providing services in the communities (inputs) to problems in monitoring the number of clients tested and the proportion that were testing positive (outputs). Paramount among these challenges was the poor documentation and the lack of an audit trail for quality assurance purposes in monitoring the supply and retrieval of materials and completed forms. These identified issues were addressed through iterative planning, implementation and evaluation over several months till we were able to come up with a comprehensive approach that documented all the details needed and left a trail that we could use to pinpoint wherever a failure may have occurred. As we implemented these more detailed processes – an improvement of the national system – we continued to see little need for volunteer counselors to report using tally sheets from the field (Table 1). Tallying was the recommended way in the national guideline in which the volunteer counselors manually counted and reported the indicators upward to the project coordinating offices. This process was observed to be cumbersome and most often fraught with errors.
The difficulty in verifying the accuracy of the results reported upward played a significant role in planning our new model of data management. Furthermore, we considered the possibility of analyzing the data on various risk factors that were being collected on the client intake forms at the time of testing. We then considered retrieving the client intake forms from the field, as this form was the most complete data collection tool from which three-quarters of the monitored and reported data could be found. The idea of retrieving a completed client intake form from the field also gave us the opportunity to do a detailed ‘postmortem’ quality review of the client intake forms back at the project management office.
In order to achieve our new process, the volunteer counselors were required to complete the client intake forms in duplicate. This was made easy through the use of carbon paper for the second copy and did not add to their workload. One copy was sent to the project office, whereas the other was retained at the health facility.
The HCT project officer was responsible for the distribution of RTKs and other supplies to each facility and the retrieval of the completed client intake forms and other data collection tools from the facilities. Each of these activities was documented in detail with both the volunteer counselor and the project officer having to sign off as agreeing to the number of forms or materials that were being retrieved or supplied. These documentations were done in triplicate with the facility keeping a copy, the project officer keeping one and the last going to the monitoring and evaluations unit. Staff of the unit then update the database and archive the hard copies in fire-proof file cabinets. The exchange between the project officer and the monitoring and evaluation (M&E) unit personnel is also documented. These multilevel documentation helped us to identify easily any weakness in the chain and take due action (Fig. 1).
Following data entry into the HEPNAP MIS, progress reports can be generated at the click of a button and through specific filters in tabular or graphical formats. The number of forms in the database by each facility for any specific month could easily be compared with the number of forms that were retrieved from the field for data quality purposes. Likewise, the behavioral surveillance data can be easily analyzed to determine the risk factors that may be associated with the HIV prevalence in an area.
- Team cohesion and understanding is significant to the success that we have achieved to date on the HEPNAP project. Open communication channels between project staff and the volunteer counselors made us identify so many gaps in our system and fix them.
- ‘Postmortem’ analysis of the forms showed that often counselors were not paying due attention to filling the client intake forms properly. This was a significant problem, as the purpose for which the intake form was designed was threatened. Occasionally, male patients were marked as being pregnant. Owing to our high regard for data quality, we set out to reeducate the volunteer counselors on the importance of the quality of the data collected. Following this campaign and continued mentoring by project staff, fewer problems were observed on the intake forms.
- Archiving the data in an electronic database places the data in a ready to use format for analysis. If by extension, other HCT projects could also adopt such a system, then it will be time to begin discussing about the possibility of having a routine HIV behavioral surveillance system through data sharing and warehousing.
- The automation of our reports significantly improved the speed of our work and reduced the frequency in which we had errors. As a result of the improved speed of work, we were able to report to our donors in a timely fashion. From this data archive, we were able to generate monthly, quarterly, semiannual and annual reports without having to return to the field for the same data and be certain of completeness. At a point when an indicator was redefined by PEPFAR, various organizations that depended on collecting summary results from facilities had to return to the field to recount their data manually. Through our HEPNAP MIS, we just redefined the query in our database and produced the new required indicator at no added cost.
Many factors are responsible for the eventual nonutilization of the HCT behavioral risk data collected on the client intake form, which can be traced to poor data management practices by the organizations that implement these projects, fund-related problems and a lack of commitment to carry out these activities. However, the possible benefits that can be derived from archiving the data electronically and using it outweigh the investments that need to be put in and commitment to such a system will eventually lead the way for routine HCT behavioral surveillance.
The authors acknowledge and appreciate the support of the US Centers for Disease Control and Prevention Nigeria Office for the support to be able to execute the HEPNAP program under the cooperative agreement 1U2GPS000983.
The authors also appreciate the efforts of Adamu Ibrahim, Aishat Maiwada, Alhassan Aminu, Blessing Arziki, Brown Princewill Bukola Morris, Christie Ikemeh, Dantani Kaura, Eleazar Gonina, Gabriel Ezekiel, Gambo Tanimu, Gbenga Ilori, Halima Salisu, Hosea Klangs, Joshua Grace, Jude Akpede, Kelechi Igbotionu, Lucky Oche, Maikasuwa Baba, Murtala Yau, Rhoda Jesse, Saidu Ibrahim, Saratu Bako, Suzan Sunday, Tony Anyanwu, Yahaya Ibrahim, Yahaya Yakubu, Yakubu Jabba and Yohanna Barje who have contributed toward the achievements of the HEPNAP program so far and continue to work tirelessly to make sure that more people know their HIV status and embrace behavioral change that will keep them and their partners protected and help enroll positive clients in care, treatment and support programs.
C.F.E. supervised the project team and contributed to the conception of this article, the study design and the write up of the manuscript.
I.J.I. provided leadership for the team and strategic guidance during the implementation of the project. I.J.I. contributed to the introduction, the study design and the conclusion of this article.
H.P.L. contributed to the introduction, the methods, the results and the discussion sections of this article.
O.A.M. led the evaluation of this project and conceptualized this article. The authors contributed to the introduction, the methods used, the results, the discussion and the conclusion of the article.
We also acknowledge Mrs Abimbola Onigbanjo-Williams for helping us review this manuscript.
Conflicts of interest
There are no conflicts of interest.
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