Results of a cluster randomized trial testing the systems analysis and improvement approach to increase HIV testing in family planning clinics in Mombasa, Kenya.

Objective To test an implementation strategy, the Systems Analysis and Improvement Approach (SAIA), to increase rates of HIV testing and counseling (HTC) in family planning (FP) clinics in Mombasa, Kenya. Design Cluster randomized trial. Methods Twenty-four FP clinics were randomized 1:1 to implementing SAIA versus usual procedures. Study staff implemented monthly SAIA cycles with FP clinic staff for 12 months. SAIA has five steps. Step 1 uses a "cascade analysis" tool to quantify the number of individuals who complete each step of a process. Step 2 involves sequential process flow mapping to identify modifiable bottlenecks in the system. Step 3 develops and implements workflow modifications to address bottlenecks. Step 4 assesses impact of the modification by recalculating the cascade analysis. Step 5 repeats the cycle. The primary outcome was the proportion of new FP clients tested for HIV during the last quarter of the trial. Results During the last three months of the trial, 85% (740/868) of new FP clients were counseled for HIV in intervention clinics compared to 67% (1036/1542) in control clinics (prevalence rate ratio [PRR] 1.27, 95% confidence interval [CI] 1.15-1.30). Forty-two percent (364/859) of FP clients were tested for HIV at intervention clinics compared to 32% (485/1521) at control clinics (PRR 1.33, 95%CI 1.16-1.52). Conclusion SAIA led to a significant increase in HIV testing in FP clinics in Mombasa. Integrating routine HTC into FP clinics is a promising strategy to achieve the UNAIDS goal of 95% of people living with HIV being aware of their status.