Optimizing Interventions Across the HIV Care Continuum: A Case Study Using Process Improvement Analysis

UNAIDS' 90-90-90 goal for 2020 is for 90% of HIV-infected people to know their status, 90% of infected individuals to receive antiretroviral therapy (ART), and 90% of those on ART to achieve viral suppression. To achieve these ambitious goals, effective care delivery programs are needed. In this paper we present a case study showing how HIV care can be improved by viewing the patient care process as a production process and applying methods of process improvement analysis. We examine the continuum of HIV care at a hospital-based HIV clinic in Kingston, Jamaica. We perform qualitative analysis to identify key programmatic, personnel, and clinical areas for process improvement. We then perform quantitative analysis. We develop a stochastic model of the care process which we use to evaluate the effects of potential process improvements on the number of patients who receive ART and the number who achieve viral suppression. We also develop a model for optimal investment of a fixed budget among interventions aimed at improving the care cascade and we use the model to determine the optimal investment among three interventions that the clinic could invest in. By viewing the patient care process as a production process and applying qualitative and quantitative process improvement analysis, our case study illustrates how clinics can identify the best ways to maximize clinical outcomes. Our methods are generalizable to other HIV care clinics as well as to clinics that provide care for other chronic conditions (e.g., diabetes, hepatitis B, or opioid use disorder).