Training and HIV-Treatment Scale-Up: Establishing an Implementation Research Agenda

Abstract

The provision of HIV treatment and care in resource-limited settings is expanding rapidly. Health-worker training is one of many factors critical to the rapid scale-up of high-quality care [ 1–6]. Large numbers of health workers require HIV training; yet, few countries have a comprehensive training plan, a clear assessment of ongoing training needs, a plan to operationalize training on a large scale, or adequate funds budgeted for training. In this setting, an extensive variety of HIV-related training programs have sprung up over the past few years. Unfortunately, there are limited data measuring their effectiveness, and there is no consensus about what constitutes effective training. Underlying the looming challenge in health-worker training, most resource-limited countries face a chronic shortage of trained health-care providers; chronic understaffing impedes the ability to adequately train health workers in HIV care. First, removing clinicians and nurses from active clinics for training purposes intensifies the strain on clinical care systems. Second, professional programs for physicians and other health workers are commonly lacking. For example, several countries in Africa and the Caribbean—including Botswana, Lesotho, and the Bahamas—do not have medical schools, and must send students outside of the country for basic professional training (see http://imed.ecfmg.org/main.asp; Table 1). Finally, trained workers (and potential recruits) commonly leave the public health sector for better compensation, benefits, working conditions, and job satisfaction found in other sectors and other countries—the “brain drain” phenomenon—further exacerbating the human resource crisis [ 7–12]. Table 1 Medical Schools in Selected Countries Faced with these challenges, and with the rapid pace of HIV-treatment expansion, few resource-limited countries have sufficient internal resources to address their training needs. As a result, most countries have collaborated with external partners to develop health-care-worker training programs, and/or to bring in expatriate specialists to provide training, at least in the initial phase of scale-up. Often, these training efforts are poorly coordinated with national training priorities, lack evidence to support their effectiveness, and are driven largely by foreign partners. As a result, many training redundancies exist alongside large, unmet training needs. We gathered information on global HIV training through a thorough review of the published peer-reviewed literature, internet sites, program reports related to training for HIV treatment in resource-limited countries, a survey of HIV training efforts in high-burden countries, and discussions with appropriate professionals in selected countries. Here, we review challenges and approaches to clinical HIV training, and suggest an agenda for implementation research—defined here as research into how proven interventions can be implemented to accelerate high-quality HIV-treatment scale-up—to address the question: what is the optimal approach to training the health workforce for an expanding HIV-treatment program in a resource-limited setting?