August is of course Winter in the southern hemisphere, but we are just finishing the “dog days of summer” here in Boston. As we do so at the Harvard T.H. Chan School of Public Health, our first class of Doctoral students in the newly refurbished Doctor of Public Health degree have been plugging away for the past two months. These superstars are working towards a doctoral degree in the actual “practice” of public health. They will learn how to be the next leaders in creating, implementing, and evaluating the impact of large public health programs, which will save literally hundreds of thousands, if not millions of lives. As in its name, our Doctor of Pubic Health course showcases What Works and Why: Building Successful Programs in Global Health.
Half of these exceptional students are from countries outside of the U.S. All are successful already in some area of health or public health. Their creative energy and intelligence have many of us old-timers at Harvard Chan feeling optimistic that the world can be changed for the better. But another recent development, the reduction of U.S. government funding of healthcare in Africa, is a cause for deep concern.
Training the next generation of health practitioners is vital to addressing the world’s pubic health needs. We are investing in many top medical and public health programs in countries with resources, such as ours. These are worthy investments. Unfortunately, much of the developing world has difficulty making such investments. In Africa especially, there is an extreme shortage of healthcare professionals available to provide basic treatment and prevention services. Africa has been estimated to have 25% of the world’s burden of diseases, but only 3% of the world’s healthcare workforce. The World Health Organization estimates that there is a minimum threshold of 23 doctors, nurses and midwives per 10,000 people in a country necessary to deliver just the most essential maternal and child health services. The majority of the countries in sub Saharan Africa do not even come close to meeting this minimum requirement.
Six years ago, our country’s President’s Emergency Plan for AIDS Relief (PEPFAR) created a small, but uniquely effective program to expand the number of doctors and nurses trained in developing countries, especially in those being devastated by the AIDS epidemic. Dr. Eric Goosby slipped the program into the PEPFAR plans as he took over leading the program when he became the PEPFAR AIDS Ambassador in 2009. Goosby quietly but quickly got the funding for the $60 million, five-year program called the Medical Education Partnership Initiatives (MEPI for short). The funding, granted directly to 14 African medical schools, went to improve medical training in Africa. These African medical schools then partnered with U.S. medical schools or in our case, the School of Public Health. In designing the MEPI program, Goosby understood that those in control should be the local leaders and organizations that would be leading, implementing, and sustaining the effort in the long run.
The MEPI program has advanced medical training for both doctors and nurses in dramatic ways these past five years. (see http://www.mepinetwork.org/ )
Last year, Goosby moved back to his home in San Francisco and UCSF, having successfully guided our government’s PEPFAR effort. As of this month, August, the U.S. government has decided to end most of the MEPI program, one of its most impactful programs in terms of expanding and improving the future healthcare workforce in Africa. (There is a smaller program continuing to network the few heads of the African schools and foster training in research, but the main effort across 32 African medical schools and other African institutions and their U.S. partners has not been continued.)
Funding which would have been used to continue the MEPI program will now go towards other important, but short-term efforts, in the PEPFAR program. I can’t imagine, though, a more valuable investment for the long-term health of Africa than to invest in correcting the severe shortage of healthcare workers in Africa. Many of the young leaders trained here at Harvard and across the developed world want to work in Africa to improve healthcare there. Yet without more skilled African doctors and nurses, there will be scant opportunity to improve and expand health systems in Africa. We can best invest in the health of Africa by investing in African health professionals and community health workers. We need to expand programs like MEPI, not eliminate them.
The KITSO AIDS Training Program in Botswana reached the milestone of having trained over 8000 nurses, doctors and pharmacists in the fundamentals of HIV/AIDS care for the expanding Masa Programme. KITSO is the Setswana word for “knowledge“. Recently a detailed summary of the results of the training program and its support to the national ART treatment program in Botswana was published in the Open AIDS Journal, 2008, 2, 10 – 16.
Since its inception in the year 2000 by Dr. Richard Marlink and colleagues at the Botswana-Harvard Partnership, the KITSO AIDS Training Program has worked under the coordination of the MOH to increase local staff capacity within the healthcare sector and ensure the sustainability of HIV/AIDS care and treatment.
When ARV therapy was first introduced in Botswana in 2002, few physicians and nurses in the country had experience in AIDS treatment. Through KITSO training and front-line experience in the ARV clinics, healthcare professionals in Botswana have gained the expertise and confidence to both provide ARV therapy and train other healthcare workers at their treatment sites. KITSO-trained staff now provide ARV therapy at 33 hospital sites and 137 satellite clinics throughout the country, and currently serve over 130,000 patients enrolled in the national ARV program.
Curriculum and Implementation
KITSO has developed a module-based training curriculum which is tailored to the Botswana National HIV/ AIDS Treatment Guidelines. The curriculum has been collaboratively developed and is regularly updated by national and international experts to ensure that healthcare professionals gain competency and confidence in the latest national standards of HIV/AIDS care and treatment.
Curriculum development and course implementation have been driven by the immediate need to train Botswana’s healthcare workers in HIV/AIDS care in formats that provide a comprehensive grounding in good clinical practice without requiring long periods of staff release for training.
As mandated by the MOH, KITSO training modules are the national standard of training for HIV/AIDS care and treatment in both public and private sectors. The KITSO-BHP team oversees the standardized training implementation, curriculum development, updating, course examination and certification.
AIDS Clinical Care Fundamentals
Since its first offering in July 2001, AIDS Clinical Care Fundamentals (ACCF) has served as a gateway course to prepare Botswana’s healthcare professionals to provide basic ARV therapy and other HIV/AIDS care. Training is carried out using either a facility-based or centralized format, depending upon the staffing needs of individual healthcare facilities. Between July 2001 and December 2009, 7078 healthcare workers completed this module. Following four days of lectures and case study discussions, the course concludes with a final examination. Participants who meet course requirements as determined by the MOH receive a certificate of successful completion.
The ACCF module has been packaged onto a CD-Rom for distance learning.
Since 2006 KITSO AIDS Training Program has been implementing distance learning as an alternative training format utilizing an audio-enhanced CD ROM of AIDS Clinical Care Fundamentals. Distance learning participants receive a training package, including the CD Rom, course binder and support materials for their self studies. A one-day classroom training activity where clinical scenarios pertaining to the learning objectives of the course are discussed. A final assessment concludes the distance learning experience.
Topics covered in AIDS Clinical Care Fundamentals:
1. Introduction to the Botswana National ARV Program
2. HIV Epidemiology and Pathophysiology
3. Laboratory Diagnostics in HIV/AIDS Care
4. Principles of ARV Therapy in the Botswana National Programme
5. Pediatric-and Adolescent-Specific Issues in HIV/AIDS Care
6. Pediatric-and Adolescent-Specific Issues in HIV/AIDS Psychosocial Care
7. ARV Drug Side Effects and Toxicities
8. Drug-Drug Interactions in ARV Therapy
9. Treatment Failure and Its Management
10. Adherence in ARV Therapy
11. Adult and Pediatric Opportunistic Infections and Other Complications in HIV Disease
12. Mother-to-Child Transmission and Its Prevention
13. Post-Exposure Prophylaxis (PEP)
14. TB and HIV Co-Infection
15. Summary of the Major Changes in the 2008 Guidelines.
AIDS Clinical Care Fundamentals Refresher/Update
This two-day Refresher/Update training module was developed in response to a high demand for refresher training, as well as the need to update already trained healthcare staff on the most recent changes to the national treatment guidelines. Incorporating information from the new guidelines along with care and treatment fundamentals, the training covers HIV testing, ARV therapy eligibility, principles of ARV therapy, management of toxicities, management of treatment failure, PMTCT, and treatment of TB and other opportunistic infections.
The module was first implemented in January 2008. All efforts will be made to re-train healthcare workers as quickly as possible in order to maintain the high standard of HIV/AIDS care and treatment in Botswana.
Medication Adherence Counseling
This three-day course is designed to enhance the adherence counseling skills of healthcare workers. Offered as a centralized training for nurses, pharmacy staff, and social workers from ARV treatment centers, Medication Adherence Counseling focuses on strategies to overcome potential barriers to adherence.
A combination of lectures, case discussions, role-playing, and interactive activities are employed to reinforce good counseling techniques and strengthen the participants’ ability to devise and implement successful adherence interventions. Implemented in collaboration with the Botswana-Baylor Children’s Center of Excellence, the course also includes teaching and case discussions about pediatric and adolescent adherence, as well as disclosure of HIV status for children, adolescents, and their families.
Advanced HIV/AIDS Care and Treatment Training
This advanced training is designed for physicians and pharmacists providing ARV therapy in Botswana. Course participants must have previously completed AIDS Clinical Care Fundamentals and be actively involved in an ARV clinic.
Training participants involved in clinical case discussions with on-looking KITSO faculty
Advanced HIV/AIDS Care and Treatment combines lectures and interactive case discussions to provide advanced and comprehensive training in ARV therapy, emphasizing treatment principles and strategies practiced world-wide and applying them to the Botswana setting. This course familiarizes participants with the full complement of ARV drugs and provides strategies for the management of treatment failure, interpretation of drug resistance assays, designing of “salvage” regimens, and understanding short- and long-term ARV side effects and toxicities. Course content equips clinicians with the skills and knowledge necessary to manage complicated patients and provide guidance and support to their colleagues, thereby strengthening the growing HIV treatment expertise in Botswana’s healthcare sector.
Advanced HIV/AIDS Care and Treatment covers adult, adolescent, and pediatric HIV care. Special emphasis is placed on primary care for HIV-infected children and on disclosure issues, especially in regards to children and adolescents.
Each advanced course also provides updates on relevant research and clinical trials conducted internationally and in Botswana as well as summaries of recent international HIV/AIDS meetings.
Introduction to AIDS Clinical Care
In 2009 this satellite training module was upgraded from a one-day to a two-day training. The training provides nonmedical professionals with a basic understanding of identification and management of HIV/AIDS in Botswana.
Course content includes an introduction to HIV pathophysiology and immunology and information about testing, eligibility and referral for ARV therapy, identification of common ARV side effects, the importance of medication adherence, counseling and referral for PMTCT, and post-exposure prophylaxis. This course is suitable for general health educators, family welfare educators, and lay counselors and social workers. Since 2006, Introduction to AIDS Clinical Care has been implemented at ARV sites by the BHP–PEPFAR Master Trainer Program.
Sexual and Reproductive Health in HIV Infection
This new module provides training for health professionals providing counseling and care in sexual and reproductive health issues for persons living with HIV. The course will empower health care workers to identify and manage sexual and reproductive health issues pertaining to HIV infection, such as STIs, family planning including conception and contraception, sexual dysfunctions, menopause, pregnancy and PMTCT, and HIV prevention. Implementation of this module started 2010.
Reference Corners and Resource Materials
KITSO AIDS Training Program has established “reference corners” in the medical libraries of Botswana’s two referral hospitals, Princess Marina Hospital and Nyangabgwe Hospital. Resources in these reference corners include textbooks, medical reference guides, specialized journal subscriptions, and relevant handbooks and guidelines.
KITSO AIDS Training Program has also provided each district hospital in Botswana with a laptop computer and an LCD projector for in-service staff education.
KITSO AIDS Training Program owes its success both to ACHAP for its financial support and to the dedicated faculty members from the Botswana MOH and Ministry of Local Government, the ACHAP Clinical Preceptorship Program, Botswana-Baylor Children’s Clinical Center of Excellence, Botswana-Harvard Partnership, University of Pennsylvania, the PEPFAR Master Trainer Program, the Private Practitioner Association of Botswana, and the World Health Organization.