Use of Project ECHO in Response to COVID-19 in Countries Supported by US President’s Emergency Plan for AIDS Relief

The US Centers for Disease Control and Prevention, with funding from the US President’s Plan for Emergency Relief, implements a virtual model for clinical mentorship, Project Extension for Community Healthcare Outcomes (ECHO), worldwide to connect multidisciplinary teams of healthcare workers (HCWs) with specialists to build capacity to respond to the HIV epidemic. The emergence of and quick evolution of the COVID-19 pandemic created the need and opportunity for the use of the Project ECHO model to help address the knowledge requirements of HCW responding to COVID-19 while maintaining HCW safety through social distancing. We describe the implementation experiences of Project ECHO in 5 Centers for Disease Control and Prevention programs as part of their COVID-19 response, in which existing platforms were used to rapidly disseminate relevant, up-to-date COVID-19–related clinical information to a large, multidisciplinary audience of stakeholders within their healthcare systems.

The US Centers for Disease Control and Prevention, with funding from the US President's Plan for Emergency Relief, implements a virtual model for clinical mentorship, Project Extension for Community Healthcare Outcomes (ECHO), worldwide to connect multidisciplinary teams of healthcare workers (HCWs) with specialists to build capacity to respond to the HIV epidemic. The emergence of and quick evolution of the COVID-19 pandemic created the need and opportunity for the use of the Project ECHO model to help address the knowledge requirements of HCW responding to COVID-19 while maintaining HCW safety through social distancing. We describe the implementation experiences of Project ECHO in 5 Centers for Disease Control and Prevention programs as part of their COVID-19 response, in which existing platforms were used to rapidly disseminate relevant, up-to-date COVID-19-related clinical information to a large, multidisciplinary audience of stakeholders within their healthcare systems. quality assurance in this context. Traditional in-person training and site visit approaches were no longer feasible or recommended because of restrictions on in-person gatherings and the priority of preserving the safety of providers and beneficiaries and limiting COVID-19 spread. We describe national and regional examples of how the Project ECHO platform was used to build capacity, rapidly and regularly disseminate evolving information on COVID-19 prevention and treatment in people living with HIV, and mentor frontline providers in resource-poor health settings supported by PEPFAR.

Methods
Respondents from a convenience sample of 9 PEPFAR-supported countries known to have implemented Project ECHO for their HIV and TB programs before the COVID-19 pandemic completed a template to capture whether and how Project ECHO was being used for COV-ID-19-related topics, session frequency, number of participants, cadre type, and geographic location. The study team entered the data into a Microsoft Excel (https://www.microsoft.com) spreadsheet for data organization and descriptive

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 (

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 limitedservice 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 indepth 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.

Conclusions
The COVID-19 pandemic heightened existing concerns over disruptions in healthcare service delivery and essential public health functions during public health emergencies. Project ECHO might help address some of these concerns by enabling the consistent delivery of clinical and public health updates and engaging communities of providers. The ability to connect multiple stakeholders could help strengthen service quality and system resilience in the face of new challenges such as COVID-19 and lead to potential long-term positive outcomes. Evaluating ECHO programs formally to establish implementation best practices and recommendations for the use of this platform could benefit the larger public health community in its response to future public health threats.