Nurse Initiated HIV/MDR-TB Management in KwaZulu Natal, South Africa
Durban, South Africa
Although curable, TB remains the leading causes of mortality among HIV infected persons in South Africa where the population prevalence of TB/HIV co-infection is greater than any other country in the world. These epidemiologic facts, coupled with the recent World Health Organization (WHO) guideline to expand access to antiretroviral therapy (ART) to anyone with a CD4 count below 350mg/dL will greatly increase the need for nurses and other healthcare workers who are competent to provide integrated TB/HIV care. The most recent South African Antiretroviral Treatment Guidelines, approved in February 2010, call for the immediate integration of TB/HIV care while simultaneously supporting increased nurse-initiation of ART and TB co-management. This means that nurses will begin bearing the brunt of TB/HIV integration within the next 12 months as this care is shifted from specialty practices and hospital settings into primary health centers (PHC). Limitations in the number of trained healthcare providers who can manage the complexities of integrated TB/HIV care impede care delivery and result in unnecessary morbidity and mortality. Physician-based care models are often impractical in many remote and increasingly underserved communities necessitating alternative practice models including nurse-initiated and managed care. Clinical cohort studies have demonstrated successful nurse-initiation and management of anti-retroviral therapy (NIM-ART) as well as TB in the region and in South Africa. Outcome data on nurse management of TB and HIV has demonstrated that such programs increase access to care and that a guideline-based approach leads to safe and effective care management (7,8). Further, advocacy groups, such as the Treatment Action Campaign (TAC) in South Africa, have called for increased participation of the government in task shifting projects (http://www.tac.org.za/community/node/2529) that improve access to care. Presently, there is little data available to describe the management of TB/HIV co-infected patients by nurse providers and there are no studies available that determine the ability of these clinicians to manage patients multi-drug resistant (MDR) TB and HIV disease. The complexities associated with such care require skilled clinicians with excellent knowledge and understanding of both disease processes as well as the pharmacologic interactions associated with management. Our first study in the overall program of research entitled, “Coordinated TB/HIV Treatment Initiation: Nurses for Effective Concurrent Therapy (Co-INFECT)” Study Group, will implement and evaluate a 6 month training program for nurses to provide inpatient (intensive phase) and outpatient (continuation phase) management of MDR-TB patients. The study will use a guideline-based approach to facilitate the treatment and management of MDR-TB by Primary Healthcare Certified (PHC) nurses at Thulasizwe Hospital and surrounding primary health centers. Certified PHC nurses are clinicians who have already met province specific guidelines for the diagnosis and treatment of basic primary healthcare needs. Our team has chosen this site due to the lack of consistent physician/medical officer coverage, the substantial distance to the MDR-TB referral site as well as the 3 to 6 week waiting period to obtain an inpatient bed at the referral hospital. As a comparison, we will enroll patients at Murchison and Fort Grey Hospitals (no intervention sites). This facility is the “standard of care” with consistent medical officer coverage. Both sites have similar HIV co-infection rates as well as MDR-TB treatment outcomes. We will monitor all clinical and research parameters at both facilities. To accomplish this study, we have created a team of co-investigators with expertise in nurse management of HIV, experts in TB and HIV disease, as well as persons with a long-standing history of international HIV and TB training for nurses. Our collaborators have ongoing clinic programs providing ART therapy in both urban and rural sites. To that end, we have developed the following Aims:
Aim 1: To complete and evaluate a 3 day intensive short course on nursing MDR-TB symptom management for PHC nurses in the Zululand district of rural Kwa Zulu Natal (KZN), South Africa.
Aim 2: To describe the symptom spectrum in inpatients and outpatients initiated on MDR-TB treatment with and without HIV treatment
Aim 3: To describe patient outcomes of a PHC nurse-drive symptom managemen
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