{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T22:41:40Z","timestamp":1775083300847,"version":"3.50.1"},"reference-count":33,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2025,6,13]],"date-time":"2025-06-13T00:00:00Z","timestamp":1749772800000},"content-version":"unspecified","delay-in-days":73,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Qual"],"accepted":{"date-parts":[[2025,5,31]]},"published-print":{"date-parts":[[2025,4]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>While the UNAIDS 95-95-95 targets have been met among adults, those for children and adolescents remain suboptimal. This study aimed to improve the return-to-care rates among children and adolescents living with HIV (CALHIV) who missed clinic appointments at a county-level rural health facility in eastern Uganda.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Between January 2023 and January 2024, we conducted a continuous quality improvement (CQI) study. A CQI committee was established through entry meetings and training, and quality of care gaps were identified through data reviews. We prioritised one gap for CQI through ranking, performed a root-cause analysis using a fishbone diagram, and developed and ranked improvement changes using the impact-effort matrix. The improvement changes were implemented using Plan-Do-Study-Act cycles. The changes included (1) line listing CALHIV with missed appointments and following up via phone calls; (2) weekly data reviews to harmonise missed appointments and (3) assigning community health workers (CHWs) to trace and return CALHIV to care. We tracked and plotted the proportion of CALHIV returning to care over time to assess improvements.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Before the implementation of CQI initiatives (August 2022\u2013January 2023), the average return-to-care rate was 35% (baseline). Following the initiation of CQI in February 2023, the average return-to-care rate increased to 59% from February to May 2023 with the introduction of line listing (phase 1), to 69% from June to September 2023 with the implementation of weekly data reviews (phase 2), and to 88% from October 2023 to January 2024 with the involvement of CHWs (phase 3), ultimately reaching a peak of 100% in January 2024.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>The CQI approach improved the return to care of CALHIV who missed clinic appointments, allowing access to optimal care and better health outcomes. These findings should serve as preliminary data for larger randomised studies.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjoq-2024-003157","type":"journal-article","created":{"date-parts":[[2025,6,13]],"date-time":"2025-06-13T07:05:35Z","timestamp":1749798335000},"page":"e003157","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Return to care of children and adolescents living with HIV who missed their clinic visits or were lost to follow-up: a continuous quality improvement study in Uganda"],"prefix":"10.1136","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-6270-4953","authenticated-orcid":false,"given":"Ssentongo Mugerwa","family":"Saadick","sequence":"first","affiliation":[{"name":"Directorate of Program Management and Capacity Development, AIDS Information Center, Kampala, Uganda, Kampala, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9065-0389","authenticated-orcid":false,"given":"Jonathan","family":"Izudi","sequence":"additional","affiliation":[{"name":"Department of Community Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda"},{"name":"African Population and Health Research Center, Nairobi, Kenya"},{"name":"Directorate of Graduate Training, Research and Innovation, Muni University, Arua, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Boniface","family":"Oryokot","sequence":"additional","affiliation":[{"name":"Directorate of Program Management and Capacity Development, AIDS Information Center, Kampala, Uganda, Kampala, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ronald","family":"Opito","sequence":"additional","affiliation":[{"name":"Directorate of Program Management and Capacity Development, AIDS Information Center, Kampala, Uganda, Kampala, Soroti, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Baker","family":"Bakashaba","sequence":"additional","affiliation":[{"name":"Directorate of Program Management and Capacity Development, AIDS Information Center, Kampala, Uganda, Kampala, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Abel","family":"Munina","sequence":"additional","affiliation":[{"name":"Directorate of Program Management and Capacity Development, AIDS Information Center, Kampala, Uganda, Kampala, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"kokas","family":"Opolot","sequence":"additional","affiliation":[{"name":"Department of Health, Serere District Local Government, Serere, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel","family":"Ogwal","sequence":"additional","affiliation":[{"name":"Department of Health, Serere District Local Government, Serere, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julius","family":"Ssendiwala","sequence":"additional","affiliation":[{"name":"Makerere University School of Public Health, Kampala, Kampala, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kenneth","family":"Mugisha","sequence":"additional","affiliation":[{"name":"Directorate of Program Management and Capacity Development, AIDS Information Center, Kampala, Uganda, Kampala, Uganda"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,6,13]]},"reference":[{"key":"2025083113425491000_14.2.e003157.1","unstructured":"UNAIDS . The path that ends AIDS: UNAIDS Global AIDS Update 2023 | Enhanced Reader. 2023."},{"key":"2025083113425491000_14.2.e003157.2","doi-asserted-by":"crossref","unstructured":"Agaba PA , et al . Treatment outcomes among older human immunodeficiency virus-infected adults in Nigeria. Open Forum Infect Dis 2017;4.","DOI":"10.1093\/ofid\/ofx031"},{"key":"2025083113425491000_14.2.e003157.3","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12981-023-00512-4","article-title":"Risk factors for interruption in treatment among HIV-infected adolescents attending health care and treatment clinics in Tanzania","volume":"20","author":"Mtisi","year":"2023","journal-title":"AIDS Res Ther"},{"key":"2025083113425491000_14.2.e003157.4","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-021-10961-z"},{"key":"2025083113425491000_14.2.e003157.5","doi-asserted-by":"crossref","first-page":"381","DOI":"10.2147\/HIV.S376053","article-title":"The Frequency and Predictors of Unsuppressed HIV Viral Load Among People with HIV in Nyaruguru District, Rwanda","volume":"14","author":"Hakizayezu","year":"2022","journal-title":"HIV"},{"key":"2025083113425491000_14.2.e003157.6","doi-asserted-by":"publisher","DOI":"10.1186\/s12879-021-06459-z"},{"key":"2025083113425491000_14.2.e003157.7","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1186\/s12981-024-00622-7","article-title":"Barriers to viral load suppression among adolescents living with HIV on anti-retroviral therapy: a retrospective study in Tanga, Tanzania","volume":"21","author":"Mushy","year":"2024","journal-title":"AIDS Res Ther"},{"key":"2025083113425491000_14.2.e003157.8","doi-asserted-by":"crossref","DOI":"10.1002\/jia2.26230","article-title":"Reasons for disengagement from antiretroviral care in the era of \u201cTreat All\u201d in low- or middle-income countries: a systematic review","volume":"27","author":"Burke","year":"2024","journal-title":"J Int AIDS Soc"},{"key":"2025083113425491000_14.2.e003157.9","doi-asserted-by":"crossref","DOI":"10.1136\/bmjopen-2022-071283","article-title":"Prior exposure to antiretroviral therapy among adult patients presenting for HIV treatment initiation or reinitiation in sub-Saharan Africa: a systematic review","volume":"13","author":"Benade","year":"2023","journal-title":"BMJ Open"},{"key":"2025083113425491000_14.2.e003157.10","doi-asserted-by":"publisher","DOI":"10.1093\/cid\/cit490"},{"key":"2025083113425491000_14.2.e003157.11","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-019-4474-6","article-title":"Loss to follow-up and associated factors among adult people living with HIV at public health facilities in Wakiso district, Uganda: a retrospective cohort study","volume":"19","author":"Opio","year":"2019","journal-title":"BMC Health Serv Res"},{"key":"2025083113425491000_14.2.e003157.12","unstructured":"World Health Organization . Consolidated guidelines on HIV prevention, testing, service delivery and monitoring: recomendations for a public health approach. World Heal Organ 2021;592."},{"key":"2025083113425491000_14.2.e003157.13","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2015-004411"},{"key":"2025083113425491000_14.2.e003157.14","unstructured":"UBOS . Population & culture | serere district. UBOS; 2014. Available: http:\/\/serere.go.ug\/lg\/population-culture"},{"key":"2025083113425491000_14.2.e003157.15","unstructured":"Uganda A , HIV C , sheets AF . Uganda aids commison. 2021. Available: https:\/\/uac.go.ug\/index.php?option=com_sppagebuilder&view=page&id=24&Itemid=140"},{"key":"2025083113425491000_14.2.e003157.16","unstructured":"MOH . Dashboard - dhis 2. 2024. Available: https:\/\/prep.mets.or.ug\/dhis-web-dashboard"},{"key":"2025083113425491000_14.2.e003157.17","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-021-06731-7","article-title":"Continuous quality improvement (CQI) Institutionalization to reach 95:95:95 HIV targets: a multicountry experience from the Global South","volume":"21","author":"Memiah","year":"2021","journal-title":"BMC Health Serv Res"},{"key":"2025083113425491000_14.2.e003157.18","unstructured":"Fishbone . Fishbone diagram - template & example. 2023 Available: https:\/\/goleansixsigma.com\/cause-and-effect-diagram\/"},{"key":"2025083113425491000_14.2.e003157.19","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1155\/2018\/1524016","article-title":"Retention of HIV-Positive Adolescents in Care: A Quality Improvement Intervention in Mid-Western Uganda","volume":"2018","author":"Izudi","year":"2018","journal-title":"Biomed Res Int"},{"key":"2025083113425491000_14.2.e003157.20","doi-asserted-by":"crossref","DOI":"10.1136\/bmjoq-2023-002314","article-title":"Use of a context-specific package to increase sputum smear monitoring among people with pulmonary tuberculosis in Uganda: a quality improvement study","volume":"12","author":"Adrawa","year":"2023","journal-title":"BMJ Open Qual"},{"key":"2025083113425491000_14.2.e003157.21","doi-asserted-by":"crossref","first-page":"262","DOI":"10.1097\/QAI.0000000000000707","article-title":"Outcomes of a Clinic-Based Surveillance-Informed 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Stakeholder Perspectives in Tanzania","volume":"32","author":"Knettel","year":"2021","journal-title":"J Assoc Nurses AIDS Care"},{"key":"2025083113425491000_14.2.e003157.31","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1089\/apc.2016.0318","article-title":"Use of an Outreach Coordinator to Reengage and Retain Patients with HIV in Care","volume":"31","author":"Bean","year":"2017","journal-title":"AIDS Patient Care STDS"},{"key":"2025083113425491000_14.2.e003157.32","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0211439","article-title":"Impact of lay health worker programmes on the health outcomes of mother-child pairs of HIV exposed children in Africa: A scoping review","volume":"14","author":"Schmitz","year":"2019","journal-title":"PLoS ONE"},{"key":"2025083113425491000_14.2.e003157.33","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s13012-018-0762-5","article-title":"Community health worker support to improve HIV treatment outcomes for older children and adolescents in Zimbabwe: A process evaluation of the ZENITH trial","volume":"13","author":"Dziva Chikwari","year":"2018","journal-title":"Implement Sci"}],"container-title":["BMJ Open 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