Addressing the educational void during the antiretroviral therapy rollout

There are 40 million HIV-infected individuals globally [1], the majority of whom live in developing countries where, until recently, antiretroviral therapy (ART) was not available. With the global push to improve access to drugs in the developing world, ART is becoming a reality. The current challenge becomes how to deliver ART effectively because misuse will have drastic consequences. The Moi University Faculty of Health Sciences (MUFHS) is one of two medical schools in Kenya (population of 32 million; estimated HIV prevalence rate 15%) [2]. MUFHS has, since its inception, been partnered with US institutions (Indiana University School of Medicine and, later, Brown Medical School) to foster collaborative medical exchange programmes. The collaboration responded to the HIV epidemic with the formation of the Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH). Using the AMPATH blueprint, MUFHS opened its first HIV treatment clinic with philanthropic donations in December 2001, with a modest goal to treat 50 patients. From this beginning, additional programmes developed: three HIV clinics at affiliated rural health centers, a core laboratory (capable of measuring CD4 cell counts and viral loads), a prevention of mother-to-child transmission programme leading to a mother-to-child transmission-plus grant (Mailman School of Public Health, Columbia University). Currently, over 2000 patients receive care at AMPATH HIV clinics; 50% are on ART. The MUFHS faculty recognized early that personnel represented a critical component of the infrastructure. However, few if any Kenyan healthcare providers had any background knowledge, experience, or training in HIV care. At the opening of the HIV clinic, Kenyan providers were mentored by US collaborators. US collaborators offered expertise in the use of ART; the Kenyan faculty provided expertise in local resource management. Together they developed protocols on the best use of ART and the treatment of opportunistic infections in this resource-poor setting. Knowledge was forged to ensure that scarce resources were not squandered and patients were not lost through missed opportunities. The current challenge is to disseminate their knowledge rapidly and effectively as demands for HIV care increases. Experience at MUFHS HIV clinics demonstrated that one clinical officer with physician supervision could see 30 HIV patients per day, 150 visits per week, a total of 7000 visits per year. MUFHS serves a catchment area of 13 million individuals (Fig. 1). Applying a local HIV prevalence of 15%, 980 000 HIV-infected individuals currently require care. Conservatively, 15% of these patients have a CD4 cell count less than 200 (CD4% < 15) or an opportunistic infection. These patients require at least 12 visits per year, either to monitor ART adherence/side-effects or to monitor and treat for opportunistic infections in patients without ART access. The 85% of HIV infected patients with CD4 cell counts greater than 200 (CD4% > 15) will require four visits per year to monitor general health and immune function. A total of 5.2 million visits per year will be needed to provide this routine care. Using these estimates, MUFHS today requires 730 clinicians trained in HIV clinical care to serve their catchment area. This calculation is not inclusive of the nurses, pharmacists, nutritionists and outreach workers required to provide appropriate multidisciplinary HIV care.Fig. 1.: Projection for HIV care visits in western Kenya.In response to this educational void, the AMPATH: HIV Clinical Care Training Programme was created. This programme consists of two modules: a didactic training programme covering issues such as HIV pathogenesis, diagnosis, laboratory monitoring, the pharmacology of ART, the prevention/treatment of opportunistic infections, tuberculosis, pediatric HIV care, and psychosocial wellbeing. Part two is a mentored internship in the HIV clinics of the AMPATH programme. The first training programme, held in September 2003, trained 30 30 healthcare workers (physicians, clinical officers, nurses, nutritionists, outreach workers and pharmacists). Subsequently, four additional courses have occurred, with plans to scale up the training programmes at the request of the Kenyan National AIDS and STI Control Programme. This programme is described as a model. A critical, early component of ART programmes must be the training of healthcare professionals to supply quality care in resource-limited settings. Without this, the expected outcome will be inappropriate drug prescribing patterns, the inadequate evaluation of adherence, missed opportunities to prevent opportunistic infections, and missed opportunities for HIV prevention. Poor education of service delivery personnel will directly result in the development of drug resistance, the loss of patient lives, and ongoing transmission. The delivery of ART drugs cannot occur in an educational void. The faculty of MUFHS urges that an educational training assessment be an early priority in areas in which ART delivery is occurring. The consequences of ignoring this educational void may be too devastating to overcome.