Abstract
HIV/AIDS affects the lives of everyone who lives in sub-Saharan Africa. In the past 3.5 years, access to free antiretroviral therapy has increased dramatically as a result of the support of the President's Emergency Plan for AIDS Relief. Health care must now include caring for those who will live with HIV/AIDS as well as those for whom HIV/AIDS is a terminal illness. This article discusses the contribution of nurse practitioners to the redesign of nurses' work with HIV1 patients in sub-Africa, especially Uganda. Strategies currently being implemented and those planned for the future to increase access to care and improve the quality of nursing care that patients receive are discussed.
Introduction
The UNAIDS/World Health Organization states that in 2006 between 21.8 and 27.7 million persons in sub-Saharan Africa were living with HIV/AIDS.[1] In addition to these staggering numbers, 14 million children younger than 15 years have lost one or both parents to HIV/AIDS.[2] This is the largest health problem in this area of the world, and large numbers of health care workers are persons infected with and affected by HIV/AIDS. In the United States, exposure of health care workers to HIV is generally through occupational exposure. In sub-Saharan Africa, the main mode of transmission of HIV is heterosexual transmission, and this is the most common exposure for health care workers also. Besides caring for upward of 100 patients per day in many outpatient clinics, nurses are concerned with accessing their own care and treatment. Although treatment is available, many nurses are reluctant to receive care in the institution in which they work because of stigma. Frequently, they are unable to get to another institution for treatment because of transportation problems or requesting released time from work to get care.
Impact of HIV/AIDS in sub-Saharan Africa
Without access to adequate care and treatment, life expectancy has decreased significantly. For example, in Botswana in 2010, the average life expectancy without AIDS was projected to be 73.2 years. Instead, with AIDS, life expectancy has decreased to 29.0 years; a loss of 44.2 years.[3] The disease trajectory in sub-Saharan Africa is also different from that in the rest of the world. In the developed world, the course of the disease in persons who do not receive treatment is 12 years from infection to death. In sub-Saharan Africa, the time frame is 5 years. Some of the difference can be explained by the virulence of the different clades (differences in genetic structure of the virus) found in sub-Saharan Africa compared with the virus clades found in the United States. The presence of comorbidities, especially tuberculosis (TB) and malaria and inadequate nutrition, also contribute to the difference in the disease trajectory. Orphaned children are also at higher risk. The usual safety net of families providing care for orphaned children has been decimated because of the high death rates of adults and the ongoing civil wars in many of the countries. The orphaned children younger than 15 years are now frequently the head of the household. They face stigma, extreme poverty, mal nutrition, impaired social and cognitive development, illiteracy, and sexual abuse.
Before the influx of monies for HIV care that began in 2003, poverty prevented most HIV-infected persons from accessing basic health care and antiretroviral (ARV) therapy. The President's Emergency Plan for AIDS Relief (PEPFAR), the Clinton Foundation, the European Union, and the individual African country governments are among the providers of ARV medications and other basic health care services. However, the needs still outweigh the resources available. Persons are at increased risk of opportunistic infections and comorbidities because of malnutrition, lack of clean water, and lack of mosquito nets. Malnutrition and infections depress immune system function. Civil wars have forced many into displaced person camps in which basic sanitation and food are not available, and the crowding further increases the risk of TB and other infections. Even when ARV therapy is available, these living conditions affect the person's response to therapy.
Involvement in Nurse Education
In 2004, I accepted a position as a nurse educator with AIDSRelief/PEPFAR. AIDSRelief is a consortium of five organizations (Institute of Human Virology of the University of Maryland, Catholic Relief Services, Interchurch Medical Assistance, Catholic Medical Mission Board, and Constella Futures) that provides ARV treatment and clinical technical assistance in nine countries. I have been involved in activating clinical sites to care for persons who will begin to receive ARV therapy; individual and group mentoring and precepting; consulting about clinic flow of patients; and developing, implementing, and evaluating a nursing curriculum. In Uganda where I am involved in teaching nurses to care for persons with HIV, AIDSRelief provides free ARV therapy and HIV care to enrolled patients at approximately 20 local partner treatment facilities. As health improves, appetite increases but many persons are unable to purchase sufficient food, so malnutrition persists and can adversely affect drug absorption, and the immune responses to therapy can be blunted.
Now that availability of free or low-cost ARV therapy and care for the average person is increasing, especially in PEPFAR sites, patients, including health care providers, need access to care and, most importantly, durable therapy for a lifetime. HIV care requires a shift in the health care system from a focus on episodic care to continuity care for all HIV-infected persons. Continuity care encompasses community care, out-patient care, and hospital care. Insufficient numbers of medical officers and clinical officers are available to provide care to all HIV-infected persons and HIV[1] patients on ARV treatment. There are few experienced ART providers in most of sub-Saharan Africa. In addition, limited evidence-based data are available for clinical decision making about HIV care in resource-limited settings.
Redesigning Nurses' Work
One proposed solution to the increasing demand for care is the shifting of HIV/AIDS care, including ART therapy, to nonphysician providers. Nonphysician providers include clinical officers whose education is similar to physician assistants and nurses. Nursing education in sub-Saharan Africa is centered in diploma schools of nursing associated with hospitals, most in rural areas. In several countries, nurses are allowed to open private practices to diagnose and prescribe for patients after having worked as a nurse or midwife for a specified number of years. In most sub-Saharan nations, the term nurse practitioner does not share a common definition with the term in other areas of the world.
Task shifting to nonphysicians will result in increased responsibilities for patient care for nurses. The use of nurses can be increased by developing and implementing critical pathways (algorithms) for clinical decision making for patient care and providing nurses with referral access to physicians with HIV expertise. In addition, the paradigm that only physicians can provide care to persons receiving ARV therapy must be changed. The purpose of this paper is to discuss the contribution of nurse practitioners to the redesign of nurses' work with HIV+ patients to increase access to care and to improve the quality of nursing care patients receive. Practitioners in general and me specifically are involved in a number of projects that will affect the redesign of nurses' work.
For the past 30 months, as part of AIDSRelief, I have traveled regularly to Uganda to assist in developing knowledge and skills for Ugandan health care providers to care for persons receiving ARV therapy. This was a major change for me because nothing in my previous career as a nurse practitioner faculty member at the University of Maryland prepared me for the sometimes risky, dangerous, but exciting settings in which I found myself. Until recently, there was war in northern Uganda where we have opened three clinics. The only way to get to two of these clinics was by air in small planes that only fly during the day, several days of the week. I had my first experience landing on a dirt runway, occasionally claimed by livestock as "their" place. One woman who lived in the area was so thrilled to have a clinic near her home because she would not have to travel over a road that was often the site of raids by the rebel forces. She was willing to make the dangerous trip monthly to get her ARV medications before the clinic opened nearer to her home.
As the senior nurse educator in a multidisciplinary team of US and Ugandan health care providers, my focus is to improve the nursing care given to HIV+ persons. My AIDSRelief nursing colleagues and I have developed a basic curriculum that will expand the nursing services provided to persons infected with HIV. The curriculum is designed to increase the nurses' knowledge and skills in multiple areas. Content includes an overview of HIV pathogenesis and transmission, prevention of mother-to-child transmission, triage, symptom evaluation and management, ARV drug therapy, drug side effects and adverse effects, common opportunistic infections, and adherence. Individual precepting to assist in integrating the newly learned knowledge and skills into practice at the clinics is an integral part of the educational process. With the overwhelming number of patients seen daily, a major focus in working with the nurses is streamlining clinic flow and integrating satellite clinics into the main clinic. In Uganda, we have taught these classes more than 20 times. Our classes are usually small and have 8 to 10 nurses. The curriculum is demanding, but the students have learned easily and accept their role expansion as a matter of fact. A few have extreme anxiety about what their new responsibilities but know that what they do may provide the only care that their villagers will receive. I remember one nurse who said, "It's too far and too expensive for them to get to the hospital so they only go when they are extremely ill. Since I am right there, they come to me first for care before they need to go to the hospital." Nursing students are also interested in increasing their HIV knowledge and skills. When the students at one nursing school learned that I was teaching basic HIV care to the hospital and clinic nursing staff, they requested that I provide the class to them also. They were preparing for national testing and gave up their only free afternoon for the class. The session was scheduled for 1 hour, and at the end of 3 hours we had to stop.
Current and Potential Nurse Practitioner Involvement
In some countries, international health care organizations have used nurse practitioners to provide direct patient care. Nurse practitioners have been visiting faculty at a number of colleges and universities, and still others are doing research with in-country colleagues to address a variety of health issues. Another area in which nurse practitioners are intimately involved in many countries is in train-the-trainer programs.
Through AIDS/Relief, we have accomplished much. However, much more needs to be accomplished. In Uganda, as in other countries, specific plans have been established for meeting the needs of patients with AIDS. Strategies have been or are being developed to do the following.
Strengthen Community Nursing Care for Patients Infected with HIV
All persons with symptoms or opportunistic infections or those receiving ARV therapy should have home visits by nurses. Patients' families must be taught how to care for patients at home. This could also include the establishment of satellite clinics for care. One aspect of community nursing is also teaching and supervising the community workers that are home care providers. Community nurses might also provide links to the traditional healers. Nurses and nurse practitioners can make several contributions to the achievement of this objective.
Care in sub-Saharan Africa has often been confined to hospitals for the more wealthy and to home care for the poor. With the illness or death of so many parents, home care services have to be redefined. In-country nurses in sub-Saharan Africa need the opportunity to increase their skills in home-based care in the areas of symptom evaluation, monitoring of patients receiving ARV therapy, and differentiating medication side effects from adverse drug reactions. Although many health facilities currently offer community or home-based care to enrolled patients, there is wide variation in the type of services offered and in the qualifications of the persons providing care. In many areas, home-based care is provided by community health volunteers who have no formal medical background. Little has been done to teach family caregivers how to care for patients in the home and when to seek care or advice from a health care provider.
The skills and appropriate approach for selecting, training, and supervising community health volunteers are integral parts of community nursing and community health. Nurses and nurse practitioners can be a resource to in-country nurses as they determine who should be a community health volunteer and what the volunteers need to know to work effectively with patients. The nursing skills combined with advanced assessment skills that are the backbone of nurse practitioner practice will be invaluable in refining and implementing training for all community health workers to increase their skills in the assessment and care of persons in their home, including the education of family caregivers. In Uganda, strengthening community nursing is a major focus for next year. We will teach community volunteers basic home care skills such as positioning, range of motion exercises, and signs and symptoms that require immediate evaluation by a health care provider. The community health volunteers will not only be able to expand their assessment skills but will also be able to teach family members how to provide care to patients at home. One of my colleagues is surveying patients, health care providers, and community health workers to determine what characteristics are necessary for community health workers. In conversations with Ugandan nurses, they are enthusiastic, overwhelmed by the idea of increased responsibility, and a little nervous about expanding their roles. In a workshop on triage, everyone was enthusiastic to learn how to examine the mouth for thrush and the lungs for abnormal breath sounds. They could not wait to incorporate these skills into home care and were wondering when the workshop leaders were coming to see them in practice, incorporating the new skills. When the question arose about diagnosing, everyone was happy to be reassured that their job was to recognize normal compared with abnormal, not to diagnose the disease.
Have Nurses Assume Primary Responsibility for Patient Triage in All Outpatient and Community Settings
The ability to extend care to more persons with HIV/AIDS requires nurses to assume increased responsibility for clinical decision making. Skills and knowledge that will enhance the nurses' decision making emphasize the development of core competencies in clinical decision making through the implementation of critical pathways for the triage of ill patients with potentially life-threatening illnesses, continuity of care, and symptom evaluation. Importantly, education should focus also on health system strengthening through the management, administration, and supervision of outpatient HIV care clinics. Nurse practitioners are ideally suited to assist nurses in developing and refining triage skills. Pertinent history taking, focused assessment, appropriate referral, integral to nurse practitioner practice, are skills that nurse practitioners can teach nurses involved in HIV care. Triage is one of the two areas in which I now expend most of my teaching efforts. Community nurses have basic patient triage skills, and we are emphasizing symptom evaluation and management. In clinics, nurses take vital signs and a short history, but they are not secure in making the decision about who should see the medical officer that day and who can wait. Often, everyone is referred to the medical officer even when it is the end of the day and the patient could easily be seen another day. In one of the clinics I frequently visit, I think the word is out that, when the mazunga (white person) is at the triage desk late in the day, patients had better be sick to be seen or they will be told to come back in the next day or two to be seen by the medical officer (Figure 1). Clinic nurses are a little concerned about support for the increased role in triage from the medical community. They feel that their decisions may not be supported or that they do not have the authority to make triage decisions when in the clinic. In many countries, nurses are not viewed as independent decision makers about patient care.
 | Figure 1. A typical clinic waiting area in Uganda |
Figure 1.
A typical clinic waiting area in Uganda
Establish Nurse-Run Clinics in Which the Nurses Will Provide Care to Patients Across the Spectrum of Hiv
Tasks include the following:
- Diagnose and manage common opportunistic infections
- Assess and manage common signs and symptoms in HIV-infected patients
- Provide community nursing for enrolled patients
- Refer patients for palliative care
- Provide palliative care
- Initiate ARV therapy that follows established protocols
- Follow patients on ARV therapy
- Change ARV therapy according to established protocols
- Recognize appropriate referral limits
- Refer patients to the medical officer or clinical officer as appropriate
In Uganda, as well as in other countries, the establishment of nurse-run clinics is somewhat controversial, although community nurses routinely perform many of the functions listed above. The redesign of nursing roles and responsibilities to more effectively care for patients with HIV/AIDS requires a different level of authority, responsibility, and accountability. The clinical knowledge base and skill set for increased clinical decision making should be designed to develop clinical expertise to increase clinical judgment skills, appropriate triage skills, skills to maximize adherence, and supervision of community health workers. Algorithms can be used as guidelines for decision making with a variety of patient problems. Nurse practice acts in sub-Saharan African countries do not explicitly recognize the nurse practitioner role as it is conceptualized in the United States and other countries. In many countries midwives and nurses who have been in practice for a specified number of years are allowed to open a private clinic with physician referral. Additional education is not required. Work needs to be done to assist the nursing councils in various countries to revise the nurse practice acts to allow for role expansion. The need to provide patient care to the ever-increasing numbers of HIV-infected persons will overwhelm the traditional barriers to enhancing nursing tasks. In many health care delivery systems support seems to be growing to expand the nurses' responsibilities for more independent clinical decision making about patients.
The knowledge base and skill set needed to enhance nursing tasks can be facilitated by nurse practitioners. Nurse practitioners, nurse educators, and other nurses with HIV expertise are part of AIDSRelief. These professionals participate in developing, implementing, and evaluating algorithms; teach formal classes using the developed curriculum modules; provide individual and group precepting and mentoring; and regularly schedule continuing nursing education that reinforces selected information or skills and provides the nurse with updated information and skills. Within a few months we will have a model health care clinic where nurses and other health care providers will have the opportunity to develop their skills in an interdisciplinary setting, practice with experts, and transfer their learning to providing improved health care in their clinical setting.
The nurses' expanded skill set and knowledge base must incorporate information for both clinical and health services administration. The health services administration information will prepare the nurses to develop, implement, and evaluate the nursing roles and responsibilities in the institutional plan for delivering HIV care in that institution. They must also be prepared to design, implement, and evaluate clinic structure and flow for continuity care. The shift from episodic to continuity care is crucial to the successful therapy of patients with HIV/AIDS. The nursing staff must be full, contributing members of the health care team. Health services administration information is a difficult area to address because of the tradition of top-down decision making. To assist in the identification of real or potential bottlenecks for patients during their clinic visit, I often accompany a patient or two for their entire visit.
Implementing increased clinical decision-making and health services administration skills can be achieved in resource-limited settings with a variety of approaches. Perhaps the most useful model to be used in the future will be intensive training sessions provided by nurse practitioners in specific geographic regions of each country. The purpose of these workshops would be to provide nurses with the basic knowledge and skills to assume expanded responsibilities for patient care and additional responsibility for clinic management and flow. The intensive workshop must be followed with individual mentoring or precepting sessions at the district health facility. The mentoring would best be done by nurse experts in clinical care and experts in health systems management.
Individual nurses who will be starting ARV therapy for patients require additional education for this task. Nurse practitioners would be responsible for intensive education to assist the "prescribing" nurses to develop in-depth knowledge about the criteria for starting ARV therapy, first- and second-line therapies, when to change therapy, and when to stop therapy. Clear lines of communication and referral to physicians must be established before the nurse moves to this level of responsibility. Evaluation of performance must be done at least monthly for several months. At the present time, there is little communication and articulation of nursing care with other providers. In AIDSRelief we have a strong commitment to interdisciplinary patient care. However, as the nurse expert, I have complete autonomy in determining the curriculum and teaching methodologies for the nurses. To assist the Ugandan nurses and physicians in working together, our interdisciplinary team uses every opportunity presented to demonstrate how to work, learn, and deliver care together. Many nurses are still seen and see themselves as subservient to physicians, clinical officers, and other providers. This may negatively affect their ability to work in a collegial role with physicians or to assume increased autonomy for nursing care.
Sustainability Strategies
As I write this article, we are in the process of opening two model clinics in Kampala and Jinja, Uganda, that will be used as teaching clinics for all health care providers. This gives us the opportunity to role model interdisciplinary patient care, clinical decision making, triage, assessment skills, community nursing, and more independent practice of Ugandan nurses.
The overriding goal of assisting the nurses to redesign their work is to develop sustainable programs that will prepare in-country nurses to provide the technical assistance necessary to continue advances in nursing roles and responsibilities. One approach under discussion is developing train-the-trainer programs. Nurse practitioner educators would be valuable in developing and implementing a train-the-trainer approach. In-country nurses with significant HIV experience and knowledge should be identified to participate in this program. The purpose of the program is to provide nurse trainers with instructional strategies and skills to use in educating other nurses for entry-level practice with HIV-infected patients in resource-limited settings.
Personal Reflections
Overall, my experience has been positive. Although we are headquartered in Kampala, the capital city, most of our time is spent in the rural areas. We generally are away for 1 or 2 weeks at a time. The accommodations range from shared rooms in hospital guesthouses to modest hotels (Figure 2). I had to learn to live without hot water and electricity, be meticulous in my handwashing, drink only boiled water, sleep under a mosquito net, do without salads, take my malaria prophylaxis, and use primitive toilet facilities. I have learned to appreciate the local foods, especially matoke served with a nut sauce.
 | Figure 2. Guest house room |
Figure 2.
Guest house room
We have several clinics in northern Uganda. This area of the country has been the site of a long civil war. Although I never felt concerned about my physical security or safety, some of the memories will stay with me forever. In the evening when we would be walking into town for dinner, hundreds of children, called the night visitors, would be walking in the opposite direction, to the safety of the hospital compound to avoid kidnapping by the rebel forces. We often found one or two sleeping on our guesthouse porch. We encountered several women who had their ears and lips cut off by the rebels to prevent them from hearing or sharing information. Many live in abject poverty, totally dependent on charitable organizations for all basic necessities, but their spirit remains unbroken. With the peace talks slowly moving forward, some are choosing to return to their original villages and farms. However, each day I know that I have made a difference to someone.
Other areas, not involved in civil war, also contributed many unforgettable memories. In the villages, I saw small farms growing coffee, tea, vanilla, sugar cane, and papyrus. I had the opportunity to see children learning their tribal dances and playing soccer. I have seen Lake Victoria, elephants up close and personal, zebras, hippopotamuses, and birds of spectacular colors. The best memories are the people I have met and those with whom I have worked.
How to Get Involved
If any nurse practitioner wants to get involved in opportunities such as this, I would suggest contacting the nongovernmental organizations that provide health care. You could also be the nurse for a group coming on a mission to build schools or orphanages or to do other charitable work. If you are a faculty member, some schools are interested in faculty exchange programs. Depending on the length of time you would be spending in a country, you might need a work permit or nursing registration.
In summary, the needs are many and the rewards are tremendous. Nurse practitioners are in a position to make unique contributions to improve the care of HIV− patients receive in resource-limited settings.
Source : http://www.medscape.com/viewarticle/569057
