HIV Project ECHO Programs Incorporating COVID-19 Topics

In 4 countries and 1 region (South Sudan, Namibia, Zambia, Kyrgyz Republic, and Central America), existing HIV Project ECHO programs were used to incorporate COVID-19 topics (Table 1). Although most of these programs targeted doctors and nurses, some also included other healthcare workers. For example, in South Sudan, ECHO sessions included participants from multiple cadres, such as clinical monitoring and evaluation staff, psychosocial counselors, laboratorians, and community health workers. Namibia included laboratorians; Zambia, pharmacists; and Kyrgyz Republic, general practitioners. Project ECHO sessions began including COVID-19 topics between January and December 2020; most started in March, around the time countries and regions began to report COVID-19 cases.

COVID-19–Focused Project ECHO Programs

In total, 4 ECHO programs (2 in Central America and 1 each in Kenya and Southern Africa) were focused on COVID-19–related content (Table 2). COVID-19 Project ECHO programs in Central America addressed laboratory-specific and clinical-specific topics. Of those 4 programs, 3 catered to audiences within the broader geographic region (2 in Central America and 1 in southern Africa). ECHO session frequency varied from weekly in the Central America COVID-19 Clinical ECHO program to biweekly for the COVID-19 Laboratory ECHO program in Central America and southern Africa and monthly for the Kenya national COVID-19 ECHO program. Similar to the HIV Project ECHO programs that incorporated COVID-19 topics, almost all programs that were COVID-19–focused included multidisciplinary participants (physicians, nurses, clinical officers, pharmacists, and laboratory staff); the exception was the Central America COVID-19 laboratory ECHO program, which only targeted laboratorians.

Enabling Factors for Implementation

Country programs using Project ECHO during the COVID-19 pandemic cited several key enabling factors for implementation. Three of four COVID-19–focused Project ECHO programs launched from existing national ECHO hubs; in doing so, those programs capitalized on previously established information technology networks, equipment, and staff knowledge of ECHO. The Central America CDC program had an existing partnership with the regional ECHO hub that hosts both the TB- and HIV-focused Project ECHO programs, which provided a foundation to rapidly launch the COVID-19–focused ECHO program. Through its established network of ECHO participants, the Central America clinical COVID-19 ECHO program quickly connected to almost 4,000 healthcare providers who had participated in HIV- and TB-focused ECHO sessions over the previous year. This immediate network enabled rapid and broad dissemination of evolving COVID-19 diagnosis and management information. Similarly, the South Sudan HIV Project ECHO hub, established in 2018, built on its existing network to incorporate COVID-19 topics into their existing HIV Project ECHO program and expanded their reach to medical teams in 40 health facilities. Zambia respondents cited the ECHO hub location within the national Ministry of Health and its connection with 10 provincial health offices throughout the country as a key enabling factor in reaching healthcare providers across the country. In Central America, support from the Executive Secretary of the Regional Ministries of Health partner (SE-COMISCA) was critical to establish regional support for Project ECHO. The CDC Central America COVID-19 Project ECHO noted that its previous experience drawing on the expertise of diverse local and national health experts from the Pan American Health Organization, ministries of health, and large hospitals, as well as local healthcare personnel, for planning, facilitation, and capacity building contributed to high attendance and reported satisfaction with sessions, which was assessed through anonymous polling at the end of sessions.

Other factors identified by country teams that aided in implementation included the virtual delivery method and reasonable time requirements of Project ECHO. Respondents in Zambia described the weekly, 60-to-90–minute format of Project ECHO sessions as “ideal to minimize disruptions in clinical duties” and noted “the flexibility of tailoring ECHO sessions to meet the specific healthcare worker COVID-19 topic needs as opposed to strict adherence to a predetermined curriculum.”

Public Health Benefit

Respondents described the perceived public health benefits of using Project ECHO to respond to COVID-19. One common theme emerged regarding the benefit of bidirectional information sharing between geographically distant frontline providers and health system leaders, which helped provide insight into the public health policy and broader service delivery challenges and ability to disseminate evolving guidelines and policies for more rapid adoption. Respondents from the Project ECHO Laboratory program in Central America indicated question-and-answer sessions were helpful in fostering dialogue between facility-level laboratory staff and national-level persons who might be responsible for influencing COVID-19 laboratory policies and procedures. The South Sudan respondents highlighted how including COVID-19 topics in their HIV Project ECHO program was “crucial to information dissemination in an extremely challenging operating environment where public health programs and impact otherwise suffer from poor physical access, limited human resource capacity, insecurity and limited-service quality oversight and supervision.”

Challenges to Implementation

Countries noted several challenges to implementing Project ECHO during and with COVID-19. Those included lack of time to identify the quantity and quality of experts who were needed to present or assist with sessions, the large volume of rapidly evolving and often difficult-to-navigate information on COVID-19 prevention and clinical management (Table 3), limited ability to maintain interactive discussion-oriented sessions while disseminating large quantities of information within the allocated time, and difficulty with long-term session planning.

Country and regional programs reported variable participation in Project ECHO sessions. In addition, CDC country staff noted information technology connectivity challenges and session-timing conflicts with clinical duties as barriers to consistent participation.

Limitations

One of the limitations of this analysis is the lack of a systematic review of all Project ECHO programs globally that were implemented in response to the COVID-19 pandemic. We used a convenience sample, limiting the generalizability of observations or conclusions beyond the contributing countries. The tool to capture Project ECHO program characteristics for this analysis was limited, and a more in-depth comprehensive tool to systematically evaluate Project ECHO programs during COVID-19 is likely needed. In addition, observing the development of communities of practice, a core function of any ECHO program, might have been limited by variable participation across ECHO programs.