Effect of health-system continuous quality improvement on long-term retention in HIV care among pregnant and breastfeeding women in the Democratic Republic of Congo: A cluster-randomized trial

In the Democratic Republic of the Congo, as in many places, a mother living with HIV faces a difficult journey after giving birth. While modern medicine can prevent her child from inheriting the virus, the treatment that keeps both of them healthy requires a long-term commitment. Women must return to clinics regularly to receive medication and monitoring, a process that often becomes harder to maintain once the immediate urgency of pregnancy fades. This period after delivery is a critical window where many women stop coming for care, leaving them and their children vulnerable. The challenge for health systems is not just to start these women on treatment, but to help them stay engaged in care for years, ensuring the virus remains suppressed and transmission is prevented.

To address this persistent gap, researchers in Kinshasa Province tested a new approach to clinic management called continuous quality improvement. Instead of simply telling doctors to do better, this method involves local teams using routine data to spot problems and test small changes to fix them. The goal was to see if empowering these local teams with information and regular meetings could keep more women in care compared to the standard way clinics operate. The study focused on pregnant and breastfeeding women receiving treatment, tracking whether they stayed connected to their doctors, whether their virus levels dropped to undetectable amounts, and whether their babies remained uninfected.

The trial took place across 105 maternal and child health clinics in the province, organized into 35 health zones. Before the study began, researchers strengthened how these clinics recorded their daily data. Then, they randomly assigned half of the health zones to receive the new quality improvement intervention while the others continued with their usual routine. In the intervention zones, local teams were formed to meet every few months. They looked at numbers showing how many patients were lost to follow-up and discussed specific barriers they faced. Using this information, they developed their own strategies to improve retention, such as finding better ways to remind patients to return. Over time, these teams took full ownership of tracking their progress and continued their discussions virtually, even as the study moved forward.

The results showed a clear, though modest, benefit to this approach. Among the nearly 2,000 women who were part of the final analysis, those in the clinics using the quality improvement method were less likely to drop out of care within the first six months compared to those in the standard clinics. Specifically, about 18.6 percent of women in the intervention group had stopped coming for care by six months, whereas 21.6 percent of women in the control group had left. This gap remained visible, though less precise, as time went on, with the intervention group showing lower rates of disengagement at one and two years as well. The improvement was most noticeable in clinics that were already supported by major international health programs and in urban settings, suggesting that the method works best where there is some existing infrastructure to build upon.

However, the study also revealed where this local approach hit its limits. While the teams successfully kept more women in the clinic, the data needed to confirm if the treatment was working biologically was often missing. For many women, the tests that measure the amount of virus in the blood were not available, making it impossible to say with certainty if the quality improvement efforts led to better viral suppression. Similarly, the results of HIV tests for the infants were frequently unavailable, preventing the researchers from drawing a definitive conclusion about whether the intervention successfully prevented the virus from passing from mother to child. The authors found that while local teams could strengthen their own processes, they could not fix failures in the wider health system that prevented these crucial test results from being generated and shared.

Ultimately, the study suggests that helping local health teams use their own data to solve problems can keep more women in care, particularly in the first year after starting treatment. Yet, the findings also indicate that this strategy alone is not enough to guarantee the biological success of the treatment or the safety of the infants if the broader system cannot provide the necessary testing. The work highlights that while local ingenuity can improve retention, a fully functional health system requires coordination at every level to ensure that the promise of treatment is delivered all the way to the patient.