From data to dialogue: How Zimbabwe's pediatric AHD service quality assessments informed action

The Critical Role of Service Quality Assessment in Pediatric AHD 

Children living with HIV (CLHIV) face unique vulnerabilities, and those with advanced HIV disease (AHD) require specialized, high-quality care to ensure optimal outcomes. Service Quality Assessments (SQAs) are indispensable tools for programs aiming to deliver such care, identifying strengths, weaknesses, and areas for improvement. Zimbabwe's experience with SQAs for pediatric AHD services, building on CHAI’s 2022 Pediatric AHD Landscape Assessment, offers a compelling case study. The overarching goal of these assessments was to map service gaps and availability to inform STOP AIDS roadmaps and future service improvement interventions.

Methodology: A Collaborative Approach to Uncovering Gaps 

Partnership in Assessment 

In 2024, CHAI initiated the SQA process in Zimbabwe by reviewing existing tools and developing a localized SQA framework that could be integrated within existing patient-level and national reporting structures. The SQA was conducted in the third quarter of the year in close collaboration with the Ministry of Health and Child Care (MoHCC) and AFROCAB. This tripartite collaboration was vital: MoHCC involvement ensured alignment with national priorities and facilitated translation of findings into policy and practice, while AFROCAB's participation guaranteed community viewpoints and patient experiences were at the forefront. By leveraging existing M&E structures rather than creating parallel systems, the initiative laid a strong foundation for the sustainable integration of quality assessment into AHD services. 

Scope of the SQA 

The SQA was implemented across eight carefully selected sentinel sites: one tertiary hospital, one provincial hospital, one district hospital, and five clinics. The diversity of sites ensured a balanced representation of pediatric AHD service delivery challenges across different tiers of the health system, allowing for a more nuanced understanding of where specific gaps in diagnostics, staffing, commodities, or guideline adherence are most acute. Consequently, the findings are more likely to reflect system-wide issues rather than facility-specific anomalies, making them broadly applicable for national planning. 

The team, comprising of AFROCAB, MoHCC Prevention of Mother to Child Transmission, Department of Pharmacy Services, Care and Treatment, Laboratory Services, and CHAI, after the conducting the SQA at Chinhoyi Provincial Hospital.

The assessment methodology involved a comprehensive review of patient data, complemented by in-depth discussions with healthcare workers (HCWs) on the STOP AIDS package of care. Data gathered through these methods were then analyzed to generate insights into the current status of pediatric AHD care, identifying both gaps and opportunities for improvement. 

Key Findings: Shining a Light on Pediatric AHD Service Gaps 

The SQA results identified the following service gaps: 

• Suboptimal utilization of CD4 testing for diagnosing AHD among people living with HIV (PLHIV), including children. Given that CD4 count is a primary diagnostic criterion for AHD, this gap has profound implications for timely detection and treatment initiation. 

• The assessment also revealed low initiation rates of cotrimoxazole (CTX) prophylaxis and Tuberculosis Preventive Therapy (TPT) among eligible clients. Both CTX and TPT are essential, life-saving interventions for preventing opportunistic infections in individuals and children with AHD. Low uptake directly impacts patient outcomes and survival. 

  
  

This reflects more than just a clinical practice gap; it points to potential underlying systemic issues. These could range from inconsistent adherence to clinical guidelines by HCWs, stockouts of these essential commodities (though access to VISITECT CD4 testing was later improved), or insufficient HCW training and confidence. While patient or caregiver factors were not explicitly mentioned in the provided information, they can also play a role. The SQA identified what the issue was, while subsequent programmatic actions aimed to address the why. 

Table 1. Key Findings from Zimbabwe's 2024 Pediatric AHD SQA 

Area of Assessment	Key Gap Identified
AHD Diagnosis (CD4 Testing)	Gaps in using CD4 testing to diagnose PLHIV with AHD.
Prophylaxis Initiation (CTX)	Low initiation of CTX prophylaxis amongst eligible clients.
Preventive Therapy (TPT)	Low initiation of TPT amongst eligible clients.

Direct Impact of SQA 

The findings from the SQA led to clear, actionable recommendations. These included targeted training for HCWs on TPT and CTX prophylaxis, reinforcing the correct clinical management of eligible clients, and, significantly, improving access to VISITECT point-of-care CD4 testing. The improvement in VISITECT access was notably achieved in the fourth quarter of 2024, demonstrating rapid translation of findings into service enhancements. This swift action highlights the commitment to responsive programming. 

Informing National Frameworks 

Beyond immediate programmatic adjustments, the SQA findings played a role in shaping broader national health frameworks. For instance, SQA insights contributed to the development of the National Scale-Up Plan for AHD Services, which outlines what is required to expand AHD service coverage across more than 1,700 facilities in Zimbabwe and includes ambitious targets, such as expanding access to CD4 testing for all eligible PLHIV from 25% in 2024 to 75% in 2025 and 95% by 2026, and increasing the number of facilities trained in the AHD package from 1,300 in 2024 to 1,752 by 2025. 

SQAs, therefore, act as a critical feedback loop into the national strategic planning process. They provide empirical evidence that can validate or challenge existing assumptions, justify resource allocation (e.g., for increased VISITECT procurement or targeted training programs), and ensure that national plans are directly responsive to actual needs identified at the service delivery level. This data-driven approach grounds the National Scale-Up Plan in context-specific, ensuring it targets areas of greatest need and is better positioned to deliver results. 

Conclusion: The Continuous Cycle of Quality Improvement 

Zimbabwe's experience with SQAs in pediatric AHD underscores their value in driving continuous quality improvement. The data generated by SQAs identifies challenges, informs targeted interventions, and shapes national health strategies. Acting on these findings domestically and sharing them internationally contributes to a broader movement towards enhanced care for CLHIV worldwide. This commitment to ongoing assessment is evident in the 2025 priorities, which include additional SQAs and site support visits by May, underscoring sustained dedication to data-driven excellence in pediatric AHD care.

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Through the generous support of Unitaid, the Clinton Health Access Initiative (CHAI)-led THRIVE Project is enabling access to critical prevention, screening, and treatment commodities for advanced HIV disease to dramatically reduce mortality among adults and children living with HIV. The THRIVE project is conducted in partnership with Afrocab and Penta.  

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 Disclaimer: The views expressed are those of CHAI and do not necessarily reflect those of Unitaid or other partners.