Well-trained medical staff key to establishing successful ARV treatment clinics say doctors in Botswana & Uganda

The development of well-trained medical staff is vital to the successful establishment of antiretroviral treatment (ART) clinics in the developing world, according to two reports in the April 1 issue of Clinical Infectious Diseases. The reports, from teams working in Botswana and Uganda, who launched some of the first public ART clinics in sub-Saharan Africa, describe some of the challenges to a rapid scale-up of ART programmes in the developing world.

For several years now, Botswana and Uganda have been on the frontlines of the battle against HIV; and the treatment and prevention programmes pioneered there serve as models for other developing nations impacted by the pandemic. The government (in both Botswana and Uganda) has demonstrated a strong political commitment to mounting a response to the HIV/AIDS epidemic via the public health sector.

Additionally, novel public-private partnerships (PPPs) between the government and Western institutions (e.g., industry, charitable foundations and medical universities) have proven crucial in addressing many of the challenges presenting during the start-up of these public sector programmes.

Masa in Botswana

In 2001, the government of Botswana promised to provide ART free to all citizens in need of treatment through the national health programme referred to as “Masa” (a Setswana word signifying “hope”).

The government received considerable assistance from partnerships with Western organizations, namely with Merck and the Gates Foundation (in an PPP known as ACHAAP); and Harvard (the Botswana–Harvard School of Public Health AIDS Initiative Partnership). These institutions have offered Botswana practical expertise as well as funding.

The first large public ART clinic in Botswana, the Infectious Disease Care Clinic (IDCC), was established at Princess Marina Hospital, a referral hospital in the capital city of Gaborone. The hospital’s environment is a challenging one: the wards operate at twice their intended capacity with half the nursing staff necessary. “Morale is exceedingly low among the staff of the medical ward, where… 3–5 patients, on average, do not survive until the morning after admission.” Most admissions were associated with HIV/AIDS.

The hospital was chosen to house the IDCC and pilot the ART programme due the presence of on-site specialists experienced in HIV management, and the requisite laboratory facilities to monitor HIV disease.

HIV experts from the Botswana–Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education, the World Health Organization, and the ACHAP, helped launch the programme by providing on-site theoretical training and mentoring for the local medical officers. Within one month, the local medical officers were able to work independently, with ongoing support provided via the mentoring programme.

While local staff received training, patients were already being enrolled into the programme. Concurrently, patient education, adherence and monitoring tools were developed and made available, and a record keeping system for the clinic was implemented.

Patient management

Pre-referral care consisted of CD4 cell monitoring, disease prophylaxis (with isoniazid and co-trimoxazole used for prophylaxis of tuberculosis and Pneumocystis jiroveci [formerly “carinii”] pneumonia, respectively), primary medical care (i.e., nonantiretroviral therapy), social support, and nutritional services.

“Because of the huge demand for treatment, the names of patients were placed on waiting lists, and many patients waited for as long as 4–5 months to initiate [ART].” Patients with CD4 cell counts of below 50 cells were given top priority for ART treatment, which consisted of stavudine/didanosine in combination with either nevirapine or efavirenz, because of the low cost and availability of these drugs.

Lessons learned

Space issues: One of the first challenges was the lack of space needed to manage the huge number of patients enrolling into the programme. “Initially, space was mainly needed for consultation while these often significantly ill patients underwent screening and initiated HAART. As the numbers of patients rapidly escalated, there soon became a need for adequate space to provide counselling on adherence to treatment.” Eventually new external facilities eventually had to be built.

Decentralization: Because ART was only initially available at the IDCC, the facility quickly became overburdened. Furthermore, it was causing patients hardship. Many had far to travel to get ART, and would have to get their total care from more than one facility. For example, patients could receive co-trimoxazole or treatment for tuberculosis, as well as social services and routine medical care, at peripheral clinics, but had attend the IDCC to be prescribed ART

Currently, Botswana is trying to decentralize Masa by establishing peripheral municipal medical clinics in closer geographic proximity to patients.

Staffing/Training Issues: When the IDCC was launched all of the medical officers at Princess Marina wanted to be involved in the programme, at least on a part-time basis, but soon it was decided to form a dedicated core team of HIV physician specialists. This team of HIV physician specialists was “critical to programme’s success because they (1) allow for continuity and consistency of care for large numbers of patients, and (2) are dedicated to intensively training other “junior” medical officers as care providers for patients with HIV infection.”

This pattern of developing a core team of HIV specialists has been replicated at other sites in other regions of Botswana, and at a number of peripheral sites. However, expansion of the programme is limited because there aren’t enough clinicians to supply treatment the vast number of patients who need it.

So the programme is considering giving nurses greater responsibility to manage patients on ART. Presently, nurses are paired with medical officers and focus primarily on adherence counselling, education, translation, and problem identification. “The role of nurses is especially important in this region with pre-existing shortages of medical officers. Allowing antiretroviral treatment clinics to be primarily run by nurses would significantly enhance the capacity of such clinics, because nurses could care for the majority of patients with minimal supervision.”

To make this work, however, “will require time and flexibility in a system that is rigid in terms of structure, responsibilities, and salary scales.”

Uganda

Ronald and Sande describe similar experiences setting up antiretroviral clinics in Uganda. Although there are a number of different ART programme models under evaluation in Uganda (see Fee for Service Study in Uganda), a PPP called the Academic Alliance for AIDS Care and Prevention in Africa Foundation (established between Ugandan and North American physicians in academic medicine, Pfizer and the Makerere University Faculty of Medicine) has set up a free ART clinic at Mulago Hospital in Kampala, Uganda.

“Our limited facilities at Mulago Hospital… were quickly overwhelmed, and sick patients who required care appeared from everywhere. Most patients were poor, and many were illiterate. Within 3 years, 18000 HIV-infected individuals have been registered in our adult and paediatric clinics.”

The authors agree that there is a pressing need to build treatment capacity with intensive training programmes. “At our site, we have trained 300 physicians to train other physicians to become trainers themselves, including 68 physicians from 13 African countries outside Uganda. These individuals have been tasked and have been given the skill set to provide training when they return to their own environment.”

Other challenges

Ronald and Sande note a number of other impediments to rapid scale-up of ART programmes in the rest of sub-Saharan Africa:

Lack of political commitment: “Few countries have made significant revisions of their national budgets or, even, their national priorities to address issues of care. In societies devastated by AIDS, there has been little serious preparation by most governments, universities, or health care institutions to prepare to meet the massive human and fiscal resources required to provide even limited programs of HIV/AIDS care.” ART programmes have only received “token support from national leaders in Africa.”

Problems in Deploying Resources: Ronald and Sande write that funding is not presently as much of a problem as an inability to rapidly deploy resources to deserving projects. Funds “often are not spent efficiently within expected time frames, because of the lack of visionary leadership, inadequate human resources, poorly developed business plans, or multitiered bureaucracy. In a sincere effort to avoid misallocation of funds, most countries have established criteria and processes that are a challenge to navigate efficiently. As a result, the introduction of expanded, scaled-up care programs takes years, instead of months, to accomplish.”

Poor drug supply line infrastructure: Drug logistics have to be efficient, and the supply chain has to work all the time, or treatment failure will rapidly occur. Governments in many parts of Africa have a deplorable record of ensuring an adequate supply of drugs and diagnostics, even when the drugs and diagnostics are freely supplied.

Inadequate Research: Often there is little data to guide clinicians trying to create an effective basic package of care — with very limited resources — for the opportunistic infections and complications of HIV disease. Ronald and Sande note however that: “widespread access to care cannot await the results of research. Research and HIV/AIDS care must proceed in parallel, and, in this case, “the boat must be built as it sails from the harbor.”

Finally, where HIV programmes or PPPs have been established, “it is essential to monitor and evaluate [their] effectiveness. Donors… should insist on documentation of the results of their investments and evidence of the effective use of antiretroviral drugs.”