TASK SHIFTING & NIMART IN SOUTH AFRICA. Steven Chang, ANP, MPH

Transcription

1 TASK SHIFTING & NIMART IN SOUTH AFRICA Steven Chang, ANP, MPH

2 THE CHALLENGE HIV Prevalence in South Africa Shortfall of health care professionals Unequal distribution & retention challenges

3 HIV Prevalence in South Africa In 2012, it was estimated that 12.2% of the population (6.4 million persons) were HIV positive, which is 1.2 million more PLWHA than in 2008 (10.6%, or 5.2 million). South African National HIV Prevalence, Incidence and Behavior Survey, : 6.9 million people (18.9% of adults) are living with HIV (UNAIDS)

4 ART Coverage in South Africa Celebrate Success: South Africa has the largest antiretroviral treatment (ART) rollout program in the world 75% increase in HIV treatment access between 2009 and Life Expectancy 52 (2005) 61 (2014) (Statistics South Africa 2014) Decreased mortality with stable prevalence = decreased new infections Treatment as Prevention (TasP)

5 ART Coverage in South Africa But there is still a lot of work ahead: By 2013 guidelines, 58% of eligible patients not on ART (UNAIDS The Gap Report 2014) # HIV+ Adults on ART Leigh Johnson - Southern African Journal of HIV Medicine (2012)

6 Physician Shortage in South Africa ECONEX Report commissioned by the Hospital Association of South Africa (HASA)

7 Out of balance: Private vs. Public Sector Half of nurses work in the private sector. MSF (2007)

8 Physician Retention 1,200 graduate / year 17% of the newly graduated doctors from 2005 to 2009 did not register for community service. Medical Schools??? stay in South Africa 150 stay in public sector Africa Health Placements: 35 work in rural setting

9 TASK SHIFTING WHO Report (2008) Staffing Challenges

10 Task Shifting In 2008 WHO published Task Shifting: global recommendations and guidelines where they define task shifting as a process whereby specific tasks are moved, where appropriate, to health care workers with shorter training and fewer qualifications Treat Train Retain

11 Task Shifting Physician Nurse Community Health Worker Cares for complicated cases at tertiary centers while providing training and consultation support through mobile teams to primary health care clinics; Shift bulk of HIV primary care and treatment to nurses based on defined algorithms to PHC nurses and refer up as necessary Shift HIV Voluntary Counseling and Testing (VCT), adherence counseling, support groups, home visits and general clinic support to community health workers and lay counselors

12 Staffing Challenges How to take on new roles and responsibilities when already overwhelmed How to aligning incentives (monetary & non-monetary) How to address poor working conditions How to prioritize treatment of health professionals living with HIV 1 out of 7 nurses and nursing students with nearly half with CD4 < 350 (Connelly, D. 2007) How to address ingrained cultural and professional norms (hierarchy, siloes, gender status, etc.) external & internal

13 NIMART Nurse Initiated and Managed Anti-Retroviral Therapy The Evidence & NIMART in South Africa Centralized / Specialized vs. Decentralized / Integrated Nursing School Based NIMART (NEPI & MEPI)

14 NIMART - Early Evidence South Africa (Bedelu, M., et al. 2007) MSF in Lusikisiki: Equivalent outcomes at district hospital but with faster enrollment, better retention and achieving near universal coverage within their catchment Botswana (WHO 2008) One of the earliest adaptors, two pilot programs of nurse centered ART delivery started in 2004 Decreased wait times for ART, alleviated congestion at centralized ART centers, reduced unnecessary travel time by service users and provided for localized adherence and education support. Rwanda (Shumbushu, F. et al. 2009) Study evaluating a nurse-initiated ART program High retention of 92% at 24 months and 7% mortality.

15 NIMART in South Africa PALSA PLUS Comprehensive set of guidelines for the PHC nurse clinical management of respiratory diseases and HIV/AIDS patient centered, user-friendly, evidence-based, algorithm-driven & syndromic A training program to facilitate implementation: Train-the-trainer on site training of nurses at PHC

16 NIMART in South Africa STRETCH (Fairall, L., et al 2012) (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) Large Cluster-Randomized Trial (31 sites, n=15,483) Control (15 sites): referral to ART treatment sites for doctor initiated ART and follow-up Intervention (16 sites): Educational and leadership support to integrate NIMART into PHCs. Results: No difference in mortality or viral suppression Expansion of primary-care nurses role to include ART can be done safely. Some indicators of improved care: 27% lower risk of mortality in CD (p value 0.52), greater increases in CD4 and weight, earlier TB detection, more frequent appropriate ART switches.

17 Decentralized / Integrated vs. Centralized / Specialized Promoting Factors Primary Nurses affected by HIV personally motivated, pride in building skills Less stigma to patient Decreased cost to patient (travel, food and opportunity cost) De-fragmentation of HIV care from rest of primary care at PHC Confounding Factors Patient preference for ART nurse: (continuity & relationship) Primary Nurses overwhelmed, low confidence & high turnover ART Nurses that want to protect status Inconsistent managerial buy-in support (need champions) Rx distribution challenges Paperwork burden & fragmented data collection Georgeu D., et al, 2013 Qualitative process evaluation of STRETCH

18 NIMART: Multi-level Approach Off-site Training Scalable & efficient, used to train-the-trainer for PALSA PLUS High level academics may be intimidating to nurses, burden to rest of staff when away, may breed jealousy On-site training and mentorship Can evaluate compentencies real-time in real-world situation PALSA-PLUS: two hours / wk over several months, saw application of skills that day Mentorship development (ICAP at Columbia) builds confidence Difficult to scale up, and often stressful to be trained when you have competing demands (e.g., patients waiting). elearning and remote case conferencing support (MLCs) What about Pre-service training in nursing schools?

19 NEPI Columbia University Mailman School of Public Health ICAP Nurse Capacity Initiative NEPI (Nursing Education Partnership Initiative) S. Strasser, ICAP Columbia University, New York, NY, NY/US, Strengthening nursing workforce: A key ingredient for achieving PEPFAR HIV prevention, care & treatment priorities. Abstract in Annals of Global Health (2015) NIMART in Nursing Schools Zambia, Malawi, Lesotho 10,000 pre-service nurses enrolled in 19 NEPI supported nursing schools 15 curricula newly developed 9 simulation skills labs and 4 model wards established 43 faculty enrolled in higher education at Masters and PhD level Tools: Campus to Clinic mentorship guide for HIV, clinical simulation training guide, webinar series on curriculum development.

20 NIMART at UKZN MEPI Medical Education Partnership Initiative Collaboration between UKZN and Columbia University: Clinical Medicine Pharmacy Nursing UKZN is the only school in the country that has integrated a major part of the NIMART process into the undergraduate program. 1 st 4 th year Case based units for Fundamental Nursing (1 st ), Community Health Nursing (2 nd ) General Nursing (3 rd ) Midwifery and Mental Health (4 th ) 20 HIV Clinical Competencies HIV Morning sessions once / week (95% favorable response) HIV Resource Room within the Nursing Clinical Skills Laboratory (CSL) HIV Clinical Mentorship: clinic rotations & CSL 2 nd Year: 5 day workshop: covering a broad range of foundational HIV care and management concepts. 4th year students & Registered Nurses 5 day NIMART Training by 17 facilitators

21 NIMART at UKZN Preliminary Outcomes ,369 Nurses NIMART Trained through MEPI ( )

22 Pre-service NIMART Serves as a strong foundation for future mentors and PHC nurses competent in NIMART. Even with widespread NIMART still face major nursing shortage. Pre-service NIMART Off-site Trainthe-trainer (mentors) By 2010, the health department estimated that the country was short of over 44,700 nurses yet we are only training around 3,500 new nurses a year. On-site training of PHC nurses

23 NIMART at UKZN Next Steps Next Steps Need to continue to evaluate post graduate registered nurse competencies once working in the field Continue to expand HIV expertise among Nursing faculty and expand MEPI Clinical Mentorship Integrating NIMART into proposed Rural Nursing Block within community health program (2 nd yr.) and PHC module (4 th yr.) Publications in progress on NIMART in general and Clinical Skills Lab experience specifically

24 The Bridge By Joy Cowley There are times in life when we are called to be bridges, not a great monument spanning a distance and carrying loads of heavy traffic but a simple bridge to help one person from here to there over some difficulty such as pain, fear, grief, loneliness, a bridge which opens the way for ongoing journey. When I become a bridge for another, I bring upon myself a blessing, for I escape from the small prison of self and exist for a wider world, breaking out to be a larger being who can enter another s pain and rejoice in another s triumph. I know of only one greater blessing in this life, and that is to allow someone else to be a bridge for me.

25 Acknowledgements Prof. Busi Ncama Prof. Petra Brysiewicz Mrs. Silingene Ngcobo Dr. Joanne Naidoo Ms. Dorien Wentzel Ms. Charlotte Engelbrecht Dr. Nisha Nadesan-Reddy Dr. Sandy Pillay Dr. Rosie Mngqibisa