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BACKGROUND: Community-led monitoring (CLM) has successfully documented HIV services availability since the beginning of the Russian invasion and may be advanced to assess quality. The secret client method, where a trained observer poses as a patient, has been used in research to evaluate service quality. We applied this methodology to CLM in Ukraine to identify barriers to and strengths of HIV service quality within the context of armed conflict.
DESCRIPTION: Between August and October 2023, the USAID/PEPFAR-funded Community Action for HIV Control project identified and trained interested community representatives/monitors on the secret client method, which includes care standards, in 12 Ukrainian regions and Kyiv city. Trained key population representatives visited 24 public health facilities, seeking HIV testing services (HTS) using the secret client approach. Findings were shared with the Ministry of Health’s Centre for Public Health to determine responsive quality improvement measures.
LESSONS LEARNED: Twenty-four HTS secret client visits were conducted. Five were incomplete as three secret clients did not have physician referrals, creating a service barrier. A further two facilities did not provide HTS despite national facility services list. Positive findings among 19 completed visits included rare experiences of stigma (1 visit); pre-test information sessions (10 visits); clients received test results (18 visits), and no wait required to see a provider (7 visits). All secret clients reported a friendly atmosphere and ability to ask the provider questions. Challenges included difficulty or inability to schedule services in advance; absence of post-test counseling for more than half of visits; partner testing was rarely offered (2 visits); and some clients noted lack of confidentiality during testing. One theme influencing HTS availability was limited provider confidence in rapid test results. Secret client information also allowed verification of routine monitoring data. Results were shared with regional CPH representatives and responsive actions included provider refresher training in HTS, updating the HTS facility list for testing not requiring physician referrals, and restoring HTS in facilities where previously unavailable.
CONCLUSIONS: The secret client approach provided important findings to improve the quality of HTS and other services. This model will be refined and expanded to evaluate services provided by NGOs