ICAP News - September 2008

Implementation of Multi-drug PMTCT Regimen Focuses on Building Nurses’ Capacity in South Africa
In support of South Africa’s national strategic plan to reduce mother-to-child transmission of HIV by 2011, ICAP has been working intensively with the Eastern Cape Department of Health and sites in the Port Elizabeth, Eastern Cape and Quakeni Regions to implement the multi-drug antiretroviral (ART) regimen for prevention of mother-to-child transmission (PMTCT) of HIV. A focus of these activities has been on building the capacity of nurses to prescribe ART for PMTCT, a specialized activity that previously only doctors were allowed to perform.

As part of the plans for implementing the more complex PMTCT regimens, ICAP supported its partners in the development of a user-friendly PMTCT training manual and conduct of training workshops for nurses and other providers. ICAP also provided assistance to sites in assessing their readiness for implementing the multi-drug PMTCT regimen, including ensuring adequate supplies of two key drugs, AZT and nevirapine.

Central to the successful implementation of the multi-drug regimen have been ICAP-supported nurse mentors, who have completed training programs in mentorship skills and as advanced practitioners in HIV/AIDS management. "The mentors work directly with nurses at the sites and help them navigate any challenges they may face," said Ulungile Sontyale, MS, regional program manager for ICAP South Africa. “They have been instrumental in building the nurses’ confidence to prescribe ART for the first time."

Photo caption: Nurse Nomonde Maureen Ntuntwana (right) of the ICAP-supported Motherwell Community Health Clinic dispenses antiretroviral medication to a pregnant woman for prevention of mother-to-child transmission of HIV.

For more about ICAP South Africa, visit here.

Task-shifting Initiative Trains Nurses to Deliver Antiretroviral Therapy in Ethiopia
Until recently, the antiretroviral therapy (ART) clinic at the regional referral hospital in Adama, Ethiopia, had only one physician and a health officer who were responsible for caring for more than 17,000 patients. This severe shortage of health care providers meant that patients had to wait for hours to obtain routine care. But, as a result of an innovative task-shifting initiative, nurses are now helping to relieve some of the workload by delivering both pediatric and adult HIV services, including ART.

The program, supported by ICAP in collaboration with the Federal HIV/AIDS Prevention and Control Office and I-TECH, consists of one-week of basic ART training followed by a three-week advanced training course. After completing the training program, nurses receive intensive clinical mentoring and supervision from ICAP clinical advisors while building experience delivering routine HIV services, including evaluating patients for ART eligibility, providing follow-up care, refilling ART prescriptions, and managing minor complaints. The program has significantly reduced patient waiting times at the Adama ART Clinic and other ICAP-supported facilities and enabled the physicians to focus on managing complicated cases.

Abebe Checkol, a client of Adama’s ART Clinic, remembers vividly waiting many hours to be seen by a physician. “The two nurses working in the ART clinic have changed all of that,” he said. “We do not have to wait for the doctor unless we have major problems. The nurses also take ample time to advise us on the side effects of medicines and how to take them.” With the support of the hospitals peer educators, nurses also play an active role in promoting adherence by tracking patients who miss their appointments.

“Around Ethiopia, scale-up of HIV services is constrained by the limited number of qualified health care providers,” said Ayele Zewde, MD, director of clinical services for ICAP Ethiopia. “The success of the task-shifting program demonstrates the potential for nurses to effectively deliver high-quality pediatric and adult HIV services.”

Photo caption: Sister Azalech Debele, a nurse at Adama Regional Referral Hospital, delivers both pediatric and adult HIV services, including antiretroviral therapy.

For more about ICAP Ethiopia, visit here.

Nurse Task-Shifting Initiative Enables PMTCT Services to Expand in Rwanda
As part of a nationwide task-shifting initiative to increase the number of health care providers who can deliver HIV services, ICAP has supported workshops and on-site mentorship for more than 30 nurses in Western, Kigali, Gisenyi Regions of Rwanda on providing the multi-drug antiretroviral regimen for prevention of mother-to-child transmission (PMTCT) of HIV.

In Gisenyi Region, the workshops have enabled nurses to deliver the multi-drug PMTCT regimen, consisting of AZT administered from week 28 of pregnancy and single-dose nevirapine at delivery, to all eligible HIV-infected pregnant women at five health centers and a district hospital. Previously, the facilities could not provide the PMTCT regimen to all eligible women because a single doctor was responsible for initiation and monitoring of PMTCT services.

In addition to PMTCT workshops, ICAP supports training programs and provides supportive supervision to nurses focusing on provision of the comprehensive package of HIV services for mother-infant pairs, including counseling and testing, immunological assessment, adherence counseling, antiretroviral therapy (ART) prophylaxis, safe delivery and follow-up of the exposed infant, and counseling and support for infant feeding.

For more about ICAP Rwanda, visit here.

Swaziland Nurses Lead Effort to Reduce Malnutrition Among Infants Born to HIV-Positive Mothers
In response to observations by nurses that a large number of infants of HIV-infected women required admission for malnutrition while breastfeeding and after being weaned, ICAP collaborated with Mankayane Hospital and four other HIV services sites in Swaziland to develop an in-service training program to address this complication.

Focusing on the World Health Organization (WHO) guidelines on infant feeding, the training program used case studies to examine appropriate infant feeding guidance, particularly how to balance the risks of HIV transmission and malnutrition. The WHO guidelines complement Swaziland’s national guidelines by promoting exclusive breastfeeding up to six months followed by nutritious complementary feeding, if nurses determine that the mother can safely wean her baby. To date, more than 57 nurses and other health care providers have participated in the training workshops.

“These workshops were critical in helping the nurses gain confidence in their counseling skills and in refining the messages that they provide to women in their care,” said ICAP-Swaziland Country Director Kerry Bruce, MPH. “They also heightened the nurses’ awareness of malnutrition as a consequence of weaning.”

Photo caption: A mother breastfeeds her child at ICAP-supported Mankayane Clinic.

For more about ICAP Swaziland, visit here.

Lesotho Health Care Providers Assess Progress in Scaling-Up HIV/AIDS Services
In a series of meetings held in Lesotho, multidisciplinary teams of health care providers from ICAP-supported sites in Mafeteng and Mohale’s Hoek Districts and Maseru reviewed their progress to date in building capacity for family-focused HIV/AIDS services, including prevention of mother-to-child transmission (PMTCT) of HIV. At the meetings, participants identified challenges to the scale-up of services and developed recommendations for addressing them, including strengthening PMTCT counseling skills, enhancing adherence support, and enlisting male partners of pregnant women in PMTCT.

Malisebo Mphale, the PMTCT focal point in Lesotho’s Ministry of Health and Social Welfare Family Health Division, who participated in the Maseru review meetings, praised ICAP for “initiating such useful and productive meetings.” She recommended that the review meetings should be scaled up at the national level for not only PMTCT and HIV care and treatment, but also other areas of the health sector.

As a follow-up to the reviews, ICAP is working with sites to develop action plans tailored to their specific needs. ICAP supported the meetings with the Kingdom of Lesotho’s Ministry of Health and Social Welfare, the Christian Health Association of Lesotho, and the Elizabeth Glaser Pediatric AIDS Foundation.

Photo caption: In a series of meetings, members of ICAP-supported multidisciplinary teams in Lesotho assessed progress towards the scale-up of HIV/AIDS services.

For more about ICAP Lesotho, visit here.

ICAP Researchers Make New Findings About HIV Management and PMTCT
Two new studies recently published by ICAP researchers are providing insights into HIV management and the use of Highly Active Antiretroviral Therapy (HAART) for prevention of mother-to-child transmission (PMTCT) of HIV.

In a study published in the Sept. 2 issue of the Annals of Internal Medicine, ICAP Director Wafaa El-Sadr, MD, and colleagues detail the latest findings of the multinational Strategies for Management of Antiretroviral Therapy (SMART). In this study, HIV-infected participants with CD4 cell counts greater than 350 cells/mm3 were randomly assigned to either intermittent or continuous ART. Those in the intermittent group discontinued ART on study entry, initiated it when their CD4 cell counts fell below 250 cells/mm3, and stopped ART when their CD4 cell counts reached above 350 cells/mm3. Findings from the study showed that even after 18 months, intermittent arm participants who had resumed ART continued to experience elevated risks of opportunistic infections and death compared to those who stayed on continuous treatment. In addition, participants in the intermittent treatment arm continued to have CD4 cell counts significantly lower than those in the continuous arm.

"These findings reinforce the recommendation to avoid use of episodic antiretroviral therapy guided by CD4+ cell counts as used in this trial,” said El-Sadr.

In another study published in the Sept. 12 issue of the journal AIDS, Elaine Abrams, MD, director of ICAP's MTCT-Plus Initiative, and colleagues from ICAP's MTCT-Plus site in Cote d'Ivoire determined that HAART, when used during pregnancy by HIV-infected women with advanced disease, substantially reduced mother-to-child transmission of HIV, but was associated with an increased risk of low infant birth weight. Researchers compared rates of pediatric infections and low birth weight in pregnant women eligible for ART who received short-course prophylactic ART for PMTCT to those who received HAART. Among the PMTCT group, the rate of pediatric infection was 16.1 percent compared to 2.3 percent among the HAART group. The rate of low birth rate, however, was 12.4 percent in the PMTCT group compared to 22.3 percent in the HAART group.

"It is noteworthy," said Abrams, "that infant mortality rates did not differ between the groups despite the higher risk of low birth weight in the HAART-treated women."