Nurse-initiated Management Of Antiretroviral Therapy Research Articles

A Conceptual Model to Strengthen Integrated Management of HIV and NCDs among NIMART-Trained Nurses in Limpopo Province, South Africa

Integrated management of human immune deficiency virus (HIV) and non-communicable diseases (NCDs) in primary health care facilities remains a challenge. Despite research that has been conducted in South Africa, it is evident that in Limpopo Province there are slits in the implementation thereof. There is a need to develop a conceptual model to guide in strengthening the clinical competence of nurse-initiated management of antiretroviral therapy (NIMART)-trained nurses to implement the integrated management of HIV and NCDs to improve clinical outcomes of patients with the dual burden of diseases in Limpopo Province, South Africa. This study aimed to develop a conceptual model to strengthen the implementation of integrated management of HIV and NCDs amongst NIMART nurses to improve clinical outcomes of patients with the dual burden of communicable and non-communicable diseases in Limpopo Province, South Africa. An explanatory, sequential, mixed-methods research design was followed. Data were collected from patient records and the skills audit of 25 Primary Health Care (PHC) facilities and from 28 NIMART trained nurses. Donabedian's structure process outcome model and Miller's pyramid of clinical competence provided a foundation in the development of the conceptual model. The study revealed a need to develop a conceptual model to strengthen the implementation of integrated HIV and NCDs implementation in PHC, as evidenced by differences in the management of HIV and NCDs. Conclusion: The study findings were conceptualised to describe and develop a model needed to strengthen the implementation of integrated management of HIV and NCDs amongst NIMART nurses working in PHC facilities. The study was limited to Limpopo Province; the model must be implemented in conjunction with the available frameworks to achieve better clinical outcomes.

The effects of antiretroviral stockout on primary health care nurses in the Ethekwini and Ilembe districts, KwaZulu-Natal

Background: Nurses face challenges of antiretroviral therapy (ART) stock out when rolling out, leading to drug resistance, poor compliance and decreased viral suppression. Poor viral suppression leads to higher morbidity and mortality rates, hence a need to strengthen supply chain principles in order to achieve equal distribution of resources amongst clinics. Nurses also need to have relevant guidelines available to prevent treatment failure. The study aimed to describe the effects of ART stockouts on primary health nurses rolling out ART in clinics in KwaZulu Natal. Methods: The study followed a qualitative approach, using a descriptive design. Two primary healthcare clinics in Ilembe and Ethekwini districts were selected for the study. The population comprised of 8 purposively selected participants. In-depth interviews and focus groups were conducted to describe the experiences of primary health care nurses rolling out antiretroviral therapy regarding stockout and how it was managed. Data collection and analysis followed Yates, Partridge and Bruce steps. Ethics and trustworthiness were maintained. Results: The singular theme of inconsistent availability of treatment emerged, as well as sub-themes of means used to manage treatment stockout and supply change management issues. Conclusions: An adequate supply of ART through an efficient supply chain management strategy, ongoing training in primary health care and nurse-initiated management of antiretroviral therapy and the availability of treatment guidelines should be enforced.

An Integrated Reporting Tool for Management of Hiv And Non-communicable Diseases for Primary Health Care Facilities in Limpopo Province, South Africa

Introduction:Reporting of a health programme such as integrated management of the Human Immunodeficiency Virus (HIV) and Non-communicable Diseases (NCDs) is essential for programme evaluation to improve patient clinical outcomes. It is a criterion that all services that are provided in primary health care facilities and hospitals are monitored, evaluated and reported according to the approved reporting tools and approved health indicators.Aim:This study aimed to develop a reporting tool to report the implementation of integrated management of HIV and NCDs in Limpopo Province, South Africa.Methodology:The South African National Indicators Data Sets (NIDS) were adopted and used to develop the integrated management of HIV and NCDs reporting tool. A Delphi technique was used to validate the developed reporting tool. Eight (8) HIV and NCDs programme experts participated in the review process to establish the validity of the developed tool.Results:Eight integrated HIV and NCDs data elements reporting tool were developed and reviewed by eight (8) programme experts. The tool was found to be relevant and useful and likely to be adopted by Limpopo province for implementation.Conclusion:This was the first integrated HIV and NCDs reporting tool to be developed for Nurse Initiated Management of Antiretroviral Therapy (NIMART) Nurses in Limpopo Province to serve as a basic reporting tool to improve the integrated management of HIV and NCDs including patient outcomes.

1644. “And the stick to fight TB is IPT”: Perspectives on TPT Implementation Among Senior Nurses in Rural South Africa

BackgroundTuberculosis (TB) disproportionately affects people living with HIV (PLH). The World Health Organization (WHO) has endorsed tuberculosis preventative therapy (TPT) in resource-limited settings with high HIV and TB burdens. South Africa has led global TPT efforts, yet implementation remains sub-optimal.MethodsIn a rural, impoverished region of South Africa with high TB and HIV prevalence, primary care clinic-based senior nurses were asked to participate in anonymous, semi-structured interviews assessing TPT knowledge, beliefs, and attitudes. The currently available regimen is isoniazid preventive therapy (IPT) for 12 months. Through an iterative process, a code list was generated and applied to each transcript. The data were analyzed using thematic analysis and Nvivo 12 software to identify facilitators and barriers to IPT prescribing.ResultsAmong 22 nurses at 14 primary health clinics, 86% were female, median age 39 (IQR 31-54.8) years, with median 10.5 (IQR3-18) years of health care experience. Nurses felt that TPT was effective at preventing TB. Barriers to implementation included limited time to counsel patients due to understaffing in high-volume clinics and lack of documentation of IPT prescription in patients’ charts, which limited effective follow-up. Nurses certified in Nurse-Initiated Management of Antiretroviral Therapy (NIMART) expressed confidence in their IPT knowledge, but those not certified wanted additional training. Nurses identified patient-level factors impeding TPT implementation, including transportation, HIV-related stigma, mobility, particularly among men, and pill burden associated with length of IPT (12 months) with concurrent daily chronic medications. Facilitators included availability of IPT in both hospitals and primary care clinics, and capacity for task-shifting to other healthcare professionals (counselors, staff nurses). The impending rollout of 3HP (12 weeks of isoniazid-rifapentine) was viewed favorably.ConclusionNurses identified limited time to counsel PLH and lack of standardized training programs as the main barriers to implementation of TB preventative therapy. Addressing these barriers will be critical to successful implementation of new TPT regimens.Disclosures All Authors: No reported disclosures

Factors facilitating trained NIMART nurses\u2019 adherence to treatment guidelines: a vital matter in the management of TB/HIV treatment in South Africa

BackgroundGlobally, the burden of tuberculosis or human immunodeficiency virus (TB/HIV) is at 24% and this alarming rate compelled the World Health Organization (WHO) to declare the African region as a critical workforce shortage area. To facilitate adherence to treatment guidelines, WHO recommended a strategy of task shifting for countries with high health workforce shortages. The strategy aimed at the redistribution of health care tasks to available workers. The study aimed to determine the factors facilitating nurse-initiated management of antiretroviral therapy (NIMART) trained nurses’ adherence to TB/HIV treatment guidelines.MethodsThe study employed an exploratory-descriptive design. The study was conducted in Ugu and Ngaka Modiri Molema Districts of KwaZulu-Natal (KZN) and North West (NW) Provinces of South Africa. The population comprised of 24 participants who were purposively selected. The in-depth focus group discussions were conducted and ATLAS T.I. was used for data analysis following the basic steps of notice-collect-think (NCT) analysis. Trustworthiness and adherence to ethics were ensured.ResultsThe singular theme of factors facilitating NIMART trained nurses’ adherence to treatment guidelines which included positive attitudinal needs and positive behavioural change emerged from raw data.ConclusionContinuous training, support supervision, and improved relationships with colleagues need to be enhanced to enable NIMART trained nurses to adhere to treatment guidelines.

Challenges influencing nurse-initiated management of antiretroviral therapy training and implementation in Ngaka Modiri Molema district, North West province.

BackgroundThe increasing number of people testing human immunodeficiency virus positive and who demand antiretroviral therapy (ART) prompted the Department of Health to adopt World Health Organization’s task shifting where professional nurses (PNs) initiate ART rather than doctors. This resulted in decentralisation of services to primary healthcare (PHC), generating a need to capacitate PNs on nurse-initiated-management of ART (NIMART). The impact of NIMART was assessed and even though there was an increased number of patients on ART, the quality of care is of serious concern.AimThe aim of this study was to explore and describe the challenges influencing NIMART training and implementation amongst PNs and programme managers.SettingThe study was conducted from the PHC facilities, in the rural districts of the North West province.MethodsAn exploratory programme evaluation and contextual research design was used in the study. Purposive sampling was used. Focus group discussion (n = 28) and individual interviews were used to collect data. Data was analysed using ATLAS.ti software.ResultsThe results revealed two themes: inadequacy in NIMART training and the healthcare system challenges that influence NIMART training and implementation. Theme 1 included among others the lack of standardised curriculum and model or conceptual framework to strengthen NIMART training. And theme 2 included patient and district healthcare structural system.ConclusionThere a need to improve NIMART training and implementation through the standardisation of NIMART curriculum, introduction of pre-service NIMART training in institutions of higher learning, addressing staff shortages and negative attitude of PNs providing ART.

Conceptual framework for strengthening nurse-initiated management of antiretroviral therapy training and implementation in North West province.

BackgroundThe implementation of nurse-initiated management of antiretroviral therapy (NIMART) management training is a challenge in the primary health care (PHC). It is evident from the literature reviewed and the data obtained from the North West province that gaps still exist. There is no conceptual framework providing guidance to NIMART training and implementation.AimTherefore, the aim of this study was to develop a conceptual framework to strengthen NIMART training and implementation in the North West province to improve patients and human immunodeficiency virus (HIV) programme outcomes.SettingThe study was conducted in the North West Province, South Africa.MethodsA pragmatic, explanatory, sequential, mixed-methods research design was followed. A descriptive and explorative programme evaluation design was used. Data were collected from two sources: antiretroviral therapy (ART) statistics from District Health Information System (DHIS) & Tier.net of 10 PHC facilities to evaluate and determine the impact of NIMART on the HIV programme and five focus group discussions conducted amongst 28 NIMART nurses and three HIV programme managers to describe challenges influencing NIMART training and implementation.ResultsThe study revealed that there was low ART initiation compared to the number of clients who tested HIV-positive. There was poor monitoring of patients on ART, which was evident in the low viral load collection and suppression, high loss to follow-up and deaths related to HIV. Challenges exist and this was confirmed by the qualitative findings, including human resource ratios, training and mentoring and the entire absence of a conceptual framework or model that guides training and implementation.ConclusionThe study findings were conceptualised to describe and develop a framework needed to facilitate and influence NIMART training and implementation to improve the HIV programme and patient outcomes. Dickoff, James and Wiedenbach’s practice-oriented theory and Donabedian’s structure process outcomes model provided a starting point in the ultimate development of the framework. Although the study was limited to the North West province’s PHC clinics and community health centres and did not include hospitals, it is of high significance as there is no such conceptual framework in the province or in even South Africa.

Barriers to tuberculosis and human immunodeficiency virus treatment guidelines adherence among nurses initiating and managing anti-retroviral therapy in KwaZulu-Natal and North West provinces.

BackgroundNurses, as front-line care providers in the South Africa’s health care system, are called upon to deliver integrated interventions for tuberculosis and human immunodeficiency virus (TB and HIV) including nurse-initiated management of anti-retroviral therapy (NIMART) and anti-TB treatment. Adherence to treatment guidelines and factors associated with non-adherence to treatment guidelines among nurses remain under explored.PurposeTo explore and describe barriers to treatment guidelines adherence among nurses initiating and managing anti-retroviral therapy and anti-TB treatment in KwaZulu-Natal and North West provinces.DesignThis study employed a qualitative exploratory descriptive design.MethodsFour semi-structured focus group interviews were conducted during 2014 each consisting of four to eight NIMART trained nurses. Audiotaped interviews were transcribed verbatim and analysed using Atlas T.I. software.FindingsDuring data analysis, two themes emerged: (1) NIMART trained nurses’ distress about TB and HIV guidelines adherence that is inclusive of lack of agreement with guidelines, poor motivation to implement guidelines, poor clinical support and supervision, resistance to change, insufficient knowledge or lack of awareness and (2) exterior factors inhibiting nurses’ adherence to treatment guidelines which incorporated organisational factors, guidelines-related factors and patient-related factors.ConclusionThis qualitative study identified that nurses have substantial concerns over guideline adherence. If NIMART trained nurses’ barriers inhibiting adherence to treatment guidelines cannot be remedied, patient outcomes may suffer and South Africa will struggle to meet the 90-90-90 targets.

Upskilling nursing students and nurse practitioners to initiate and manage patients on ART: An outcome evaluation of the UKZN NIMART course

Background. Currently, there is a need in South Africa to implement strategies to upskill nurses in the clinical management of HIV and AIDS, for effective and efficient management of people living with HIV. One such strategy is the nurse-initiated management of antiretroviral therapy (NIMART) course. Objectives. To evaluate the effectiveness of the NIMART course in increasing the knowledge of trainees in select clinical competencies, to assess whether perceived knowledge gain varied according to individual-level characteristics of trainees, and to determine trainee perceptions of the value and delivery of the course. Methods . A 5-day training course focusing on various areas of HIV was developed and delivered by experts in the field of HIV to multiple cohorts of fourth-year nursing students at the University of KwaZulu-Natal, and to post-basic nursing practitioners, over a 5-year period. A single-group pre- and post-quasi-experimental design was used to assess knowledge change and perceptions about the course among 1 369 trainees who had benefitted from the course during the implementation period. Results. Post-workshop test scores were significantly higher than pre-workshop scores ( p <0.0001), based on both pooled and cohort-specific data. For pooled analysis, the pre-test median score was 67% (interquartile range (IQR) = 60% - 73%) and the post-test median score was 77% (IQR = 70% - 80%), with p <0.0001. The knowledge gain was the highest in respect of HIV prevention, followed by prevention of mother-to-child transmission, then HIV treatment and lastly, general knowledge of HIV. The vast majority were very satisfied with the content of the training, although 31.3% strongly disagreed that they were ready to apply the knowledge they had learned in their workplace. Conclusion. The training was generally well received, and improved the knowledge of participants in HIV and its management. However, this outcome represents short-term benefits of the programme, and there is a need for on-the-job mentorship and support in order to maximise on clinical outcomes related to HIV.

Timing of antenatal care and ART initiation in HIV-infected pregnant women before and after introduction of NIMART

In this review of routinely collected data from five community health centres in the Johannesburg Health District, we assess timing of antenatal care and antiretroviral therapy (ART) initiation in HIV-infected pregnant women before and after the introduction of nurse-initiated management of ART in antenatal clinics. There are important lessons to be learnt as we reflect on the South African prevention of mother-to-child transmission of HIV programme.

Timing of antenatal care and ART initiation in HIV-infected pregnant women before and after introduction of NIMART

In this review of routinely collected data from five community health centres in the Johannesburg Health District, we assess timing of antenatal care and antiretroviral therapy (ART) initiation in HIV-infected pregnant women before and after the introduction of nurse-initiated management of ART in antenatal clinics. There are important lessons to be learnt as we reflect on the South African prevention of mother-to-child transmission of HIV programme.

Analysis of queries from nurses to the South African National HIV &amp; TB Health Care Worker Hotline

Background. Since 2008, the Medicines Information Centre (MIC) has run the South African National HIV &amp; TB Health Care Worker Hotline which provides free information on patient treatment to all healthcare workers in South Africa. With the introduction of nurse-initiated management of antiretroviral therapy (NIMART) in the public sector, the need for easy access to HIV and tuberculosis (TB) information has increased, especially among nurses. The hotline aims to provide this, most importantly to nurses in rural areas, where clinical staff often have little access to peer review.Objective. To describe the queries received from nurses by the hotline between 1 March and 31 May 2012 and identify problem areas and knowledge gaps where nurses may require further training.Methods. All queries received from nurses during the study period were analysed. An experienced information pharmacist reviewed all queries to identify knowledge gaps.Results. During the study period, the hotline received a total of 1 479 HIV- and TB-related queries from healthcare workers. Of these, 386 were received from nurses, of which 254 (66%) were NIMART-trained. The most common query subtopic was initiating antiretroviral therapy (ART) (20%), followed by adverse drug reactions (18%). The most common knowledge gap identified was the ability to interpret laboratory results before initiating ART (10%).Discussion. We conclude that the hotline is providing clinical help to an increasing number of nurses on the topic of treating HIV and TB throughout South Africa. In addition, queries directed to the hotline may assist in identifying knowledge gaps for the further training of nurses.

Analysis of queries from nurses to the South African National HIV &amp; TB Health Care Worker Hotline

Background. Since 2008, the Medicines Information Centre (MIC) has run the South African National HIV &amp; TB Health Care Worker Hotline which provides free information on patient treatment to all healthcare workers in South Africa. With the introduction of nurse-initiated management of antiretroviral therapy (NIMART) in the public sector, the need for easy access to HIV and tuberculosis (TB) information has increased, especially among nurses. The hotline aims to provide this, most importantly to nurses in rural areas, where clinical staff often have little access to peer review. Objective. To describe the queries received from nurses by the hotline between 1 March and 31 May 2012 and identify problem areas and knowledge gaps where nurses may require further training. Methods. All queries received from nurses during the study period were analysed. An experienced information pharmacist reviewed all queries to identify knowledge gaps. Results. During the study period, the hotline received a total of 1 479 HIV- and TB-related queries from healthcare workers. Of these, 386 were received from nurses, of which 254 (66%) were NIMART-trained. The most common query subtopic was initiating antiretroviral therapy (ART) (20%), followed by adverse drug reactions (18%). The most common knowledge gap identified was the ability to interpret laboratory results before initiating ART (10%). Discussion. We conclude that the hotline is providing clinical help to an increasing number of nurses on the topic of treating HIV and TB throughout South Africa. In addition, queries directed to the hotline may assist in identifying knowledge gaps for the further training of nurses.