Evaluation of AIDS Healthcare Foundation’s HIV Medic Program in...

Evaluation of AIDS Healthcare Foundation’s HIV Medic Program in Uganda and Zambia

Final report July 20, 2007

Prepared by: Cynthia A. Hiner, MHS

JHPIEGO Baltimore, MD USA

Genevieve Mwale-Musokwa

Khulu Associates Lusaka, Zambia

Evaluation of AHF’s HIV Medic Program Page 1 Final Report

TABLE OF CONTENTS ABBREVIATIONS AND ACRONYMS .........................................................................................2 ACKNOWLEDGMENTS...............................................................................................................3 EXECUTIVE SUMMARY ..............................................................................................................4 1.0 INTRODUCTION...............................................................................................................7 2.0 BRIEF DESCRIPTION OF THE EVALUATION PROCESS.............................................8 3.0 GENERAL FINDINGS ....................................................................................................10

3.1 Methods of implementation ................................................................................. 10 3.2 Scope of practice................................................................................................. 10 3.3 Impact on client care ........................................................................................... 11 3.4 Impact on health facility programs....................................................................... 12 3.5 Patient tracking and follow-up ............................................................................. 13 3.6 Remunerations .................................................................................................... 13 3.7 Entry qualifications .............................................................................................. 13 3.8 Continuing education........................................................................................... 13

4.0 EVALUATION QUESTIONS AND FINDINGS................................................................14

4.1 Is this new cadre appropriate to supplement HIV care delivery in the two countries?............................................................................................................ 14

4.2 Where does this new cadre of HIV Medics function best and why?.................... 17 4.3 What new factors need to be introduced to enhance their effectiveness and

sustainability in health care delivery systems?.................................................... 18 4.4 Are the HIV Medics adequately trained? Are they “doing no harm”? .................. 19 4.5 Is the training adequate?..................................................................................... 22 4.6 How does this cadre move to legitimacy within the health sectors of each

country?............................................................................................................... 23 5.0 CONCLUSION ................................................................................................................23 6.0 RECOMMENDATIONS...................................................................................................23 Appendix A: Names of sites visited and partner support ......................................................... 25 Appendix B: Health care providers’ interviews—HIV medics sites .......................................... 27 Appendix C: Health provider interview— non-HIV Medic sites ................................................ 41 Appendix D: HIV Medic interview............................................................................................. 45 Appendix E: Former HIV Medic interview ................................................................................ 60 Appendix F: Focus group discussions..................................................................................... 64 Appendix G: Checklist for HIV Medics ..................................................................................... 68 Appendix H: Checklist for HIV Medics who work at site where an HIV Medic said

they do basic assessments ................................................................................. 71 Appendix I: Client service data for sites with and without Medics .......................................... 75 Appendix J: Stakeholder interviews ........................................................................................ 77 Appendix K: Review of HIV Medic curricula for Uganda and Zambia...................................... 95

Evaluation of AHF’s HIV Medic Program Final Report

ABBREVIATIONS AND ACRONYMS AIDS Acquired Immune Deficiency Syndrome ART Antiretroviral therapy BP Blood pressure CDE Classified Daily Employee CHW Community Health Worker CO Clinical Officer CT Counseling and testing DCT Diagnostic counseling and testing EHT Environmental Health Technician GNC General Nursing Council HBC Home-based care HCA Health care assistant HCP Health care provider HCT HIV counseling and testing HE Health education HIPC Heavily-Indebted Poor Country HIV Human Immunodeficiency Virus HRH Human resources for health HW Health worker MCZ Medical Council of Zambia NA Nursing assistant NAC National AIDS Council OI Opportunistic infection OVC Orphans and vulnerable children PE Personnel emoluments (compensation) PMTCT Prevention of mother-to-child transmission (of HIV) RPR Rapid plasma regain TOT Training of trainers VCT Voluntary counseling and testing WHO World Health Organization ZEN Zambia Enrolled Nurse ZNA Zambia Nurses Association


ACKNOWLEDGMENTS The evaluation team would like to thank the individuals at the health facilities visited for their support and participation in this study—their cooperation was critical in making this evaluation a success. Thanks also goes to the various stakeholders interviewed who helped to provide insight into the HIV Medic program. We would also like to thank the clients and communities of the various districts for their strength and courage during this challenging period. Finally, we are grateful to the AIDS Healthcare Foundation for supporting this field evaluation and the evaluation team in organizing the site visits and interviews.


EXECUTIVE SUMMARY In 2004, AIDS Healthcare Foundation (AHF) developed the HIV Medic program, an innovative solution to the shortage of health care workers in resource-constrained settings. Through this 12-week intensive program, lay people are trained to become paraprofessional “extenders” of treatment who provide basic triage and intensive adherence support, and assist in the provision of antiretroviral therapy (ART). This task-shifting program is designed so that the HIV Medic’s main role is to take some of the clinical, counseling and administrative responsibilities from the nurses and doctors so that the clinical team will be able to care for and treat larger numbers of patients in less time. HIV Medics are trained to provide the initial screenings of patients, compile complete histories and refer patients to physicians for physical exams and initiation of ART. They can also provide adherence counseling, dispense medications, do phlebotomy, and conduct HIV counseling and testing (HCT). When the HIV Medics complete these tasks, doctors and nurses are able to spend quality time with patients who need more attention, and the professional health care providers (HCPs) are thereby also freed up to enroll more new clients. These factors contribute to the overall goal of increasing the numbers of people receiving ART. In 2007, AHF and JHPIEGO collaborated on a field evaluation of the program in Uganda and Zambia, the two countries where the program has been implemented to date. The main objectives of this evaluation were:

To document the progress of the HIV Medics

To identify the factors that promote or hinder the effective integration of the new cadre into each country’s health care delivery system

HCPs and HIV Medics were interviewed at 24 health care sites in Uganda and Zambia. In addition, focus group discussions (FGDs) were conducted with clients, stakeholders were interviewed and aggregated client data were collected. The evaluation in both countries revealed that all of the HCPs interviewed who worked with HIV Medics agreed that the introduction of the HIV Medic program positively changed the way that health care services were provided in the clinic. Examples of how health care had changed include: increase in outreach programs, lessening of the workload of HCP staff, increase in the provision of adherence counseling, increased assistance with patient tracking, and rise in the number of clients receiving HCT because of the health education provided by the HIV Medic. One HCP explained that the health facility “used to have three nurses and a lot of patients. With the coming of the HIV Medics, each nurse has a simplified workload as tasks have been divided.” When asked to rate the overall performance of the HIV Medics in their program, 30% of HCPs interviewed rated them as “excellent” and 63% rated them as “good.” Reasons stated included: “because the HIV Medics supplement what the nurses are able to do,” and “they are able to do some of the jobs nurses did previously, [now] nurses are able to visit [assist] the clinical officers and doctors.” An impressive 86% of the HCPs agreed that the overall functioning of the clinic


was “much improved” since the introduction of the program, and 97% stated they would recommend implementation of the HIV Medic program to other clinical programs. The HCPs were also asked about the number of clients seen each day before and after implementation of the HIV Medic program, as well as about client adherence rates before and after. Though many were unable to answer the questions specifically because of lack of data, almost all did agree that their clinics were now able to see more clients and that client adherence rates had increased. HCPs were also asked if the use of HIV Medics had influenced the clinic’s goal of increasing the number of patients on ART. All but two (93%) agreed that there was either a “much greater” or “somewhat greater” number of clients on ART because of the HIV Medics. In general, the HIV Medics who were interviewed also believed that they were accepted by the doctors, clinical officers and nurses, in almost all cases, citing the same reasons as the HCPs. All of the HIV Medics interviewed said that the clients also accepted them as part of the clinical team. During the site visits, 28 HIV Medics participated in a skills assessment, which was based on a checklist that covered client history and physical examination. It was developed from the course materials and approved by AHF staff in Zambia. However, only 15 of the 28 HIV Medics stated they performed physical exams; consequently, there were some tasks on the skills assessment that showed areas for improvement. The HIV Medics are trained to do the observations but there are variations in what they are allowed and not allowed to do in the field. For example, the evaluation showed that, depending on the location and facility where the HIV Medics practice, some are not allowed to screen clients, which helps to explain the variable practical competency in some of the areas. Nine FGDs were held with clients at the sites visited. All FGDs concluded that the clients were pleased with the services they received from the HIV Medics. However, three groups were not aware of the HIV Medic program, commenting that “everyone here is a provider. We do not know the difference.” They stated they were happy with the services because the HIV Medics were kind, welcoming, respectful and approachable. They rated services as good or excellent for the following reasons: the HIV Medics teach the patients about HIV; people have responded well to treatment because of the commitment of the HIV Medics; and the HIV Medics treat them respectfully. In addition, the members of the FGDs said that the doctors, clinical officers and nurses all accepted the HIV Medics as part of the clinical team. There were varied responses from the stakeholders interviewed, with some of them wary of the program and others in favor of it. Of the stakeholders who had heard of the program, most agreed that it was a good program and that the HIV Medics were helpful. However, some of the stakeholders who had not previously heard of the program were more skeptical. One commented that it should be integrated with other programs and one thought it would be rejected because “now there are too many nurses [in Uganda] on the streets who have no jobs. Why can’t the government employ them?” When asked about the country-wide acceptance of the new cadre, five stakeholders thought they would not be acceptable to doctors and nurses because they do not have a medical background and because of the current unemployment rate of nurses in Uganda. However, all but one of the stakeholders thought that the program would be accepted by the clients.


When discussing the integration of the HIV Medics with the health care system, most stakeholders thought that integration should be done by the government. Some said that there would need to be a more formal training for them. The evaluation demonstrated that the HIV Medic program has had a positive impact on the ground, both at the facility level and in the communities where the HIV Medics live. The program has been well received in both countries and the number of clients accessing treatment has increased. Challenges remain, however, in relation to the scope of practice, remuneration, continuing education and recognition by government and other professionals. Among the most significant findings is that the professionals at the facility level recognize and work well with the HIV Medics, but professionals at the policymaking level are more skeptical about the impact that this cadre can make. The stakeholders did agree that the government should be involved in moving this role into a more widely accepted professional cadre.


1.0 INTRODUCTION Fifty-seven countries, mostly in sub-Saharan Africa, face crippling health workforce shortages. The World Health Organization (WHO) estimates that over 4 million health workers are needed to fill the gap. Sub-Saharan Africa faces the greatest challenges. With 11% of the world’s population and 24% of the global burden of disease, the region has only 3% of the world’s health workers.1 The chronic shortage of well-trained health workers is a global issue. For a variety of reasons, such as the migration, illness or death of health workers, countries are unable to educate and sustain the health workforce that would improve people’s chances of survival and their well-being.2 According to the WHO, shifting tasks between health care workers and expanding the clinical team can relieve short-term human resource limitations in settings with low resources. Rapid scaling up involves:3

• Shifting tasks to the lowest relevant cadre; • Expanding the clinical team by including people living with AIDS; • Placing strong emphasis on patient self-management & community involvement.

AIDS Healthcare Foundation (AHF) has developed a program, the HIV Medic program, to help address the human resource crisis. HIV Medics are paraprofessional health care workers trained to assist clinicians in the provision of antiretroviral therapy (ART) for patients with HIV/AIDS. The program trains lay people and general health care workers to be treatment extenders and alleviate some of the burdens facing resource-constrained countries that have limited numbers of medical professionals. Using lay personnel to assist in the delivery of ART is an approach recommended by the WHO in the development of health systems that can adequately respond to the HIV/AIDS epidemic in resource-poor countries.4 This paraprofessional, task-shifting program is designed so that the HIV Medic’s main role is to take some of the responsibilities away from nurses and doctors, and so the clinical team will be able to care for and treat larger numbers of patients in less time. HIV Medics can provide the initial screenings of patients, compile complete histories, and refer patients to physicians for physical exams and initiation of ART. They can also provide adherence counseling, dispense medications, do phlebotomy, and conduct HIV counseling and testing (HCT). When the HIV Medics complete these tasks, doctors and nurses have more time available to spend with patients who need more attention. Professional health care providers are also freed up to see more new clients and initiate more patients on ART. These factors contribute to the overall goal of increasing the number of people receiving ART. AHF piloted the HIV Medic program in Uganda in 2004, and has since conducted subsequent trainings in Zambia as well. AHF is in the process of pursuing official recognition of the HIV Medic training and cadre in the countries where it has been implemented. Through this process, policy makers and stakeholders requested that an independent assessment of the program be completed. AHF approached JHPIEGO to conduct an evaluation of the program and assessment 1 Taking stock: health worker shortages and the response to AIDS. WHO HIV/AIDS programme 2006 2 Working together for health. The World Health Report 2006. WHO 3 Working together for health. The World Health Report 2006. WHO 4 Scaling up antiretroviral therapy in resource-limited settings: guidelines for a public health approach. Geneva, World Health Organization, 2003 (Department of HIV/AIDS, 2003 revision).


of the impact of the cadre. The outcomes of this assessment and evaluation will be used to drive this process forward. In 2007, AHF and JHPIEGO collaborated on a field evaluation of the program in the two countries. The main objectives of this evaluation are:

To document the progress of the HIV Medic program in the two countries where it has been implemented to date.

To identify the factors that promote or hinder the effective integration of the new cadre into the health care delivery systems of Uganda and Zambia.

Within any task-shifting program, there are numerous questions and issues that deal with sustainability, government approval, acceptability by professional bodies and availability of supervisors. While those items are partly beyond the scope of this initial evaluation, an effort was made to gather data and opinions from key informants on the value and sustainability of the HIV Medic program. 2.0 BRIEF DESCRIPTION OF THE EVALUATION PROCESS For the Zambia portion of the study, undertaken between March 20, 2007 and April 11, 2007, the evaluation focused only on the first graduates of the HIV Medic program since the second group had completed the program in March and were just beginning their work. The evaluation process involved identifying the sites where the HIV Medics were working and determining which HIV Medics were working and which were not. The team then purposefully selected a convenience sample of HIV Medics from the 20 HIV Medics who were working based on location. For some of the sites that were chosen, the evaluation team visited a comparative site that was similar to the site where HIV Medics were working. A letter was obtained from the Ministry of Health (MOH) to seek permission to undertake the evaluation. The sites where the HIV Medics work were then contacted about the evaluation and informed of the proposed dates of the visits. The evaluation team visited 13 health facilities and interviewed 14 HIV Medics who worked either full-time or part-time at the health facilities. For the Uganda portion of the study, undertaken between April 24, 2007 and May 4, 2007, the focus of the evaluation was all graduates of the HIV Medic program in the country. The evaluation process involved identifying the sites where the HIV Medics were working and which HIV Medics were not currently working. The team then purposefully selected a convenience sample from the more than 40 HIV Medics who were working as HIV Medics; some of those who were not working as HIV Medics were also interviewed. The evaluation team chose two comparative sites, similar to the sites where HIV Medics were working. The team contacted the sites where the HIV Medics work about the evaluation and informed them about the proposed dates of the visits. The evaluation team visited 11 health facilities and interviewed 23 HIV Medics who worked either full-time, part-time or as volunteers at those health facilities. In both countries, the HIV Medics were assessed at the site where they worked and the following evaluation tools were used to collect data:


Interviews with health providers (doctors, clinical officers and nurses) who worked with the HIV Medics

Interviews with the HIV Medics who were working either full-time or part-time

Checklist for the physical examination to assess the HIV Medics’ skills

An FGD with clients at the clinic and in the community

Client data from the service sites For those sites where the HIV Medics do not exist, the following was done:

An interview was undertaken with health providers working at the ART clinics

Client service data were collected In Zambia, HIV Medics are working either full-time or part-time and their salaries are paid for by AHF, other NGOs or the MOH (there are a few certified daily employees (CDEs) who were employed in government clinics as dressers, registry clerks, etc and have been trained as HIV Medics and work either full-time or part-time in that role). In Uganda, HIV Medics are working either full-time or as volunteers, and in some cases work as part-time nurses. Those who receive a salary are paid by AHF, not the government. Unlike the Zambia sites, where the ART clinic is part of the hospital program, the Uganda sites are situated at the government health facilities as stand-alone HIV/AIDS sites built and supported by AHF. Two employees from an independent consulting firm based in Lusaka conducted all of the interviews and focus group discussions (FGDs). The interviewers asked all participants for their oral consent before they interviewed them and informed them that choosing not to participate would not cause any repercussions related to their jobs. The facilitators did not tape record the interviews or FGDs, but did take notes. All interviews and FGDs took place in private areas of the facilities. Participants were not compensated for their time. In addition to the data collected at the health care sites, interviews with various stakeholders were also conducted. Finally, a JHPIEGO staff member reviewed the curriculum used for training the HIV Medics. Appendix A lists the sites that were visited along with the number of HIV Medics and health care providers (HCPs) interviewed. Table 1, describes the people interviewed and type of data collected.


Table 1: Data collected for the evaluation

LIST OF DATA ZAMBIA UGANDA TOTAL

Health Provider Interview–HIV Medic Sites 13 17 30 Health Provider Interview–Non–HIV Medic Sites 9 3 12 HIV Medic Interview 14 24 38 Former HIV Medic Interview 1 4 5Client Focus Group Discussions 4 5 9Evaluation of HIV Medic Checklist 12 16 28 Client service data collection tools for sites with HIV Medics 6 8 14 Client service data collection tools for sites without HIV Medics 5 3 8Stakeholder Interview 10 11 21

3.0 GENERAL FINDINGS 3.1 METHODS OF IMPLEMENTATION The methods of implementation varied from site to site in both countries. In some sites in Zambia, if the HIV Medics are on the government payroll (CDEs), then they normally do not work in the ART clinic but revert back to their pre-training posts on return from training—they then work once a week on a rotation basis at the ART clinic. Where the HIV Medic is on the AHF or other NGO’s payrolls, including CHAZ and CIDRZ (the Center for Infectious Disease Research in Zambia), he or she will work full-time in the ART clinic. In one site, the HIV Medic is on the farming communities’ payroll and is the sole health provider at the farms’ health facility. A striking feature of the Zambia ART programs is that in most centers, non-medical personnel who have not been trained are allowed to take baseline readings and enter findings in the clients’ records. In Uganda, most of the sites visited were AHF Uganda Cares sites and are situated in government health facilities. However, even across the AHF Uganda Cares sites, the methods of implementation of the HIV Medic program varied. In some sites, the HIV Medics have been practicing as volunteers for the past three years, and are not on a payroll. In others, the entire health facility staff, including HIV Medics, are employed by AHF Uganda Cares. This scenario seems to cause a little uncertainty with the HIV Medics. Currently, none of the HIV Medics are on the government payroll.

3.2 SCOPE OF PRACTICE In Zambia, the scope of practice of the HIV Medic ranged from community outreach to dispensing drugs and conducting phlebotomy. The 12-week training for the HIV Medics enables them to conduct physical examination of clients, among other things. However, as most of the HIV Medics are not conducting the full physical examination post-training, it seems that this skill is quickly being lost. The range of skills that the HIV Medics are using varied with each site. In some sites, they are allowed to do things including take blood, screen clients and review medical records. At almost all the sites, the HIV Medics do not dispense drugs.


In Uganda, the scope of practice ranged from community outreach to ordering and dispensing drugs, and in rare cases managing the drugs logistics system. Similar to the Zambian situation, the scope of practice of the HIV Medics in Uganda varied with each site and according to the number of staff available at the site. In sites where the lab was nearby and there were trained counselors available, the HIV Medics referred the clients to the qualified counselors. As in Zambia, in some sites, the HIV Medics did not conduct full physical assessments of clients. In some sites, they were allowed to take blood, screen clients and review medical records; in other sites they were not allowed to do these tasks. In almost all of the sites, the HIV Medics were allowed to dispense drugs for both opportunistic infections (OI) and ART. In all the sites, it was stressed that the HIV Medics were very knowledgeable about the drugs, but lacked basic medical and nursing skills and experience managing drugs logistics systems. It’s important to note that nursing skills and management of drugs logistics systems are not a focus of the HIV Medic curriculum, as the goal of the training is that HIV Medics are able to perform a streamlined list of HIV specific clinical services and functions to help alleviate the burden of other, more highly trained HCPs. In one site, an HIV Medic was managing the CD4 machine and was greatly praised by her colleagues and health care staff for the excellent way in which she managed the lab services. HIV Medics were also greatly praised for managing the drugs, maintaining the drugs logistics system and doing phlebotomy. In both countries, all of the HIV Medics received the same training and believed their core competencies were the same. However, their actual scope of practice varied greatly by site. This range in the scope of practice made some of the other HIV Medics feel less appreciated than their colleagues, especially when they heard that other HIV Medics were drawing blood. In addition, the specific job descriptions of the HIV Medics are not well-documented. In some instances, the team was told that the HIV Medics have formal job descriptions but we, as a team, were not shown any such documents.

3.3 IMPACT ON CLIENT CARE In both countries, the HIV Medics have had an impact on clients’ care and are accepted by clients as part of the clinical care team. Most clients are first seen by the HIV Medics in order to have their vital signs taken. The HIV Medics will also review the clients’ charts and pass information onto the health provider. Where necessary, they remind the doctor of the need to have an HB done if the client is on AZT. This has greatly reduced the waiting time of clients at the health facilities. In the group discussions held in the morning at the ART clinic, clients prefer to get the information from the HIV Medics. In the Zambia clinics with HIV Medics, most of the clinicians appreciate the HIV Medics’ role and readily utilize their services. In all sites, the achievements of the HIV Medics program have included the following:

Creating a link between the health facility and the community: most of these HIV Medics live in the community and are the first point of contact for communities in relation to HIV/AIDS, this helps clients feel freer to consult and seek health care.

Adherence support: the HIV Medics have contributed to the improved adherence rates in most communities.


Monitoring and management of side effects and signs of treatment failure: as the patient’s first point of contact in the community and often at the clinic, the HIV Medics are often the first to be contacted about any problems with their medication.

At all of the sites in Uganda, the health care providers acknowledged the great impact that the HIV Medics had made on service provision. The health care providers at AHF Uganda Cares sites felt strongly that the HIV Medics have improved patient outcomes in the districts. This view was also held by those health care providers (primarily doctors and nurses) at the government facilities who work on a rotation basis at the ART centers. In the clinics with HIV Medics, most of the providers appreciate their role and readily utilize them. In all sites, the achievements of the HIV Medic program have included the following:

Adherence support and treatment literacy: the HIV Medics have contributed to the improved adherence rates in most communities.

Quality assurance in the management of the drugs logistics chain: the HIV Medics have contributed greatly to the recording, ordering and storing of ART drugs. In some sites it was mentioned that because of the HIV Medics, the center never ran out of drugs and there was no query from the MOH Kampala pharmacy on the amount or usage of drugs.

Client waiting time reduced: this has improved the attendance of clients at the health facilities; most clients were seen and screened by HIV Medics while waiting for the doctor.

3.4 IMPACT ON HEALTH FACILITY PROGRAMS At all of the health facilities it was found that the HIV Medic is accepted as part of the ART team. There is no differentiation between them and the professional staff. In most centers, they are the permanent staff of the ART clinic and are the ones who orient the part-time staff, including doctors and nurses, to the site when they arrive at the health facility. The doctors, nurses and clinical officers appreciated the work of the HIV Medics. This was demonstrated by one doctor (a hospital mission director in Zambia) who said, “Send me more guys like him, he is great, and we can feel his presence and the impact he has made on health service delivery.” A nurse in charge of the ART clinic stated, “We wouldn’t be able to follow up patients in the community and have such high adherence rates if it wasn’t for this young man. The patient waiting times have been reduced drastically. He is so smart and assertive that as clients are waiting in the queue he is able to review the files and quickly ensure that those on AZT have a lab form signed and blood collected so that by the time the client reaches the doctor’s room he already has his lab results and he can be immediately attended to.” At one site in Uganda where the HIV Medics only come in during clinic days, the medical superintendent stated, “We really appreciate these young people. Unfortunately, we cannot put them on the payroll as we have been told that they are not on the establishment register and so sometimes we provide for a few allowances from our own funds.” A nurse in charge of the ART clinic stated, “We appreciate what they are doing…they have very shallow knowledge on medical and nursing issues. So when they see something that is not HIV-related they don’t know what to do. They really need skills in basic nursing.” However, it is worth noting that the HIV Medic’s primary purpose is to provide HIV care—not basic nursing care.


3.5 PATIENT TRACKING AND FOLLOW-UP In Zambia, because of their community presence, the HIV Medics are able to track patients who have defaulted and in some cases provide feedback to the health facility on the client’s condition. If the client cannot afford to attend the health facility, the HIV Medics usually are able to take drugs to the patient if the patient is doing well. HIV Medics are able to sensitize the community about HIV and AIDS and subsequently motivate people to seek care. In addition, at several of the sites, AHF and other partners have provided motorbikes or bicycles for the HIV Medics to help them with patient tracking. Unlike the situation in Zambia, the HIV Medics in Uganda do not seem to have as strong of a community outreach component even though they live in rural communities. They complained about lack of transport and too heavy a workload in the clinic, which prevents them from undertaking community outreach programs.

3.6 REMUNERATIONS In both countries, there are some issues around remuneration for the HIV Medics. In Zambia, most of the HIV Medics are paid by AHF and other NGOs (including CIDRZ and CHAZ) and those paid by the government are still working in their primary posts as nursing auxiliaries or registry clerks. In Uganda, most of the HIV Medics are paid by AHF and there are a few employed by other NGOs. However, a few others have been working as volunteers for the past three years and are very frustrated by the situation. In one center, the evaluation team was informed that the morale of the team was low because the HIV Medics had been working without contracts. The government’s failure to formally recognize the qualifications of the HIV Medics also has some negative impact on the program. The HIV Medics believe that because of this they have no long-term career prospects and have a disadvantage compared to other health care staff. There is a need for the HIV Medics to be formally recognized and integrated with the health care system.

3.7 ENTRY QUALIFICATIONS In both countries, the entry qualifications for the HIV Medics to enter the program are graduation from grade 12 and fluency in English. For the majority of HIV Medics, the highest level of education was completion of grade 12. However, in a few cases, nurses had also been trained as HIV Medics—in Zambia they then reverted to their previous roles part-time on return to the health facility, and in Uganda they subsequently worked as HIV Medics. Since nurses do not always receive HIV training as part of their nursing curriculum, the HIV Medic training helped provide some of the information and knowledge they need to care for people living with HIV/AIDS.

3.8 CONTINUING EDUCATION In both countries, there are questions around continuing education (CE) programs for the HIV Medics, and most of them have not undergone a formal subsequent training or attended update programs after their initial training. In Uganda, most of the HIV Medics lamented the fact that they need a lot of counseling skills. Most of them do not have the funds to take this course. Although AHF staff does regularly visit the HIV Medics to conduct on-site mentoring, it was clear that the HIV Medics did not view these visits as sufficient or formalized additional training.


4.0 EVALUATION QUESTIONS AND FINDINGS The evaluation consisted of interviews with numerous people in both Uganda and Zambia, as described in section 2.0. Appendixes B through K summarize the results of each of the different types of interviews. The evaluation was broken into six main questions to be addressed and the findings are presented here.

4.1 IS THIS NEW CADRE APPROPRIATE TO SUPPLEMENT HIV CARE DELIVERY IN THE TWO COUNTRIES?

This question was addressed by asking health care providers, clients and HIV Medics about their experiences with the program. Questions included items such as change in health care at sites since implementation of the HIV Medics program and acceptance of the HIV Medics. Thirty health care providers who work with HIV Medics were interviewed. The program had been implemented at their sites for seven months to four years, and ranged in size from one to six HIV Medics. The sites varied in staff size from only two nurses and two or three HIV Medics to up to four doctors and two or three clinical officers, with rotating nurses and a few HIV Medics. All of the HCPs interviewed who worked with HIV Medics agreed that health care had changed since the program’s introduction. Examples of how health care had changed include: increase in outreach programs, lessening of the workload for HCP staff, provision of adherence counseling, assistance with patient tracking, and rise in the number of clients receiving HCT because of the health education provided by the HIV Medic. One HCP explained that they “used to have three nurses and a lot of patients. With the coming of the HIV Medics, each nurse has a simplified workload as tasks have been divided.” Another HCP spoke of a time when “nurses stopped coming to clinic for two months and he [the HIV Medic] managed the clinic alone.” When asked to rate the overall performance of the HIV Medics in their programs, nine (31%) of the HCPs rated them as “excellent” and 19 (66%) rated them as “good.” The HCPs were also asked about the number of clients seen each day before and after implementation of the HIV Medics program, as well as about client adherence rates before and after. Though many were unable to answer the questions specifically because of lack of data, almost all did agree that their clinics were now able to see more clients and that client adherence rates had increased. Table 2 shows responses from HCPs who were able to provide estimates for both before and after implementation. Figure 1 shows the average number of patients, based on responses from Table 2, before and after implementation of the HIV Medic program. The average increase in the number of patients seen by a physician was 67%. The HCPs were also asked if the use of HIV Medics had influenced the clinic’s goal of increasing the number of patients on ART. All but two agreed that there was either a “much greater” or “somewhat greater” number of clients on ART because of the HIV Medics. Two responded that there had been no change because: 1) the HIV Medic did not do community outreach; and 2) the HIV Medics were not responsible for initiation of ART.


Table 2: Number of patients each physician was able to see in one day before and after the clinic’s implementation of the HIV Medic program

RESPONDENT BEFORE THE CLINIC’S USE OF HIV MEDIC(S)

AFTER THE CLINIC’S USE OF HIV MEDIC(S)

1 12 35 2 50 50 3 60 100 4 28 50 5 60 70 6 30 45 7 0 10 8 50+ 70 9 30 15

10 30 40–50 11 7 40 12 20–25 35–40 13 30 50 14 20 70 15 80 80 16 50 40 17 20 45 18 20 20

Twenty-five (86%) of the HCPs agreed that the overall functioning of the clinic was “much improved” since the introduction of the program, and 29 (97%) stated they would recommend implementation of the HIV Medic program to other clinical programs. Reasons stated included: “because the HIV Medics supplement what the nurses are able to do,” and “they are able to do some of the jobs nurses did previously, [now] nurses are able to visit [assist] the clinical officers and doctors.” There were only two HCPs (one doctor and one nurse) who answered that the doctors/clinical officers did not accept the HIV Medics. They said this was because the “medical knowledge they hold is quite shallow but the responsibility they hold is big” and that the doctors do not believe the HIV Medic training was sufficient. The other HCPs thought the doctors and clinical officers did accept the HIV Medics because “they do some of the things nurses are supposed to do,” and “they work hand in hand as a team.” All the HCPs believed the nurses and clients accept the HIV Medics for a lot of the same reasons: “they are helpful doing everything, counseling and observations,” “they work as a team,” and “the patients don’t know the difference.”


Figure 1. Average number of patients before and after implementation of the HIV Medic program

Average Daily Number of HIV/AIDS Patients Treated Per Physician

(67% average increase)

0

5

10

15

20

25

30

35

40

45

50

1Evaluation of AIDS Healthcare

Foundation HIV Medic Program in Uganda and Zambia

Average Number of Patients Treated

Site beforeimplementation ofHIV Medic programSite afterimplementation ofHIV Medic program

Nine FGDs were held with clients at the sites visited. All FGDs concluded that the clients were pleased with the services they receive from the HIV Medics. However, three of them were not aware of the HIV Medic program, stating, “everyone here is a provider. We do not know the difference.” Clients stated they were happy with the services because the HIV Medics were kind, welcoming, respectful and approachable. They rated services as good or excellent for the following reasons: the HIV Medics teach the patients about HIV; people have responded well to treatment because of the commitment of the HIV Medics; and the HIV Medics treat them respectfully. In addition, the members of the FGDs said that the doctors, clinical officers and nurses all accepted the HIV Medics as part of the clinical team. In order to understand if sites that did not currently have HIV Medics would be open to the program, 12 health care providers at sites without HIV Medics were interviewed. Of the 12 HCPs interviewed, 11 thought that doctors, clinical officers and nurses at their sites would accept the HIV Medics as care providers, and all 12 thought the clients would accept them. The one who thought the doctors and clinical officers would not accept them asked who would be responsible for paying them. When asked which responsibilities their staff needed help with, all 12 HCPs agreed with task-shifting roles such as assistance in obtaining patient medical histories, taking vital signs, pre-test counseling for HIV testing and adherence counseling. In general, the HIV Medics who were interviewed also believed that they were accepted by the doctors, clinical officers and nurses in most cases, for the same reasons as given by the HCPs. All of the HIV Medics interviewed said that the clients accepted them as part of the clinical team.


4.2 WHERE DOES THIS NEW CADRE OF HIV MEDICS FUNCTION BEST AND WHY?

During the interviews with doctors, clinical officers and nurses, they were asked to rate various job functions, if they were performed by the HIV Medics at their site (See Table 3). They were then asked which of the job functions were most beneficial. Adherence counseling was the only job function that all of the HIV Medics perform, and of the 30 HCPs interviewed, 63% thought that was the most beneficial. The second and third most common responsibilities were: 1) taking vital signs; 2) reviewing and documenting in-patient charts; and 2) presenting findings to supervising HCP (tie). However, only 23%, 7% and 13% respectively, of HCPs thought these activities were the most beneficial. After adherence counseling, taking medical histories and taking vital signs were considered most beneficial by 23% of HCPs. Table 3: Job performance rating of HIV Medics by health care providers

Which of the following responsibilities are performed by the HIV Medics and how would you rate their job performance in each area?

Perform Job performance rate Yes No Excellent Good Fair Poor

Patient medical histories 23 7 8 34.8% 13 56.5% 2 8.7% 0 0.0%Basic patient assessment and physical examinations

17 13 3 17.6% 9 52.9% 4 23.5% 1 5.9%

Taking vital signs 27 2 10 38.5% 13 50.0% 3 11.5% 0 0.0%Pre-test counseling for HIV counseling and testing

20 10 9 45.0% 10 50.0% 1 5.0% 0 0.0%

Conducting HIV rapid test 5 22 3 60.0% 2 40.0% 0 0.0% 0 0.0%Post-test counseling for HIV CT

19 11 9 50.0% 8 44.4% 1 5.6% 0 0.0%

Adherence education, counseling and support

30 0 16 64.0% 7 28.0% 2 8.0% 0 0.0%

Review and document in-patient charts

25 4 6 26.1% 15 65.2% 2 8.7% 0 0.0%

Present findings to supervising physician, clinical officer or nurse

25 3 6 26.1% 12 52.2% 5 21.7% 0 0.0%

Dispense and or deliver medication prescribed by physician

16 12 10 66.7% 4 26.7% 1 6.7% 0 0.0%

Phlebotomy 18 11 9 52.9% 8 47.1% 0 0.0% 0 0.0%Insert IVs 10 17 4 40.0% 5 50.0% 1 10.0% 0 0.0%Community outreach 20 9 9 64.3% 5 35.7% 0 0.0% 0 0.0%Other (follow-up) 4 0 1 25.0% 3 75.0% 0 0.0% 0 0.0%


4.3 WHAT NEW FACTORS NEED TO BE INTRODUCED TO ENHANCE THEIR EFFECTIVENESS AND SUSTAINABILITY IN HEALTH CARE DELIVERY SYSTEMS?

Part of this question is beyond the scope of this evaluation as it involves information on sustainability and support from the MOHs and the professional associations. However, some information on this topic was covered during the interviews with stakeholders. Twenty-one stakeholders were interviewed, and 14 of them were aware of the program before the interview. In Zambia, there were varied responses from the stakeholders, who included officials from the MOH and the professional associations. The major stakeholders at the MOH were divided in their opinion with some of them wary of the program and others in support of it. The MOH is currently undertaking an initiative to introduce a new cadre of worker that will be known as the nursing/health care assistant, which may affect the viability and sustainability of the HIV Medic cadre. Other stakeholders, such as the Medical Council of Zambia and the General Nursing Council, stated that they were not aware of the program but felt that the program needed to be thoroughly planned with the government taking the lead. CHAZ, a Global Fund funded partner in Zambia, which is currently funding some HIV Medics training programs, is very positive about the impact that the cadre would make and insisted that the professional associations and professional bodies were aware of the program. However, the HIV Medics are currently found mostly at the mission health facility, though there are a few stationed at health facilities owned by the government. However, even there the HIV Medic is not employed as an HIV Medic but as a research assistant. In Uganda, the program manager from the National AIDS Council (NAC), the medical superintendents from the various district hospitals and the East, Central and Southern African College of Nursing and Midwifery (ECSACON) country representative were interviewed. There were varied responses from the stakeholders. The major stakeholders at NAC were very appreciative of the program. The nursing professionals and the medical superintendents were divided in their opinions, with some wary of the program and others in support of it. Other stakeholders such as the ECSACON representative and a hospital assistant commissioner, who are both on the regional nursing body for the ECSACON council, stated that they were not aware of the program but believed that the program needed to be thoroughly planned with the government taking the lead. They also expressed the opinion that the program should train nurses who have failed to find employment in nursing as HIV Medics as an entry point for them to join the MOH structure. Of the stakeholders who had heard of the program, most agreed that it was a good program and that the HIV Medics were helpful. However, some of the stakeholders who had not previously heard of the program were more skeptical. One commented that it should be integrated with other programs and one thought it would be rejected because “now there are too many nurses in Uganda on the streets who have no jobs. Why can’t the government employ them?” When discussing the integration of the HIV Medics with the health system, most stakeholders thought it should be done by the government. Some stated that there would need to be a more formal training for them. Most stakeholders agreed that the government should fund the development, deployment and salaries of the new cadre, with several saying donors/NGOs/partners could fund them initially, but then the government should assume responsibility and authority. However, they were unsure if the government had resources to do so.


One stakeholder stated that the creation of this new cadre “would be a problem with the professionals. They are even refusing to accept nursing auxiliary. They don't want to even have anything to do with them. Who will supervise them is my question. There is need for a sense of ownership of this program, by the government and the professional bodies. To achieve this, the curriculum must be designed, developed, implemented by either one of the various regulatory bodies. Who designed the curriculum, who is supervising them?”

4.4 ARE THE HIV MEDICS ADEQUATELY TRAINED? ARE THEY “DOING NO HARM”?

Currently, knowledge tests are conducted during the training, follow-up visits to assess skills are conducted after deployment, and skills assessments are informally completed by the doctors and nurses with whom the HIV Medics work. In addition, in Zambia AHF staff provide regular CME type interventions with most of the HIV Medics. This includes a half-day of observation and a half-day of review and discussion on any areas of concern that came up during the morning. There is also an HIV Medic and a Clinical Officer (both AHF staff) in Uganda who have similar roles, but they provide fewer CME visits than the Zambia staff. Question 2 (where does this new cadre of HIV Medics function best?) addressed the job responsibilities performed by the HIV Medics and how their HCP co-workers rated their performance in those areas. That section should also be considered here, and it is worth noting that that only one HCP rated one area of responsibility as “poor.” When asked to rate the general, overall performance of the HIV Medics in their program, nine HCP stated they were “excellent,” 19 stated “good” and one answered “fair.” Twenty-six (87%) providers answered “yes” when asked if the HIV Medics seemed sufficiently trained to execute their responsibilities. When asked to rate the level of training, seven (25%) providers said “excellent” and 16 (57%) stated “good.” In response to these two questions, two different providers stated that they thought the training should be longer. FGD participants were also asked to rate the overall performance of the HIV Medics and whether they seemed sufficiently trained. Participants rated their performance positively on both questions and stated that the HIV Medics “know their work well.” When HIV Medics were asked to rate their overall performance in the program, all but two rated their performance as either excellent or good. However, when asked if there was further knowledge needed to enhance their career or performance, all but one HIV Medic answered yes. Most replied that they needed either refresher training or more training on certain areas such as family planning and HIV integration. During the site visits to the HIV Medics, 28 HIV Medics participated in a skills assessment, which was based on a checklist that covered client history and physical examination. It was developed from the course materials and approved by AHF staff in Zambia. A member of the evaluation team conducted the assessment by observing the HIV Medic with a client. Although 28 HIV Medics were assessed, only 15 stated they did physical exams; consequently, there are several areas of the checklist on which they performed poorly. Some areas that were weak in the assessments were handwashing before and after seeing a patient, asking about family


medical problems, alcohol use, and other problems or concerns. There were several items on the checklist that ended up not being relevant to the HIV Medics’ responsibilities, including asking about tetanus immunization status and treating the client for syphilis. A separate analysis of the skills checklist was performed with HIV Medics who worked at sites where HIV Medics said that they perform basic patient assessment and physical examinations. Since the checklists were confidential, this resulted in 20 HIV Medics who might conduct assessments at seven sites. The overall results for this group were the same as for the larger group of all 28 HIV Medics. In some areas they did perform slightly better, overall they passed, at 80%, in the same number of areas as the entire group. The full results from both groups are in Appendices G and H. Table 4: Comparison of skills assessments for HIV Medics

ALL HIV MEDICS

PERFORMED SATISFACTORILY*

SELECT HIV MEDICS

PERFORMED SATISFACTORILY**

GETTING READY # % # % 1. Prepare the necessary equipment. 28 100.0% 20 100.0% 2. Greet the client respectfully and with kindness and

introduce yourself and ask her name. 26 92.9% 18 90.0%

3. Offer the client a seat. 26 92.9% 20 100.0% 4. Explain to the client what is going to be done and

encourage her to ask questions. Get her permission before you begin.

25 89.3% 17 85.0%

5. Listen to what the client has to say. 26 92.9% 18 90.0% HISTORY (ASK/LISTEN) 1. Ask the client her name, age, marital status,

address, occupation of self and partner, and religion.

24 85.7% 16 80.0%

2. Ask the client how she is feeling and respond immediately to any urgent problems.

21 75.0% 16 80.0%

3. Ask the client about her family medical problems. 9 32.1% 6 30.0% 4. Ask the client about previous medical conditions. 11 39.3% 8 40.0% 5. Ask the client about general health problems. 27 96.4% 20 100.0% 6. Ask the client about HIV status. 14 50.0% 11 55.0% 7. Ask the client about medications. 26 92.9% 19 95.0% 8. Ask the client about alcohol use and smoking. 3 10.7% 3 15.0% 9. Ask the client about tetanus immunization status. N/A 10. Ask the client about social support. 13 46.4% 11 55.0% 11. Ask the client about other problems or concerns. 24 85.7% 17 85.0%


ALL HIV MEDICS


SELECT HIV MEDICS


PHYSICAL EXAMINATION (LOOK/FEEL) 1. Ask the client if she needs to empty her bladder.

Save and test urine, if necessary. 2 7.4% 2 10.5%

2. Observe the client’s general appearance. 27 96.4% 19 95.0% 3. Explain each step of the physical examination. 21 75.0% 15 75.0% 4. Take the client's blood pressure, pulse, respirations

and record findings. 26 92.9% 20 100.0%

5. Help the client on to the examination table. 18 64.3% 11 55.0% 6. Wash and dry hands thoroughly. 1 3.6% 1 5.0%7. Check the client’s conjunctiva, tongue, nail beds

and palms for pallor. 25 89.3% 17 85.0%

8. Check the client's face and hands for edema. 24 85.7% 18 90.0% 9. Perform all steps of chest examination. 15 53.6% 12 60.0% 10. Perform all steps of abdominal examination. 17 60.7% 10 50.0% 11. Perform all steps for a lymph nodes examination. 21 75.0% 15 75.0% 12. Perform all steps for examination of the skin. 22 78.6% 15 75.0% 13. Perform all steps for a heart examination. 12 42.9% 9 45.0% 14. Wash and dry hands thoroughly. 3 11.1% 2 10.5% 15. Ask the client if she has questions. Help her from

the table and offer her a seat. 22 78.6% 14 70.0%

16. Record all relevant findings from the physical examination on the client’s record card.

28 100.0% 20 100.0%

17. Discuss findings with the client. 25 89.3% 19 95.0% 18. Wash and dry hands thoroughly. 3 11.5% 2 11.1% 19. Record the results on the client’s record/antenatal

card and discuss them with her. 27 96.4% 19 95.0%

20. Refer client for HIV screening, if the client chooses. 25 89.3% 19 95.0% IDENTIFY PROBLEMS/NEEDS 1. Identify the client’s individual problems/needs,

based on the findings of the history, physical examination and screening procedures.

16 59.3% 12 60.0%

PROVIDE CARE/TAKE ACTION 1. Provides counseling on safer sex, arranges for her

partner to be treated and counseled. 2 14.3% 2 18.2%

2. Develop or review individualized birth plan with the client.

9 32.1% 7 35.0%

3. Provide tetanus immunization based on need. N/A 4. Dispense necessary medications. 13 46.4% 9 45.0% 5. Provide counseling about necessary topics. 26 92.9% 18 90.0% 6. Develop a plan for complications with the client. 11 40.7% 11 55.0%


ALL HIV MEDICS


SELECT HIV MEDICS


7. Record the relevant details of care on the client’s record antenatal card.

26 92.9% 18 90.0%

8. Ask the client if she has any further questions or concerns.

24 85.7% 16 80.0%

9. Thank the client for coming and tell her when she should come for her next visit.

27 96.4% 19 95.0%

*All HIV Medics assessed **HIV Medics assessed who worked at a site where they performed physical exams

4.5 IS THE TRAINING ADEQUATE? This question is connected to Question 4 but is intended to be more specific in relationship to the curriculum. A JHPIEGO technical advisor reviewed the curriculum. It should be noted that some of the recommendations are based on the reviewer’s assumption that “you want providers who can manage ARV therapy.” That the reviewer was unclear on this point after reviewing the curriculum denotes that the curriculum is not specific enough about the roles and responsibilities of the HIV Medic upon completion of the program. Some general recommendations for the curriculum are included in Table 5 and a full review is in Appendix K.

Table 5: Summary recommendations based on curriculum review

General

Provide a job description that clearly outlines the expectations after completion Include learning objectives in the course syllabus Clarify exactly what is expected in the objectives of the training The course syllabus should be more specific in the requirements for the clinical part

of the training Provide reference manual other than PowerPoint handouts

Didactic

Revise body system presentations to have a clearer focus on HIV and ARV management

Ensure that each presentation should include objectives Remove OI presentations to allow more time for clinical decision-making skills Start with general concepts and then get specific Include history-taking documentation

Clinical

Specify their role related to ARV management and revise curricula accordingly Emphasize clinical decision-making skills in clinical practice and increase use of case

studies/simulations in didactic portion Do not wait until the end for clinical Ensure adequate clinical experiences Provide more specific clinical guidance

Assessment

Include more activities for formative assessment Revise exam questions to be more consistent with objectives Review and revise weekly exam questions and final exam questions to be more

consistent Provide clear guidance on how to assess participants clinically Specify how they will be either qualified/certified/approved to practice and which

professional body will provide the approval


4.6 HOW DOES THIS CADRE MOVE TO LEGITIMACY WITHIN THE HEALTH SECTORS OF EACH COUNTRY?

This question is beyond the scope of this initial evaluation. However, some ideas on how to integrate this cadre with the existing system were addressed. In general, the stakeholders interviewed felt that the process needed to be implemented by the government and MOH. Some thought that this would work, while others were concerned about the lack of a medical background of the candidate and the current unemployment situation for nurses (in Uganda). When asked whether changes would need to be made to the health sector infrastructure to support the cadre, seven stakeholders replied that no changes would be needed. Others replied that bigger clinics would be needed to accommodate increased patient volume; there should be greater general planning; recruitment criteria would need to be developed; an increase in supplies would be needed; and the cadre “should be strictly deployed where there are nurses to supervise them.” Most stakeholders did not know if there were data available to help assess potential costs. Some stated that current information such as what other volunteers are paid and nursing costs could be used to help in planning. 5.0 CONCLUSION The evaluation demonstrated that the HIV Medic program has had a significant impact on the ground, both at the facility level and in the communities where the HIV Medics live. The program has been well received in both countries by health care providers working with the HIV Medics and by patients. The HCPs interviewed accept the HIV Medics as part of the ART team and appreciate the tasks and activities that they do. The number of clients accessing treatment has increased, according to available data. Challenges remain in relation to the varying scopes of practice the HIV Medics perform, as they differ widely by country and even by sites within a country. In addition, there are concerns among the HIV Medics over both remunerations and the need for more ongoing and continuing education. Finally, there were some tasks on the clinical skills assessment that showed areas for improvement. Among the most significant of the findings is that while the professionals at the facility level recognize and work well with the HIV Medics, professionals at policy level are mixed about the impact that this cadre can make, with many of them being skeptical. The stakeholders did agree that the government needs to be involved in moving this cadre into a more widely accepted role. 6.0 RECOMMENDATIONS AHF should work with the current HIV Medics and the health facilities to standardize their scopes of practice. As mentioned, this varies widely among the sites and is of some concern to the HIV Medics. There is a need for clearly defined job descriptions and orientation packages to be developed and documented for this cadre. In addition, AHF should explore the possibility that


there are areas that HIV Medics are being trained in yet few of the HIV Medics are using those skills. That might lead to some modifications of the training curriculum. The issues of pay, or lack thereof, should also be addressed because it seems to be unequal among HIV Medics, and some are becoming frustrated by the current system. There is also a need for continuing education for the HIV Medic due to the ever-changing HIV scenario and the length of time that has passed since some of the initial trainings. Although AHF does continually conduct site visits to the HIV Medics, it was clear that the HIV Medics were looking for more formal continuing education courses. AHF could make some modifications to the training itself. The training may need to be modified once the scope of practice is clarified. In addition, the objectives of the training need to be clearly defined. AHF could also make modifications such as providing other reference manuals, integrating the clinical sessions throughout the 12 weeks and revising the exams to be consistent with the objectives. AHF needs to work with the governments of Uganda and Zambia to move this cadre toward legitimacy to gain a wider acceptance among HCPs and stakeholders. In order to start achieving buy-in from government and other stakeholders, AHF should have an orientation for all stakeholders about the program and its potential impact. Because each country is at different stages of implementing the HIV Medic program, there is a need to revisit the strategies being used to get project approval from stakeholders and the government. There are currently many ongoing discussions about the human resource crisis. In Zambia, the MOH is developing a health assistant curriculum that would usher in a new cadre to provide basic nursing care in the hospitals. Because of the current justification that is being presented for the development and training of the health care assistant, CHAZ can help lobby for the integration of this cadre into the MOH structure. The HIV Medic program could be promoted as a part of the professional development program for the lower cadres, for example, dressers or registry clerks. This program could also provide credit points for entry into higher level colleges of education and training. In addition, ECSACON is undertaking a serious debate about the human resource crises in the ECSA region. AHF, through Uganda Cares, can use this opportunity to advocate for and sensitize the region on the impact of the HIV Medics in providing quality care and improving patient outcomes. On the regional and international levels, AHF should work with WHO since they are advocating for task-shifting programs as a way to address the “brain-drain” in many African and other resource-constrained countries. Finally, it is recommended that AHF continue capturing quantitative and qualitative information to document the program’s impact, including tracking the number of clients on ART and conducting brief interviews with HCPs and stakeholders.


APPENDIX A: NAMES OF SITES VISITED AND PARTNER SUPPORT

NAME OF SITE DISTRICT COUNTRY # MEDICS INTERVIEWED

# HCPS INTERVIEWED PARTNER

ZAMBIA

1. Chikankata Mission Hospital

Mazabuka Zambia 5 HIV Medics 1 CO 2 Nurses

CIDRZ CHAZ Salvation Army

2. Chisoba Farms Mazabuka Zambia 1 HIV Medic Private 3. Nameembo Rural

Health Centre Mazabuka Zambia 1 HIV Medic MOH

CIDRZ 4. Monze Mission

Hospital Monze Zambia 2 HIV Medics 1 CO

1 Nurse MOH CIDRZ

5. Choma General Hospital

Choma Zambia 1 HIV Medic 1 CO 1 Nurse

AHF CIDRZ

6. Macha Mission Hospital

Choma Zambia 1 HIV Medic 1 MD 1 Nurse

CHAZ ECR AIDSrelief

7. Mpongwe Mission Hospital

Mpongwe Zambia 1 HIV Medic 1 Nurse CHAZ MOH

8. Mtendere Clinic Lusaka Zambia 2 HIV Medics 3 Nurses CIDRZ 9. Mazabuka District

Hospital Mazabuka Zambia Comparative

for Chikankata Mission Hospital and Monze Mission Hospital

1 Nurse CIDRZ MOH

10. Kalomo Hospital Choma Zambia Comparative for Choma General Hospital

1 CO MOH

11. St Luke’s Hospital Mumphanshya

Chongwe Zambia Comparative for Macha Mission Hospital

3 Nurses CHAZ MOH

12. Luanshya Thompson Hospital

Mpongwe Zambia Comparative for Mpoongwe Mission Hospital

1 MD 1 Nurse

ZPCT MOH

13. Kanyama Clinic Lusaka Zambia Comparative site for Mtendere Clinic

1 Nurse CIDRZ


NAME OF SITE DISTRICT COUNTRY # MEDICS INTERVIEWED

# HCPS INTERVIEWED PARTNER

UGANDA

1. Masaka Healthcare Centre

Masaka Uganda 6 HIV Medics 1 MD 1 Nurse

Uganda Cares

2. Lyantonde Health Center

Lyantonde Uganda 2 HIV Medics 1 MD 1 Nurse

MOH Uganda Cares

3. Gombe Hospital Mpigi Uganda 2 HIV Medics 2 Nurses MOH 4. UCOM Hospital Masaka Uganda 4 HIV Medics 2 Nurses UCOM 5. Kalisizo

Healthcare Hospital

Rakai Uganda 1 HIV Medics 1 MD Uganda Cares

6. Rakai District Hospital

Rakai Uganda 1 HIV medics 1 MD 1 CO 1 Nurse

Uganda Cares

7. Mbale Health Facility

Mbale Uganda 4 HIV Medics 1 CO 1 Nurse

Uganda Cares JRC

8. Soroti Healthcare Facility

Soroti Uganda 3 HIV Medics 1 MD 1 Nurse

Uganda Cares

9. Kampala market clinic

Kampala Uganda 1 HIV Medic 1 Nurse Uganda Cares

10. Villa Maria Hospital

Masaka Uganda Comparative site for Masaka Healthcare Centre

1 Home Care Provider

Catholic Church AIDSrelief MOH

11. Tororo District Hospital

Mbale Uganda Comparative site for Mbale Health Facility

2 Nurses MOH


APPENDIX B: HEALTH CARE PROVIDERS’ INTERVIEWS—HIV MEDICS SITES

QUESTION RESPONSE

1. Country Uganda: 17 Zambia: 13

2. Gender Male: 10 Female: 20

3. What type of HCP are you? Doctor: 6 Clinical Officer: 5 Nurse: 19 Other (Specify): 0

4. What is your age range? Less than 25 years: 1 25–34 years: 9 35–44 years: 19 45 years or more: 0

4. What department of this site do you work in?

ANC: 0 Outpatient care: 2 Surgery: 0 HIV care: 2 ART clinic: 20 Other (specify): 5

8a. Do you know if there are any HIV Medics working at this site?

Yes: 30 No: 0

9. How many HIV Medics currently work at this site?

Range of one to six.

9a. Do the HIV Medics have a job description for working at this site?

Yes: 23 No: 2 Don’t know: 5

9b. Was there an orientation of the medics program undertaken at this site?


9c. Were the HIV Medics given an orientation as to their roles and responsibilities when they joined this site?

Yes: 19 Don’t know: 6

12. How long has the HIV Medic program been implemented at this site?

Range of 7 months to 4 years


QUESTION RESPONSE

13. Has the provision of health care changed since the implementation of the HIV Medic program?

Yes: 29 No: 0 Don’t know: 1 For the “don’t know” = Not possible to state definitely because the clinic started with HIV Medics

13a. How has provision of health care changed since the implementation of the medics? • Nursing shortage—when they are there work is much easier

• They are tracking patients, track follow-up • At least the medics have supplemented on the efforts done by the staff here • People are more open to them because they live with them in the community • Very much • They are very helpful • There was a workshop before starting to work with HIV Medics. After the workshop they

have worked with the medics as a team • We used to have 3 nurses and a lot of patients. The coming of the HIV Medics each nurse

has a simplified workload and tasks section and a medic—have been divided • Health education is done every day. She is able to identify very sick patients and refers.

Vital signs are done on every patient • Client flow has improved; record keeping • In terms of staffing, the workload is less. They are able to identify some patients • Very much. They are very knowledgeable and are cushioning the staffing and are able to do • They are very helpful. They collect specimens, does observation, Escorting patients

towards complete • We are able to increase outreach programs • Because they have been trained in counseling, assist with the staffing level, taking patients

as they are from the village and community, adherence counseling • The medics program has improved the workforce. There was a time nurses stopped coming

to clinic and for 2 months he managed the clinic alone • It has changed because at the beginning we had a lot of work and few staff, so now we

have a lot of help • Patients are coming to this site • Clients are going for VCT voluntarily because of their health education • HIV Medic has more time with clients and is directly responsible for clients • They are skilled, they counsel clients, they were trained. When I joined the clinic I didn't

know anything until learnt • We are more sensitive to the problems of HIV and helping to treat things differently. They

are a critical part of the ministry • She has implemented what she was taught,, e.g., counseling has improved; adherence and

confidentiality • Re-admission for HIV patients are few. Even mortality rate has reduced • They work hand in hand with nurses • It is not possible to say • Reduced waiting time and workload; good record keeping since they came • They are the majority and are providing care • Very much because they have lessened the burden for nurses


QUESTION RESPONSE

14. Do the doctors/clinical officers who work here accept the medics as professional care providers? Why or why not? Please explain

Yes: 26 No: 3

• It’s shown by or interaction • The doctors are a little skeptical as they feel that health information should be handled by

health professionals • They help and are active in health education • At times they will ask the medics (consult) or clients. It is not always that the nurses are

around • They appreciate his efforts, they will consider the vital, weighs and his comments • The medics have been accepted because they do some of the things nurses supposed to

do. This gives the nurse some relief • They help—they are able to identify the patients who need emergency care • They do involve and consult them where necessary • Medics would notice mistakes from the HCP • It was the doctors who told us to put her on the ART timetable • They know their job description • However some do not. They are not happy to allow the medics to do things like staging and

physical assessment • They work hand in hand • Helps the doctors, well informed and also assists us where we find problems • We work as a team. We can consult them as we know she knows what she is doing • They are not accepted because they are not in MOH structure we had a meeting here when

everyone complained about why they were attending the meeting. As they are not known outside the Uganda Cares circle

• Because they HIV Medics have been trained to do all the work that is here • The doctors see them during the work. They are part of the team and attend team meeting,

including the hospital staff meeting • They consult them. They are the ones doing most of the work • In a situation where we have no skilled manpower. These medics have proved to be

effective • Actually doing a good job. Patients who don’t have an Ols are usually given their drugs and

this saves time • This centre was under-staffed and as people who work here also perform other duties at the

hospital but with her she is permanently here • They do better than a nurse who is not oriented to HIV • She works very hard and lessens the burden of nurses • No = Medical knowledge they hold is quite shallow but the responsibility they hold is big • No = They feel their training was not enough


QUESTION RESPONSE

15. Do the nurses who work here accept the HIV Medics as professional care providers?


15a. Why or why not? Please explain • It’s shown by or interaction

• They have been helpful as they are doing everything, counseling, observations • They are helping during observations, record review dates • They are knowledgeable and they do whatever the nurse can do, blood collection,

adherence getting history • The medics have taken some of the nurses’ duties • They are doing counseling, bleeding clients [drawing blood] • They incorporate them in day to day activities • Lessen the burden for the nurses • The major job she does is contributing and helping us • We work as a team • They know their work • Again to a limit. Some nurses feel threatened by them that they are taking away his/her job.

They feel that the medics are not able to have achieved enough knowledge in the short space of time

• I am able to consult from her. She is eager to learn • Have been working hand in hand with them. She also helps and orients them as some have

never worked with HIV clients • We work as a team. We can consult them as we know she knows what she is doing • For us who work with them we have seen the impact that they are making • I have always worked with them, I see them as potential people and help in dispensing,

health education and outreach • We work as a team • As they are taking on nurses’ tasks which can be handled by them • They accept her as she has helped reduced work overload fro them • Explanation given to nurses and placed under supervision • They work hand in hand with nurses • We work hand in hand • Very helpful especially in the outreach program • For the same reason give in 14a • Because we learn a lot from them where HIV and ARVs is concerned. Even consult for

them • Consult them. They are treated as an equal part – outreach


QUESTION RESPONSE

16. Do the clients accept the HIV Medics as professional care providers

Yes: 28 No: 1

16a. Why or why not? Please explain • Patients enquire from them

• This was confirmed by the research • They feel free to tell them about HIV, how drug helps • Clients do not know difference on the cadre as long as they are attended to nicely • The client accept his to screen them including staff • Just do the functions as the professional nurses • They will come in and ask for them; They are never harsh with patients • Confidence in them • As the counselor, the patients are free to talk to her when they find her at this clinic • Most patients have come out in the open • They act as role models • ARV clients • Interacts very well with patients. She is experienced in ART • She recently got married and the patients contributed to the wedding with the little that they

had and they came out to support her • Patients don't know the difference. Patients cannot tell as long as we talk the same

language • Patients like them as they reduce patient waiting time and have improved the functioning of

the clinic • Since the provider came to them, so long as a client is given he/she accepts the one

providing as a professional • I always see them interacting with the clients • As they don't differentiate us and some are doing unique work such as CD4 and

coordinating changes • As some of the HIV medics are positive, they are able to disclose. They don't look at

themselves as over qualified and identify with their patients • She saves patient when they come for health care • She is courteous and clients like her • Because there is no clear demarcation between HIV medic and HCP • She works very well with her clients • They are very patient to them and very welcoming • Many of the patients want to see a doctor when they come to the clinic. They do not explain

their problems to the HIV medics first • The bond between them is more than HCP • They have knowledge and the way they treat patients. They are very compassionate


QUESTION RESPONSE

17. Which of the following responsibilities are performed by the HIV Medics and how would you rate their job performance in each area?

Perform Job performance rate Yes No Excellent Good Fair Poor Not

Applicable a Patient medical histories 23 7 8 13 2 b Basic patient assessment and

physical examinations 17 13 3 9 4 1

c Taking vital signs 27 2 10 13 3 d Pre-test counseling for HIV CT 20 10 9 10 1 e Conducting HIV rapid test 5 22 3 2 f Post-test counseling for HIV

CT 19 11 9 8 1

g Adherence education, counseling and support

30 16 7 2

h Review and document in-patient charts

25 4 6 15 2

i Present findings to supervising physician, clinical officer or nurse

25 3 6 12 5

j Dispense and or deliver medication prescribed by physician

16 12 10 4 1

k Phlebotomy 18 11 9 8 l Insert IVs 10 17 4 5 1 m Community outreach 20 9 9 5 n Other (follow-up) 4 1 3 18. Which of their above job functions do you think is the most beneficial to the clinic and the

clients? Why—please explain. Clinic: Reduce the workload; Client:

Counseling

Adherence and pre-test counseling As there is a multiplier effect follow up and seek client in the field as they live in the community

Adherence education, counseling and support

Because they can follow up patients

Adherence counseling and nurses desk where they: Pull out files; Observation; Need for referral, e.g., patient diet

Patient medical histories; Taking vital signs; Adherence education, counseling and support; Phlebotomy;

Because the shortage of health providers. As these are nurses functions which are covered by them in the absence of nursing staff

Patient medical histories; Adherence counseling

The history taken is usually beneficial to the clinical officer

Adherence counseling general support to the clients

As nurses don't have the time off a patient can adhere to medical and they will live long


QUESTION RESPONSE

Pre-test client assessment; Observation They quicken [speed] up services Patient medical histories; Basic patient

assessment and physical examination; Taking vital signs; Adherence education, counseling and support; Phlebotomy

Because they perform it much better, the other roles need much more training

Adherence education, counseling and support; Present findings to supervising physician, clinical officer or nurse; Follow-up

Especially in adherence counseling they find out where the patient is having a problem and find a solution

Patient medical histories; Basic patient assessment and physical examinations; Taking vital sign; Pre-test counseling for HIV counseling and testing; Post-test counseling for HIV CT

Make the work easier, patients feel comfortable with her during counseling even when taking blood

Adherence education, counseling and support; Follow-up

There is the impact. We are able to track [follow-up on] these patients

Adherence education, counseling and support; present findings to supervising physician, clinical officer or nurse; Sensitization

Helping patients to open up and getting better

Enrolling clients taking vital signs; adherence counseling

The HIV medics are able to do adherence in their home communities

All of the above To help in care for the patient Adherence and Post-test counseling This is the crucial part of care Patient medical histories; Conducting HIV

rapid test;

Clinic dispensing and record keeping; clients adherence counseling; dispensing of drugs

We can order drugs correctly and we are keeping accurate records

Health education counseling, adherence and going ARVs and treating opportunistic infections when the clinic receives many clients the HIV medics do assist to see some of the patients and new ones are joining everyday

Clinic dispensing the drugs; client adherence counseling

You have to write a note to stress on what you do

All are beneficial If they have capacity built they can do better Triage area dispensing data section; VCT

(phlebotomy side) Phlebotomy [as] there are too many clients and the nurses do other tasks; even in dispensing, it’s the HIV Medics who are supplementing

Taking vital signs; Pre-test counseling for HIV CT; Adherence education, counseling and support

The vitals are essential and work as monitoring the clients. Treatment education improves adherence. We have a good adherence percentage. We use the data to collect the drugs

Recording and reporting of drugs This is excellent as it helps us to get our drugs correctly


QUESTION RESPONSE

Adherence education, counseling and support; Taking vital signs; Pre-test counseling for HIV CT; Post-test counseling for HIV CT

Without counseling then HCP would be doing nothing. Would not know the progress of patients

Patient medical histories; Basic patient assessment and physical examinations; Adherence education, counseling and support; Review and document in-patient charts; Present findings to supervising physician, clinical officer or nurse; Community outreach

Especially community outreach because she is able to bring patients from the community

Community outreach; Pre-test counseling for HIV CT; Post-test counseling for HIV

They are able to track patients from the community through HIV sensitization

Patient medical histories; Basic patient assessment and physical examinations; Taking vital signs; Review and documents in-patient charts; Present findings to supervising physician, clinical officer or nurse

They greatly facilitate the doctors and nurses ability to handle clients faster and effectively

Adherence education counseling and support

Because without adherence counseling we cannot forge ahead

The counseling and compassion they demonstrate

They follow up all our positive clients to let them know they are not forgotten once they leave [the clinic]

19. How would you rate the general, overall performance of the HIV Medic(s) in your program?

Excellent:9 Good: 19 Fair: 1 Poor: 0 Don’t know: 1

19a. Why (give specific example) • They are conscientious and knowledgeable experts in HIV/AIDS

• Everyone appreciates the work they do • There are teachable, obedient and have been learning very fast • They know what they are supposed to do • They know their job description and are able to correct the mistakes • The work done has been excellent and beneficial • Adherence counseling patients do not default • Even if there are no nurses one can work with them • The way they handle patients. They maintain confidentiality and are good listeners • Especially on drugs, able to identify that this combination is not good and will go back to

clinical officers and patients to follow up • He is able to assess and tell • Generally has been good • Number of follow-ups has increased • They have helped to maintain patients in the clinic. Medics can tell us if patient is not doing

well • We are able to increase the number of clients on our books. More clients are coming for

VCT, awareness has increased • She has interest in her job. She is able to ask when she is not sure • Because they are there at the clinic all the time • They have been trained to do some of the work that the nurses do; they dispense ARVs


QUESTION RESPONSE

• The ones we have here they are good – phlebotomy. Martha is really good at - CD4; IVs are dispensing the drugs. They are very prompt in identifying priority cases. In quality assurance the data is being handled well

• She is good at recording timely reporting of drugs. As we are able to record the drugs and there are no queries from Kampala on drugs

• They have been dispensing drugs well and the reporting and ordering of drugs—they are even better than some nurses

• Reduce workload, waiting time; patient flow is good; drug dispensing good • They are doing a good job by being around, especially counseling patients • Issues of medical assessment and training clients is their greater weakness

20. Do the HIV Medic(s) seem sufficiently trained to execute their responsibilities?

Yes: 26 No: 4

• They need a longer period 6 months–1 year • Because some things they don't know like doses of drugs. Interpreting the prescription—

one of the medics was a nursing auxiliary and is doing well • When I compare them with the nursing assistants, the HIV Medic is well trained • Sometime we even consult her • I can say As what they are doing now is the work of a nurse • Because I know they understand what they are doing

21. How would you rate their level of training? Excellent: 7 Good: 16 Fair: 5 Poor: 0 Don’t know: 2 • Medics training is HIV, there is more nursing

that is being done so they need training in basic nursing and counseling

• Training needs to be extended 22. To what extent has the use of HIV Medic(s)

influenced the clinic’s goal of increasing the number of patients treated with ART?

A much greater number of patients can be started on ART each month: 24 A somewhat greater number: 3 Only a few more patients: 0 There has been no change in the number of patients: 2


QUESTION RESPONSE

22a. How? (Please explain how the HIV Medic(s) have affected patient uptake numbers?) • Live in community

• As patients rely on the Medic before seeking care • Patient update has increased • They have allocated the staff shortage • They have helped as we are the targets for new clients • Very much • As Ivan works in the counseling room and patients feel free to be brought by her to the ART

clinic • Numbers have increased • A good number is coming to the clinic • Patients are closer to Medics than HCPs • Number of patients is increasing • When clinic begins, they are taking care of patients • Patients spend less time and this encourages them to bring more people; Outreach • The patient number has increased • Because of the outreach she conducts and the treatment counseling and is the first point of

conduct of patients • As we work as a team we are providing right information, right staff and patient waiting time

has reduced • More patients are coming to the clinic • The number of patients attending the clinic has increased • We have been able to identify and refer positive patients more effectively • Community outreach and sensitization • They have been advocators for ART wherever they live • Because they do a lot of work and our contributions are equal • They are helping with H.E and we have formed support groups • The number has increased due to the awards conducted • Awareness has increased however more clients come to the clinic • They don't do community outreach as a result - no patients come from the community • They do not participate in initiation of ARVS


QUESTION RESPONSE

23. How many patients was each physician able to manage in one full clinic day prior to the clinic’s use of HIV Medic(s)?

24. How many patients is each physician able to manage in one full clinic day now that the clinic uses HIV Medic(s)?

Unknown 50–70 12 35 50 50 60 100 28 50 60 70 30 45 0 10 50+ 70 Unknown 70–90 30 15 30 40–50 7 40 20–25 35–40 30 50 20 70 100—We were working on alternative days 100—It has changed so much. The

publicity for ART has increased 100—In the beginning 40—We are sharing tasks so that those

who don't need to see a doctor are attended by either one of us

80 80 50 40 20 45 20 20 Unknown 25–30 25. What are the current client adherence rates

for ART? % 26. What were the client adherence rates for

ART before the HIV Medics started? % 95 Unknown 90 50 70 Unknown 90 90 60 50 75 0 82 65 95 80 95 95 94 Unknown


QUESTION RESPONSE

70 and more 85 90–100 Unknown 98 Unknown 80–95 80 or below for some patients 98 Unknown 90 50 95 95 95 90 85 68 70 50 27. What has been the effect of HIV Medic(s)

on the overall functioning of the clinic? Much improved functioning: 25 Some improvement in functioning: 2 No change in functioning: 2 Not functioning as well as before: 0 Functioning much worse than before: 0

27a. Please explain your response; give an example • Workload has reduced; Patient outcomes has improved

• As they screen the new patients • They counsel clients well • We are able to divide ourselves during each clinic day • Arranging opening files good at H.E. controlling the clinic • Patients understand more clearly; Spend more time with patients • Numbers have increased both in VCT and ART and patients are adhering to treatment • They work hand in hand with peer educators • Able to bring patients from the community • As she was trained in keeping records. As she works there daily she keeps track of what is

going on • Involved in the clinic we have increased the clinic days from 1–4; Organized record keeping • We don't experience workload. This is because at first one person used to do all the things,

e.g., screen patients, take blood, dispense drugs and write reports. Now all these tasks have been divided

• The record keeping has improved. All patients now have the vitals done • We have them full-time not like other staff in the government clinics who may be committed

to other duties. She is here full-time • Adherence is very good • HIV Medics have been trained to do a number of tasks relating to clients • It has enabled us to treat patients more effectively in our prison ministry with prophylaxis • Nurses are able to consult with Medics if they are not sure about anything • Scaling up patients. There has been an increase in numbers • Involve meeting • Because the Medics supplement what the nurses are able to do • We now have a more systematic approach • Because we are having the same number of patients since we started • Actually the Medic has been around since the ART program started


QUESTION RESPONSE

28. Would you recommend the HIV Medic(s) to other clinical programs?

Yes: 29 No: 1

28a. Why or why not? • Can spend more time with patients

• Will the exodus of professionals, medic can do [the job] since they are trained in basics • HIV manager • They help • It is working in ART, it can work elsewhere • Because the TB and ART clinics are doing well because of the HIV Medic • We want many people to come to VCT • They are very confident in what they are doing • Each department so that they can be counseling patients • They know how to handle the patients • Because we health professionals are few • As they are permanent and it improves the clinic function • Yes, especially for these who (did not complete sentence) • Especially if they are trained for these other areas • We have waited to take them to children’s ward. ANC to improve patient numbers and give

everyone test • They need enough training and refresher courses • They have interest in the work and they work well • They are the true experts on HIV and recognizing it early • In the community where we go they are able to see any cadre of patients • We have been able to achieve high patient rates as there are no qualified personnel • So that they can monitor what is happening in the other areas • The medics have been trained in basic procedures, which they are able to perform

excellently • They are able to do some of the jobs nurses did previously, however, nurses are able to

visit the clinical officers and doctors • Because they are trained • Especially ANC and PMTCT • If doctor compares HIV Medics and nurses he is of the opinion that nurses have more

medical knowledge than HIV Medics. He has no problem with nurses being trained as HIV Medics

29. Please share any other thoughts or comments on the HIV Medic program. • Refresher courses for the medics as every day things are changing

• Medics need to use capacity building to enhance their skill • It’s a good program as they are helping a lot and improving patient • Recommendations: 1. It is a good program as HIV knowledge is dynamic and the needs

update, ongoing program. It should continue. 2. Motivation should be recognized by MOH as they are a CE scale

• Program very new; longer period of training, add on their syllabus as they will help to reduce patients load

• They need to train more • The Medic has improved the outreach program. She has contributed to the awareness programs • They are doing fine. Doctors and nurses can be trained as well • They are doing a great job. Acting as role models • They have lost morale because they are not being paid. Otherwise it’s a good program • Train more Medics and put more than two at each clinic • They have helped in making work easier • More HIV Medics trained; Need pediatric counseling • Improves the clinical skills, especially in examination and in the management of common


QUESTION RESPONSE

illness. They are good at ART drugs but other drugs no • Refresher courses for them; counseling as they are not committed to their work; They had

an attitude problem as they believed that they were Uganda Cares staff • The HIV Medics have improved service delivery as far as ART service delivery is

concerned. They need to be accepted by government, e.g., prescribing: There was a time we were all very busy and we forgot to write a patient drug on a prescription paper. The HIV Medic then copied the drugs from the file and wrote them on the slip and sent the patient to the pharmacy. There were a lot of problems and the patient was sent back as the pharmacist stated that the government does not recognize the prescriber. So government needs to recognize the HIV Medics

• The HIV Medic program was a good innovation and should be extended to other good clinics. The HRH crisis has led to us now being able to get a full-time nurse. We should employ two for this clinic

• They should be trained longer than three months • Some of the HIV Medics cam be trained further to become professionals, e.g., nurse • The only request would be for additional training to recognize and treat common diseases

such as malaria • Very good program. AHF should train more Medics. Even drama performances should be

incorporated in their training • These are sincere people who are trained to do specific tasks where as the nurse might not

want to work here. Some nurses cry when seconded here as they don’t like HIV work. The Medics are trained for this and enjoy what they enjoy

• Program has been good. Any other place that has not Medics can use them as long as they are willing to train them

• We need government to note the important part that Medics are playing in health care delivery. This program will help cushion the brain drain

• Introduction into more ART centers • It is a good program. However, it needs to be acknowledged by the government. I feel that

the doctors, clinical officers, nurses would let the Medics do more if they were supported by the government

• It’s a good training but they are not being paid • Increase their training in dispensing and clinical presentation and examination • Every HIV Medic should have a recognized medical training before being trained as an HIV

Medic. The Soroti Health Care Clinic did not have health care providers with medical training background before they were trained as HIV Medics. The training should be for at least 1 year instead of the current three months


APPENDIX C: HEALTH PROVIDER INTERVIEW— NON-HIV MEDIC SITES

Twelve health care providers at sites without HIV Medics were interviewed—three in Uganda and nine in Zambia.

QUESTION RESPONSE


2. What type of HCP are you? Doctor: 1 Clinical Officer: 6 Nurse: 8 Other (home care provider): 1

3. What is your age range? Less than 25 years: 0 25 – 34 years: 5 35 – 44 years: 3 45 years or more: 4


ANC: 0 Outpatient care: 0 Surgery: 0 HIV care: 0 ART clinic: 9 Other (general nurse – including ART, home care): 3

9. Do you think the doctors/clinical officers who work here would accept the HIV Medics as professional care providers? Why or why not? Please explain

Yes: 11 No: 1

• If they have appropriate training • Will lessen the burden of HCP • It's because a high number of doctors are overworked • Due to shortage of staff • They would agree currently we have dressers who are doing BP, T, R, weight and (did not

complete sentence) • Already we have 4 ART centers as at times we are short staffed and CHW help the clinic

staff • Especially when we go for outreach activities , this would ease the workload, currently we

have an adherence supporter who is currently doing this • When trained it will remove pressure but under supervision • They will be help and lessen burden of HCP • They would help if properly trained • If he is well trained • Who would pay them?


QUESTION RESPONSE

10. Do you think the nurses who work here would accept the HIV Medics as professional care providers? Why or why not? Please explain

Yes: 11 No: 0

10a. • Will lessen the burden of HCP • As they would be helped • Due to the overload • The nurses are overworked • Because we have a staff shortage • Due to the workload • Due to increased number of ART clients and there has been no corresponding increase in

trained HCPs • They will be helpful • If these are trained and have basic skills

11. Do you think the clients would accept the Medics as professional care providers? Why or why not? Please explain

Yes: 12 No: 0

11a. • Because we have CHW and these are doing a lot of work • Whoever is giving help to them is acceptable • As there is workload we would help patients • As we have a peer educator who attends to them • Clients generally don’t know the difference • They do accept them now • As we don't normally go with our titles, all the clients are interested in quality care • Clients are already used to the dresser doing this • Will improve the staffing • If these have identities and are properly trained • If the person is well-trained • At the ART clinic we have support groups who are trained in taking vital signs; adherence;

health talks, patients accept the people when trained


QUESTION RESPONSE

12. The following are some of the responsibilities that can be performed by the Medics. Do you think it would be beneficial for this clinical site to have more staff to help with these functions?

Beneficial Yes No Comments a Patient medical histories 12 0 As long as they can write b Basic patient assessment and

physical examinations 9 3 If they are competent

c Taking vital signs 12 0 d Pre-test counseling for HIV CT 12 0 e Conducting HIV rapid test 9 3 If trained f Post-test counseling for HIV CT 11 1 g Adherence education, counseling

and support 12 0


4 8


6 6 Simple things like vital signs; this would be a problem

j Dispense and/or deliver medication prescribed by physician

6 6 Not dispense, but deliver

k Phlebotomy 2 10 l Insert IVs 3 8 m Community outreach 9 2 13. Which of their above job functions do you think would be the most beneficial to the clinic and the

clients? Why – please explain Taking blood, Medical History; Adherence

counseling Due to shortage in these areas

All of the above Helping care for the clients Counseling It needs more time and needs more people Community outreach As nurses can't manage, especially the

adherence and follow-up Patients medical histories; Pre-test

counseling for HIV CT; Post-test counseling for HIV CT; Adherence education, counseling and support

Adherence education, counseling and support; Basic patient assessment and physical examination; Taking vital signs; Patient medical histories; Review and document in-patient charts; Present findings to supervising physician, clinical officer of nurse; Community outreach

Make clinic to move faster

Pre-test counseling for HIV CT; Basic patient assessment and physical examinations; Dispense and/or deliver medication prescribed by physician; community outreach

When patients is tested


QUESTION RESPONSE

Patient medical histories; Basic patient assessment and physical examination; Taking vital signs; Pre-test counseling for HIV and testing; Adherence education, counseling and support

They are currently being done by dressers and for counseling we have counselors

Adherence education, counseling and support; Community outreach

Adherence counseling Without adherence these people will not be able to take med

Vital sign; Counseling; Adherence These are currently too much for staff 14. How many patients is each physician able

to manage in one full clinic day? 15 – 1 20 – 2 30 – 2 40 – 2 45 – 1 50 – 2 60 – 2

15. What are the current client adherence rates for ART?

50% - 1 80% - 6 85% - 1 95% - 1 98% - 2

16. Please share any other thoughts or comments on the HIV Medic program. • I know about the great work that Martha is doing in handling the CD4 machine

• It's a good program and it would be good for the patients • How can they be trained; what levels of education • It’s important to help client and improve quality care • I don't know about the program, so it’s difficult to comment • I think it’s a good program, make life easier and enroll more clients • I would prefer that these are currently doing the jobs such as the dressers should be the

ones trained. Currently the dressers are taking vital signs, screening patients, weighing them; it would be good if they were trained. If this program takes off

• We need HIV Medics at this clinic • This program should be advertised and the criteria for enrollment clearly discussed • It's okay • Motivation, supervision and training. As ARVs is too dynamic and constantly changing;

Drugs are constantly changed, because by litigation we need to register to protect them


APPENDIX D: HIV MEDIC INTERVIEW Thirty-seven HIV medics were interviewed—23 in Uganda and 14 in Zambia.

QUESTION RESPONSE

1. Gender

Male: 17 Female: 18

2. What is your age range? Less than 25 years : 5 25 – 34 years: 17 35 – 44 years: 11 45 years or more: 4


ANC: 0 Outpatient care: 2 Surgery: 1 HIV care: 2 ART clinic: 23 Other (specify): 9 • Laboratory • Nameembo rural Health Centre • Chisoba Clinic • Training department - I work every where

as I am an HIV Medic trainer • Dispensing • Triage we normally work • Pharmacy • Outreach ministries (2)

4. How long have you been working at this site? Range from 10 months to 17 years 5. Where did you work before that?

N/A: 5 I didn’t, I was in training/school/university: 3 A hospital: 6 A clinic: 0 Other (specify): 22

5a. How were you selected for the HIV Medic training? • At Mtendere Clinic was doing voluntary after testing position. Joined a support group for

four years and was working very well and then selected for training • Because of community experience was a volunteer at the clinic as he had been trained as

an early childhood care development by ECCD • Chosen by Chikankata Hospital • Chosen by clinic • I was just called by the nursing manager • Just selected from administration • Management choose me as I was a CHW • Picked by the clinic • Through application • Through application • Through hospital management • Was a ward auxiliary nurse • Working as a volunteer—Anti Aids Club Chikankata Hospital • Working at CHW at Chikankata


QUESTION RESPONSE

9. How long has the HIV Medic program been implemented at this site?

Range from 10 months to four years

10. Do you have a job description for the role of an HIV Medic?

Yes: 30 No: 7

10a. Did you receive an orientation when you came to this site?

Yes: 31 No: 3

11.

Do you think the doctors/clinical officers who work here accept the HIV Medics as professional care providers? Why or why not? Please explain

Yes: 32 No: 3

11a. • Everyone has appreciated my work, e.g., community outreach • Because we work as a team. We are learning and they are supportive • They ask help from Medics when they are not sure • I think we are helping the doctors and nurses to do the work faster • I help them a lot • Also because of [the] experience and knowledge of us Medics. The work is shared with us

at the clinic • As they seek advice and consult us when working with us • We are contributing to lessening the workload • Do consult me as HIV Medic • They have not said any negative things about us. They really teach us • As we work hard, as we assist we are the ones doing vitals, history taking, drawing blood,

adherence counseling, follow up patient • They consult with Medics when they are not sure • I assist them so much where work is concerned • As they help us and we were given an orientation • When I came the doctors and clinical officers wanted me to work in the clinic but the people

there at ART refused and said they were new staff • Clinical Officers accept as they ask question when they don’t know. Nurses fear as they

think we have more knowledge about HIV than them • They do consult me, especially on drug side effects • Some not all of them. It’s not known to every (HCP) • We consult each other at the triage center • Some do consult with Medic when they are not sure • Because we work under minimal supervision • Some do, some don’t. This program is not yet known to all HCPs • They sometimes consult with us medics • Because when we are absent they call us. When we complain about being tired of

volunteering they plead that we don’t leave • Because we make work easier • As we are working with doctors and I don’t have problems • I help them so much to care for the patients • We have been helping in caring for the patients • Some do some don’t. Because they don't trust us in our work • The things you do are relative to what nurses are doing • By the way they supervise me. I am corrected whenever I go wrong • We work under the supervision of nurses • N/A • There is a problem with the cadre. There is a controversial issue as they don’t know what to do • Zero doctors/clinical officers


QUESTION RESPONSE

12. Do you think the nurses who work here accept the HIV Medics as professional care providers? Why or why not? Please explain

Yes: 35 No: 1

12a. • We consult each other where work is concerned • They help us. What we don’t know we report to the nurses. We are directly reporting to

nurses. They provided good corrective advice • Ask for any opinion • Because nurses will come and delegate us • We work together as a team to care for the patients • The knowledge and experience in us to work with them • As we have no problem working with them • Lessening workload and free them to do other work • Work hand in hand to save lives of patients • They are ready to teach • Because since we came here the workload has been reduced. Before we came they used

to do all the things. As you have seen they are not here they are attending a workshop and so we are running the clinic

• Consult from Medics • Lessen the workload • As we work hand in hand with them • Because now I am on the timetable • They do consult me where possible • Because they teach us when we don't know and they also teach us. We also teach them on

ARVs, we help then in dispensing drugs • We work together with the nurses. We are always allocated together with the nurses • We are working together but the HIV is not in the nurses’ syllabus so we are helping them • Medics are very helpful, e.g., drug dispensing and drawing of blood • Because most of the time they do consult with us • Our work is better than some nurses. We have more knowledge about HIV than nurses • Some do some don’t. Sometimes they talk bad things about us. They think we will take

away their jobs • We help in work of prescribing and dispensing. We are taught to prescribe ordering

medicine but only ARVs • They appreciate the work we do at the ART clinic • Some accept me and some don’t want me to work here. They feel I am getting more money

and I am working for Uganda Cares • They usually consult with me • We work hand in hand with nurses • They give us work to do under minimal super vision • As we have kept to our scope of work and we are not indulging in the clinical work • Because we work together as a team • Nurses keep thanking us and appreciate what we do • Nurses are not accepting as professionals as we have more knowledge than them


QUESTION RESPONSE

13. Do you think the clients accept the Medics as professional care providers? Why or why not? Please explain

Yes: 37 No: 0

13a. • Because we are the first point of contact that they see when they come here • Medics help so much in the community to sensitize • We give a lot of counseling and a lot of support • They are more open to me than to the nurse I work with • Clients seem to see no difference in my care, given by nurses and Medics. It's the same • As we have good relationship with them • Give them information about HIV; Allow them to ask questions • They approach us and disclose information to us. We have good communication • Because I respect and interact with them very well • They come to us for assistance and don’t segregate and ask for Medic or nurse. The literate

ones know and understand the difference • Services offered to them. They don't wait too long on a queue • How I interact with them concerning their health • When I am not around they all wait for me; I visit them in their villages • Due to our relationship and response to them • Like the TB patients most of them are on ART • I am very good at tracking defaulters from villages. Before Medic were only two patients,

now there are 17 patients on ART • Very much as they consult us when we are in the community • The way I interact wit them • As I have a good relationship with my clients • They take the information that we give them as we have the knowledge • We know that they accept us. We have never had any problem • Patients usually come to Medics, when they want to know more about HW and ARVs • Patients come to the clinic because of our sensitization in the community and we are part of

the same community • They feel free with Medics because we are always with them • The care we give our clients • Because patients say we are happy • Because of how we treat them • Because of the way we counsel and communicate with patients • We are always here and we are the first point of contact for the patients • I educate then so much on HIV/AIDS and adherence • The way we take care of them, we always emphasize on confidentiality • Because sometimes nurses are too rude to them • Because patients usually ask us a lot of questions on treatment • Through the session conducted. Always see us for advice • Although we need other skills they do accept us the way we are handling them • We make work faster and easier • We help them a lot where care is concerned


QUESTION RESPONSE

14. Which of the following responsibilities do you perform at your place of work?

Yes No a Patient medical histories 34 3 b Basic patient assessments

and physical examinations 15 22

c Taking vital signs 34 2 d Pre-test counseling for HIV

CT 28 9

e Conducting HIV rapid test 15 21 f Post-test counseling for HIV

CT 29 7

g Adherence education, counseling and support

35 2


32 5


35 2


23 14

k Phlebotomy 26 11 l Insert IVs 17 20 m Community outreach 28 9 n Other (specify) 21 Other items specified included: CD4 count – 3; Client follow-up – 5; Community mobilization;

Drawn Blood; Enrollment; Entering data; Health Education; Open files, Observation; Patient tracking in wards; Refill; Report writing to MOH

15. Which of your above job functions do you think is the most beneficial to the clinic and the clients?

Why – please explain

Pre-test counseling for HIV counseling and testing

As this enables the client to get assistance if it is done well

Basic patient assessments and physical examinations

These help improve the overall functioning of the clinic

All of the above Without these procedures above, we cannot give our best care for our patients

Adherence support Keeps patient on treatment and improves quality of life

Taking vital signs; Adherence education; Counseling and support; Pre-test counseling for HIV CT; Dispense and/or deliver medication prescribed by physician

Because here we can work without supervision


QUESTION RESPONSE

Taking vital signs; Pre-test counseling for HIV CT; Post-test counseling for HIV CT; Adherence education, counseling and support; Present findings to supervising physician, clinical officer or nurse; Dispense and or deliver medication prescribed by physician; Community outreach

In cases of HIV and adherence counseling this part is done by HIV Medics because there are no trained counselors at ART clinic

Adherence education; Present findings to supervising physician, clinical officer or nurse; Taking vital signs

This is because it makes work faster. The vital signs help pre-determine client’s condition

Adherence education, counseling and support Because patients don't know how to take drugs Dispense and/or deliver medication prescribed

by physician Because it’s important to know the history

Adherence education, counseling and support; Taking vital signs

More information is supposed to be given to the patient before actual treatment to avoid drug resistance

Pre-test counseling for HIV CT; Post-test counseling for HIV CT; Conducting HIV rapid test; Taking vital signs; Review and document in-patient charts

Help nurses when they are busy with other things

Taking vital signs; Pre-test counseling for HIV CT; Adherence education, counseling and support; Dispense and/or deliver medication prescribed by physician

They help in the care of the patients

All of the above They make the work for the doctor much easier Adherence education, counseling and support;

Community outreach; Taking vital signs Especially adherence counseling because we educate patients on side effects and how to take their drugs

Conducting HIV rapid test; Dispense and or deliver medication prescribed by physician; Adherence education, counseling and support; Taking vital signs; Pre-test counseling for HIV CT; Post-test counseling for HIV CT; Community outreach

Have been doing these every day and have more knowledge on them

Counseling; Adherence education As I am doing most of the counseling when the counselors are now here. Counseling on adherence

Taking vital signs; Pre-test counseling for HIV counseling and testing; Post-test counseling for HIV CT; Adherence education, counseling and support; Review and document in-patient charts; Dispense and or deliver medication prescribed by physician; Community outreach; Phlebotomy

Because I am very good at doing them

As I am in the pharmacy I do stock taking and drug ordering/complete drug orders

Because it helps in planning and enables us to predict and see number of patients who will be ready for treatment

Adherence counseling; Triage is the most beneficial

This improves patients’ goals; improve quality of life; We have improved the management of client. Patients don't wait long


QUESTION RESPONSE

Reviews and documents in-patient charts; Adherence education, counseling and support

Help us to know whether we are progressing or not; This will help reduce resistance and improve quality of life of patients; Suppress and improve immunity

Adherence education, counseling and support; Treatment education; Patient medical histories; CD4 Count

If they are not adhering and have not been prepared well they cannot start ART. Counseling is also important as most people have problems. VCT is also important

Counseling Because it’s the core of patient care All are beneficial As they improve client care Adherence education, counseling and support;

Taking vitals signs To help clients understand why they have to take drugs every day

Patient medical histories; Taking vital signs; Adherence education, Community outreach

Give right medication to the patients; Help HCPs

Adherence, Taking vitals, Patient medical histories, Pre-test counseling of HIV CT; Post-test counseling for HIV CT

To cut out a numbers of defaulters

Adherence education, counseling and support Because as that is the biggest problem. As clients lack knowledge on adherence we find we have to teach the client three times or more. As they don't understand the importance of adherence due to food and transport

Patient medical histories; Basic patient assessment and physical examination; Pre-test counseling for HIV CT; Adherence education, counseling and support

Help patient in their day- to-day life

Patient medical histories, Adherence education, support; Post-test counseling for HIV CT

Because I am able to give proper information to my clients

Basic patient assessment and physical examinations; Taking vital signs; Pre-test counseling for HIV CT; Post-test counseling for HIV CT

Helps in care for the patients

Adherence education, counseling and support; Patient medical histories; Basic patient assessment and physical examinations; Taking vital signs; Review and document in-patient charts; Dispense and/or deliver medication prescribe by physician

Because I need to know that patient is adhering to the treatment, to prevent complications

Health Education on drugs; Sanitation; Taking History

Patient medical histories; Taking vital signs; Adherence education, counseling and support

As they improve the health outcomes of patient adherence

All of the above: A-N All my jobs are connected and patients finally get better

Documentation; Triage The need to keep the records is important, all things need documentation; Help to find out who needs help

Everything is vital


QUESTION RESPONSE

Pre-test counseling for HIV CT—but we are not doing as we have no counseling skills

15b. How would you rate the general, overall performance of the HIV Medic(s) in your program?

Excellent: 14 Good: 19 Fair: 2 Poor: 0

15c. How would you rate the performance of the other Medics you work with? Why (give specific example)

Excellent: 10 Good: 20 Fair: 1 Poor: 0 N/A: 5

16. • Because after our initial counseling we see how many clients come for testing and the numbers are high so we are good

• As we have stayed for long and with experience we are excellent • I work under minimal supervision • Because we consult each other • Our helping at ART clinic is really beneficial, e.g., community outreach • At the dispensing area and the Medic is always there. It’s the Medics that is the first point of

contact with clients • Works alone here • This is because we are not doing a lot of practicals and therefore lack skills • We work even without motivation • Because I know how to draw blood from patients • Because we all work as a team • Able to perform whatever was learned in class • Number of patients has increased a lot • We are very good at community work because we are able to track patients • Only one Medic—I am experienced in my work • Like Martha is doing CD4 and we are learning from each other • Because we need more training • As we taken training for three months, we didn’t focus on other general illness so we are

lacking in skill. We only focused on HIV illness • Their performance is good like Martha running the CD4 and Alfred running the pharmacy.

From the knowledge we got from Mama Mary we are doing good work • They do everything we have learned perfectly • We are working as a team • Sometimes we work without HCPs • Medics are able to perform all the duties • As we follow up clients in each department • I work hand and hand with HCPs • Able to help my clients in whatever problem they are facing • I work with minimal supervision • Because we are calm to patients • As we are working well • They are well equipped with knowledge on HIV/AIDS treatment • I think we need more knowledge in the management of other general illness • As I normally go for outreach I can leave her to attend • One of us doing data for drugs, filling stock cards. I think he is doing well


QUESTION RESPONSE

17. Do you think there is some more knowledge you need to enhance your career and performance at your place of work?

Yes: 36 No: 1

17a. If yes, what are they and if no, why not? Please explain • Constant updating with information. Also to go for further studies

• Medicine is changing and we need updating of knowledge; we need capacity building • Capacity building HIV information change every time • More training in pediatrics as currently only nurses and doctors are being trained • Family planning for HIV positive people • Have more capacity building in ARVs, counseling • Psychosocial counseling • Counseling; Physical examination • To know more about ART. Be updated with latest information • More knowledge about CD4 counseling • Capacity building; Refresher courses • Capacity building need to be updated with latest information • Refresher courses • HIV and drugs • Refresher course to update • Refresher courses • As we had been shown to dispense drugs but we do dispense drugs. We are not practicing

what we were taught • Refresher courses • Drugs as there are some I don’t know; HIV • Management • We need more knowledge on general medicine • More trainings • Trainings, e.g., family planning course for HIV/AIDS • Refresher courses • Some trainings, e.g., management of OIs • Training on CD4 machine and other types of ARVs • We need more practicals as we are not practicing • Counseling • Training: Basis nursing skills, counseling with children more CMES (continuous medical

education) • To be updated with latest information on HIV/AIDS • Train medics in HIV counseling. The one we did for two weeks was not enough • Refresher courses to keep us informed on the latest information • Counseling— as we don’t have any counseling skills; - Pediatric HIV care • 1. In pharmacy drug procurements; 2. Report writing; 3. Counseling; 4. Training in the

nursing field • Counseling skills, more training on logistics how to do data • Information on new types of drugs

17b. If no, why not? They just need refresher knowledge


QUESTION RESPONSE

18. How is the training from the AHF Medic program helping uplift your career needs? • It has helped me as I would like to be a nurse and a counselor

• It is very good • It has helped me as I didn't know anything and has provided me with on-the-job skills to be

a better trainer • Before training I did not know anything about HIV • Yes • We are given material to read from time to time • It has improved my knowledge of ARVs • Has helped me a lot and now I could do most of the things, e.g., drawing blood from

patients • Its not helping me as I want to work with computers • Very helpful. It teaches something you do know, e.g., drug side effects • I now know side effects of ARVs • Very helpful • Has helped as I am now employed • I want to be enrolled nurse and I have been for interviews • Very helpful • Not helping • Very much • I wanted to be a nurse when I finish school. I hope with the money I am making I can do

nursing • When I completed school, I did social work and this work is helping me as I am still working

with communities • This has been great as I have always wanted to work with the community • Very helpful because now we are able to help patients in different aspects • Has helped me a lot because before I didn’t know anything about ARVs • Has broaden the capacity of understanding ARVs • Has helped me so much. Because I didn't have any knowledge about ARVs • I want to become a medical (did not complete sentence) • As I waited to become a nurse the training has helped me in the medical field • Has helped me to gain more knowledge about health and how to help the needy • As I was not in the medical field as I am HIV-positive, this helping me treat others well.

That’s how I came into the HIV Medic program as I was a patient • Has helped me so much because now I know the ARV combination • It has helped me so much because training I didn’t have any idea about HIV/AIDS very well • Has helped me so much because before I didn't know anything about ARVs • I dropped out of school and I am now employed and I can go to school and attend

university. I am doing HR management with Kampala University • I waited to be a nurse and couldn’t make it due to funds, so I am at least doing some

nursing • We are now able to teach patients on adherence • It has helped by improving my knowledge at recognized institution


QUESTION RESPONSE

19. How are you applying the skills you got in relation to the type of work you do at your health facility?

• Being HIV-positive I know more about HIV drugs. Also able to help • Some work we are doing is different form our job description • I am now training other Medics • Very well • Yes • Very well • Most of them although some are limited • Yes • Applied on the patients except physical exam • Very good • Very good • No, as we are not dispensing drugs • TB and ART clinic is where I am applying • Very well • In the community I am able to assist and train the people in the community • Very much • Yes • We are not applying all skills we learned, especially as we don’t do physical examinations • Yes, I would say so • I am able to apply the skills exactly the way I was taught • Very well • Very well, especially teaching clients on positive living • Very well • Yes • We are not applying the skills that we learned and this has begun this year. We are no

longer working as we were trained and I don’t know why • I am using all that I learned from the training • Very well • Very well • The skills are helping me, especially when I am doing counseling • At first I couldn’t but with experience I can now do • Although I work in pharmacy I am part of the clinic’s adherence, phlebotomy, IVs • Taking vitals • Following whatever was learned in class • By working at ART clinic • Blank


QUESTION RESPONSE

20. What are some of the challenges you are facing at your health facility? • None

• Lack of capacity building • Type of work. Not dispensing drugs, assessing patients • No recognition from the government • Money very little compared to the job I am doing; I need transportation allowance • Not dispensing drugs; Lack of updated information • There are some clients who are deaf and as such there is no communication • Place is small and no privacy; Too much workload; Patient follow-up is not done • None • Too much work and I cannot go to school in the evening • Hospital doesn’t consider us when they are having workshops • Salary too low; In-charge doesn't like me • I am overloaded with work. Also work as clinic CDE; No salary as a Medic • Transport from homes—if we had a motorbike • I am not very involved in the ART clinic so I am not utilizing my skills • Salaries too low compared to the work am doing (farm is paying me) • The salary is not enough; as we live far from hospital—transport; No lunch • Under paid; Lot of work • Inadequate ARVs/drugs, salary I am being under paid • Morale going down as there are no appointments: Too much workload • Dealing with death, I am still haunted; Lack of salary for one year; Salaries are now paid the

same salaries • Poor salaries • Working without being paid • Running short of ARVs: No salaries; No stationery • We are only volunteering; No salary for two years • Volunteer for too long; Transport to hospital; No lunch • Lack of recognition • Distances for clients to seek care • Training was short and we have gained experienced from nurses • Too much work compared to the salary • When you come across a client who is difficult to counsel, you need to go to the hospital

and find a counselor • They don't recognized us as HCPs—no salaries • Cooperation among staff; Inadequate staff (doctor) it slows down work • We don’t have a medical background, this is a challenge • Since we are doing CT we don’t have counseling skills, it’s a big challenge • No salary; Place is congested; We are not accepted • There are more clients and so Medics are less—no motivation


QUESTION RESPONSE

21. What do you need to help you overcome some of your challenges? • If we could go for more training

• Allow us to do some of our job description • Would be recognized by the MOH • Send more HW medics to Market Clinic • Attend seminars • To be trained in sign language • Transport should be provided; More staff; Increase space • More manpower • Administration should be educated about us • Support from AHF • AHF should put me on a salary • Motorbike • Talk with management to utilize me more • AHF to put me on a salary • Provide transport; Increase salary; build skills • AHF should put me on a salary • I don’t know • If they give appointment • Counseling; Improve salaries • Put on government payroll • AHF should start paying us • AHF to put us on a salary; Government to look at drug shortage • To put us on a salary • We would be recognized by government. It’s difficult when I leave this job, I will not be

allowed to work elsewhere as qualification is not recognized. We cannot negotiate for salary increase as the employers know that the qualifications is not recognized and we cannot go anywhere

• I have more outreach and field work • Increase the training period • Increase the salary • AHF should train us Medics in HIV/AIDS counseling • To be recognized by MOH; to give us a salary • More staff needed; The new doctor is not good • Training • Trained in counseling • Put us on payroll; Staff to be oriented on HIV Medic program • The need to be motivated because there’s more women at my clinic

22. How many clients do you see on a “normal” workday?


QUESTION RESPONSE

23. Since you graduated as an HIV Medic and you started working with this facility, have you tried to access another kind of training?

24 Yes 12 No

23a. If yes, what type of training was that? • Counseling

• PMTCT • Adherence counseling • Stigma and discrimination • Intensive counseling • ART management; CD4 training • Counseling; TOT • Counseling • Counseling (VCT) • Certificate in counseling • Human resources management • HBC • HIV Medic counselors for two weeks • Palliative care • Counseling course • ART management • Pediatric HIV • CD4 testing • PMTCT; home counseling and testing (HCT) routine counseling and testing (RCT) • Counseling for two weeks • Guidance and counseling developmental studies • No • Counseling • VCT training

23b. If yes, was it run by AHF?

Yes: 9 No: 13

23c. If not, where did you access the training? • TASO

• Through Chikankata by CHAZ • CDRZ • New Start Centre • Chikankata Health Services • MOH • Didn’t have the chance • Kampala University • Kampala University • Private Health Centre • MOH • TASO/self sponsor • Mulago Hospital • MOH • Kampala University - friend is sponsoring me

24. Have you received any follow-up support from AHF since training?

Yes: 29 No: 8


QUESTION RESPONSE

25. Please share any other thoughts or comments on the HIV Medic program. • I was able to access ART. I was trained as expert patient trainer by WHO. I am not an ART

and access care since 2004. I really thank AHF for bringing ART to this country and helping patients. I think the Medic program should be expanded and more trained

• Refresher courses as we have forgotten all the drugs that we learned • Train more medics • To train more medics even involve people living with HIV • More support from government • Good training; training more medics • Medics should be given a better package. As we are dong more than the nurses. We are in

all aspects of the clinic • Very happy and appreciate the course. It’s very helpful • Re-organization by the people of Uganda is important and we feel frustrated that we are not

recognized • More trainings to enable us to acquire more experience • The Medic program is good—we still need more skills as we work in HIV setting as people

need help. Workshop; Continuous medical education • We have learned more—now I am employed and I can pay for myself I can do some health

service to Ugandans • The contract reads differently to what we are being paid. Contracts have not been renewed.

The three months of training is not enough. The Africa bureau meeting we were not invited and yet we work so hard. Even other important workshops we were not called. Transport for outreach and follow-up is not being done. The logistics first and not taking too long to apply. The logistics management is chaotic. There is no transport to take samples to Kampala or Masaka when you do apply for it

• Should train more Medics • Train more people and sensitize people on Medics. Due to instability there are and we

should train more people • Continuous capacity building • Program has been very helpful, need more trainings to update us on the latest information • HIV Medic program is good. I urge AHF not to lose it • It’s a good program; It takes some time for HIV Medic to be recognized • It’s a very good program and there is need to train more Medics • Good training. AHF should train more Medics • I have children and since AHF is not funding us we are suffering. We are just wasted and no

future here. I am hoping to finish and make a decision where to go • Train more HIV Medics; Capacity building • I was told about the refresher course, this has been done. I was also told that they were

going to change the name from HIV Medic and I have been waiting • It’s important to ensure the government recognizes us and that would help. Improve salaries • AHF should train more Medics to help the community • HIV Medic program is very good because it increases staffing at ART clinic • The training is for non professionals but they are also training nurses • Improve our capacity and involve in training workshops • Need for refresher courses • More different trainings. We should be able to attend the different workshops so that we can

learn more • Capacity building; upgrading of staff; allow staff to go for training • It’s a good training; should train more Medics; please motivate us • I feel I am tired of being a volunteer and I would like to be employed. We are not benefiting • Thanking AHF on what they have done. I would like to encourage those who are HIV

Medics—there has to be a deep down commitment from us for the benefits of the clients. There is also a great need for the government to recognize us


APPENDIX E: FORMER HIV MEDIC INTERVIEW Five former HIV Medics were interviewed—four in Uganda and one in Zambia. Four of them had previously worked as a Medic and one was trained as a Medic but never worked as a Medic.

QUESTION RESPONSE

1. Gender

Male: 0 Female: 5

2. What is your age range? Less than 25 years: 1 25–34 years: 4 35–44 years: 0 45 years or more: 0

3. What department of the site did you work in? If the Medic never worked as a Medic go to Q17

ANC: 0 Outpatient care: 0 Surgery: 0 HIV care: 0 ART clinic: 2 Other (TASO clinic; UCOM): 2 N/A: 1

4. How long did you work at this site?

Two medics had worked for one year and two had worked for two years.

5. Where did you work before that?

I didn’t, I was in training, school, university: 1 A hospital: 1 A clinic: 0 Other (registry, unemployed): 2

10. Do you think the doctors/clinical staff who work there accepted the Medics as professional care providers?

Yes: 3 No: 1

10a. Why or why not? Please explain • Because the Medics have been helpful in vital signs and adherence counseling

• They were accepted, not as medical department but in the counseling department Because we were doing a lot of work

11. Do you think the nurses who work there accepted the Medics as professional care providers?

Yes: 3 No: 1

11a. Why or why not? Please explain • Sometimes the two nurses are not here and it’s the Medics doing all the nursing care

• Now as Health Care Medical Professionals but on counseling • They just liked us • They welcomed us

12. Do you think the clients accepted the Medics as professional care providers? Why or why not? Please explain

Yes: 4 No: 0

• At least they have helped shorten the time (waiting time) • Because we counseled them a lot. Clients always came to consult us also because of the

follow-up care • Because we were helping them by education, giving them drugs • They always seek our help


QUESTION RESPONSE

13. Which of the following responsibilities did you perform as a Medic at your place of work? Yes No a Patient medical histories 3 1 b Basic patient assessment and physical

examinations 2 2

c Taking vital signs 3 1 d Pre-test counseling for HIV counseling and testing 3 1 e Conducting HIV rapid test 1 3 f Post-test counseling for HIV CT 3 1 g Adherence education, counseling and support 4 0 h Review and document in-patient charts 4 0 i Present findings to supervising physician,

clinical officer or nurse 4 0


3 1

k Phlebotomy 3 1 l Insert IVs 0 4 m Community outreach 3 1 14. Which of your above job functions do you think is the most beneficial to the clinic and the

clients? • Review and document in-patient charts—as it improves the data entry especially when

wrong drugs were prescribed • Clients counseling and treatment—helped patients to deal with problems; Clinic team work • Clinic, educating about drugs—doctors didn’t know about drugs • Preaching—because these clients had less hope they would regain their hope

15. How would you rate the general, overall performance of the HIV Medic(s) at your site

Excellent (As they have never failed in anything. As they are able to put into practice all that they were taught): 1 Good: 2 What Medics do is almost what the doctors do; Tried to handle patient; Able to put in practice what we were taught) Fair: 0 Poor: 0

16. Why did you not work as an HIV Medic after attending the training? • Management decision

• Program not successful as sometimes we would spend months not working and I was not putting [training] into practice

17. Why are you not currently working as a Medic? • Management decision

• I was volunteering for one year and three months and I was now paid so I decided to go back and work

• Because I was already working as a PMTCT counselor when I went for the training (the one who never worked as a Medic)

• I changed my mind and don't want to be a Medic. I am now getting more money here. I used to get 125.000 as an HIV Medic


QUESTION RESPONSE

18. Where are you currently working? • ART clinic as a clerk

• Not working • Studying guidance and counseling • PMTCT counselor • Supermarket

19. Do you think there is some more knowledge you need to enhance your career and performance?

Yes: 3 No: 2

20. Why or why not? Please explain For the three who answered yes:

• HIV testing—we need to be taught as we only watched at the lab. Also on ARVs dispensing we need more skills

• Basic nursing skills • Counseling: The counseling component of the course

21. How is the training from the AHF Medic program helping uplift your career needs? • I didn’t know anything about Medics

• Helped—ARVs I know more about drugs. The course helped expose me to other types of HIV patients apart from antenatal mothers

22. How are you applying the skills you got in relation to the type of work you do now? • When I review records and there is something wrong I can go back

• As I am teaching in the community • It has helped me in picking the correct patients. I had fear in handling patients. The things I

studied are being used in my current course • Yes, I am as I know more about drugs and use this with my current work

23. What are some of the challenges you are facing at your health facility? • Not being allowed to work as an HIV Medic

• Workload, number of clients was so (did not complete sentence) • Patients’ denial; male involvement; communication

24. What do you need to help you overcome some of your challenges? • Be re-deployed

• Improve more staff • Community sensitization

26. Since you graduated as an HIV Medic and you started working with this facility, have you tried to access another kind of training?

Yes: 4

27. If yes, what type of training was that? • Psychology counseling

• Counseling • Guidance and counseling • Counseling

28. If yes, was it run by AHF? No 29. If not, where did you access the training? • Paid for myself

• TASO • YMCA • Mildmay


QUESTION RESPONSE

30. Please share any other thoughts or comments on the HIV Medic program. • Improve the employment opportunities for HIV Medics; Improve capacity building

• There is need to add on counseling to the course • Counseling: The course needs to improve on the counseling • It would have been better to have more short courses to upgrade their knowledge and skills

31 What did you do before you were trained as a Medic? • Registered clerk

• I was a sales lady in a bookshop • I was just from school • I was a PMTCT counselor • I did a business course when I finished course

32. How were you selected to train as a Medic? • Was sent by hospital

• Advertisement and I applied and was short listed and trained • It was advertised and everyone came and we were interviewed • Interviews were done at the clinic and I was selected • My dad is a clinical officer and they advertised and I applied for the training


APPENDIX F: FOCUS GROUP DISCUSSIONS A total of nine focus group discussions were held—five in Uganda and four in Zambia.

QUESTION RESPONSE

Please enter the number of each Males: 56 Females: 107 Total: 163

What is the age range of the group? Less than 25 years: 21 25–34 years: 66 35–44 years: 49 45 years or more: 25

1. What type of health providers are at this center? Doctors, nurses, clinical officers, Medics, other helpers, counselors. Only three of the nine FGD mentioned Medics.

2. Are you are aware of the HIV Medic program? Six FGD were aware of the Medic program and three were not.

3. Where did you hear about it? Those who had heard of it had heard of it from the clinic or hospital health care providers, or from the Medics themselves (when they introduced themselves).

4. What do you know about it? They do counseling about HIV; help the HCP with work; they sensitize people on HIV in the community; and they draw blood, dispense drugs and do health education.

5. How has provision of health care changed since the implementation of the Medics? Ask for specific examples.

• Very much better. Children have improved in health

• Yes, because of good services they render to the patients

• Since I started the ART clinic with them I have not seen any setback on 2005. They are good they help us

• With help of Medics, patients don't spend many hours at the clinic. Help nurses dispense drugs even counseling

• Has been great change more clients are coming to this clinic

• Yes, doctors don’t take long to commence patients on ART

• There has been accurate attendance to patients


QUESTION RESPONSE

6. Do you think the doctors/clinical officers who work here accept the Medics as professional care providers? Why or why not? Please explain

• They know their work very well • Because she knows her work • I think so—we see them consult one

another. They respect each other and they all attend to the client. They are also limited

• They work as a team • See them work hand in hand to care for

the patients • Very hard working • They help each other very well • They are aware and they do appreciate

the services the Medics provide as professional

7. Do the nurses who work here accept the Medics as professional care providers? Why or why not? Please explain

• They consult from them most of the time • She works hand in hand with one nurse

who is here • We think so, the same, they respect

each other • They mix with them very easily even

consult from Medics • Most of the time they consult the Medics • Lessen burden of nurses where work is

concerned • We have no nurses at our center but

when it come for mobile services they complete and they appreciate the Medic

• They work hand in hand 8. Do you, the clients, accept the Medics are

professional care providers? Why or why not? Please explain

• Everyone here is a provider. We do not know the difference

• She has love and respect for the patients • They give them respect • We accept them. They handle us well.

They have good manners. They are hospitable and pay attention. They are also social and approachable at anytime

• Kind and welcoming • She is very polite and humble • Home visits • We interact with them very well in the

community; Give patients respect • We accept the professional care what

the Medic does to us patients


QUESTION RESPONSE

9. How would you rate the general, overall performance of the HIV Medic(s)? Why (give specific example

• Well – They work well. They receive us well and treat us well

• Excellent – Patients have started coming to the ART clinic

• Excellent – Because patients are closer to her than to HCP

• Good – We get services on time. Emphasis is made on the return date. They teach and remind clients

• Good – Some medics are better than nurses

• Excellent – She is able to teach patients about HIV and how to protect others

• 75% – First people to see before HCP • 75% • 95% – Performance has been good, out

of 100% of patients 95% has responded well on treatment because of the commitment of the Medic

10. Do the Medic(s) seem sufficiently trained to

execute their responsibilities? All FGDs responded positively. They know their work well. They promote good explanations to the clients, others don't do this. They are very good; one replied they thought they needed more training.

11. What has been the effect of Medic(s) on the overall functioning of the clinic? Please explain your response; give an example.

• There has been good information flow to the clients

• Functioning of the clinic has improved because stigma has reduced at the clinic and the community due to their sensitization

• There is more work • Clinic is very busy because Medics are

tracking patients from the community through sensitization

• Functioning of the clinic has been very well since she started working at this clinic. She is very kind and able to be with the last patient up to the end of the clinic

• After community outreach we come to the clinic voluntarily

• Lessen workload of HCPs • Treatment has improved due to

professionalism of the Medics, counseling/encouraging people to VCT early by giving health talk

12. Would you recommend the HIV Medic(s) to other health care programs?

All FGDs responded that yes, they would recommend the program to other health care programs. Reasons cited included: They are able to handle any problem; Their performance is excellent; Looking at the commitment they show in the field


QUESTION RESPONSE

13. Please share any other thoughts or comments on the HIV Medic program.

• They are very helpful • Train more Medics • The number of Medics should be

increased; Open more centers like this as we come from far; We need more doctors as there is only one here and we wait a long time to see him; We need food as we spend a long time there; Transport; We also need the Medics to know how to link us to other programs such as OVCs. Me and my husband are both ill and we need support for our children

• Medics should access more trainings, to help in patient’s care and support

• Train more Medics to come to this hospital because she is alone at this center and she has so many things to do alone

• Train more Medics • Give good information and proper

instructions of which we follow • They encourage the patients to venture

into other activities, sports. I suggest to train the Medics on high levels because I attend to vast problems that are first in society


APPENDIX G: CHECKLIST FOR HIV MEDICS

SATISFACTORILY NOT SATISFACTORILY

NOT OBSERVED TOTAL

GETTING READY

1. Prepare the necessary equipment.

28 100.0% 0 0.0% 0 28

2. Greet the client respectfully and with kindness and introduce yourself and ask her name.

26 92.9% 2 7.1% 0 28

3. Offer the client a seat. 26 92.9% 2 7.1% 0 28 4. Explain to the client what is

going to be done and encourage her to ask questions. Get her permission before you begin.

25 89.3% 3 10.7% 0 28

5. Listen to what the client has to say.

26 92.9% 2 7.1% 0 28

HISTORY (ASK/LISTEN)

1. Ask the client her name, age, marital status, address, occupation of self and partner, and religion.

24 85.7% 4 14.3% 0 28


21 75.0% 7 25.0% 0 28

3. Ask the client about her family medical problems.

9 32.1% 19 67.9% 0 28

4. Ask the client about previous medical conditions.

11 39.3% 17 60.7% 0 28

5. Ask the client about general health problems.

27 96.4% 1 3.6% 0 28

6. Ask the client about HIV status.

14 50.0% 14 50.0% 0 28

7. Ask the client about medications.

26 92.9% 2 7.1% 0 28

8. Ask the client about alcohol use and smoking.

3 10.7% 25 89.3% 0 28

9. Ask the client about tetanus immunization status.

0 0.0% 11 100.0% 17 28

10. Ask the client about social support.

13 46.4% 15 53.6% 0 28

11. Ask the client about other problems or concerns.

24 85.7% 4 14.3% 0 28



NOT OBSERVED TOTAL

PHYSICAL EXAMINATION (LOOK/FEEL)

1. Ask the client if she needs to empty her bladder. Save and test urine, if necessary.

2 7.4% 25 92.6% 1 28

2. Observe the client’s general appearance.

27 96.4% 1 3.6% 0 28

3. Explain each step of the physical examination.

21 75.0% 7 25.0% 0 28

4. Take the client's blood pressure, pulse, respirations and record findings.

26 92.9% 2 7.1% 0 28

5. Help the client on to the examination table.

18 64.3% 10 35.7% 0 28

6. Wash and dry hands thoroughly.

1 3.6% 27 96.4% 0 28

7. Check the client’s conjunctiva, tongue, nail beds and palms for pallor.

25 89.3% 3 10.7% 0 28

8. Check the client's face and hands for edema.

24 85.7% 4 14.3% 0 28

9. Perform all steps of chest examination

15 53.6% 13 46.4% 0 28

10. Perform all steps of abdominal examination

17 60.7% 11 39.3% 0 28

11. Perform all the steps for a lymph nodes examination

21 75.0% 7 25.0% 0 28

12. Perform all steps for examination of the skin.

22 78.6% 6 21.4% 0 28

13. Perform all steps for a heart examination

12 42.9% 16 57.1% 0 28


3 11.1% 24 88.9% 1 28

15. Ask the client if she has questions. Help her from the table and offer her a seat.

22 78.6% 6 21.4% 0 28


28 100.0% 0 0.0% 0 28

17. Discuss findings with the client.

25 89.3% 3 10.7% 0 28


3 11.5% 23 88.5% 2 28

19. Record the results on the client’s record/antenatal card and discuss them with her.

27 96.4% 1 3.6% 0 28

20. Refer client for HIV screening, if the client

25 89.3% 3 10.7% 0 28



NOT OBSERVED TOTAL

chooses.

IDENTIFY PROBLEMS/NEEDS

1. Identify the client’s individual problems/needs, based on the findings of the history, physical examination and screening procedures.

16 59.3% 11 40.7% 1 28

PROVIDE CARE/TAKE ACTION

1. Treat the client for syphilis if the RPR test is positive, provides counseling on safer sex, and arranges for her partner to be treated and counseled.

0 0.0% 14 100.0% 14 28

1a. Provides counseling on safer sex, arranges for her partner to be treated and counseled.

2 14.3% 12 85.7% 14 28


9 32.1% 19 67.9% 0 28

3. Provide tetanus immunization based on need.

0 0.0% 12 100.0% 16 28

4. Dispense necessary medications.

13 46.4% 15 53.6% 0 28

5. Provide counseling about necessary topics.

26 92.9% 2 7.1% 0 28

6. Develop a plan for complications with the client.

21 75.0% 7 25.0% 0 28

7. Record the relevant details of care on the client’s record antenatal card.

26 92.9% 2 7.1% 0 28


24 85.7% 4 14.3% 0 28


27 96.4% 1 3.6% 0 28


APPENDIX H: CHECKLIST FOR HIV MEDICS WHO WORK AT SITE WHERE AN HIV MEDIC SAID THEY DO BASIC ASSESSMENTS

The following checklist shows the results on the checklist for the following 20 HIV Medics who are highlighted in grey in the table below.

FACILITY # HIV MEDICS INTERVIEWED

# HIV MEDICS STATED THEY PERFORM “BASIC PATIENT ASSESSMENT

AND PHYSICAL EXAMINATIONS”

# HIV MEDICS ASSESSED

Chikankata 5 1 4

Chisoba Farms 1 0 1

Choma General Hospital 1 1 1

Gombe Hospital 2 0 1

Kalisizo Hospital 1 1 1

Lyantonde Health Centre 2 0 2

Macha Mission Hospital 1 0 1

Masaka Health Care Centre 6 4 6

Mbale Regional Hospital 4 1 4

Monze Mission 2 1 2

Mpongwe Mission Hospital 1 0 0

Mtendere Health Centre 2 2 2

Nameembo Health Centre 1 0 1

Rakai Health Care Centre 1 0 1

Soroti Health Care Centre 3 1 0

St. Bali Kuddembe Market Clinic 1 0 1UCOM 4 3 0

Total 38 15 28


Checklist for HIV Medics who work at site where an HIV Medic said they do basic assessments


NOT OBSERVED TOTAL

GETTING READY 1. Prepare the necessary

equipment. 20 100.0% 0 0.0% 0 20

2. Greet the client respectfully and with kindness and introduce yourself and ask her name.

18 90.0% 2 10.0% 0 20

3. Offer the client a seat. 20 100.0% 0 0.0% 0 20 4. Explain to the client what

is going to be done and encourage her to ask questions. Get her permission before you begin.

17 85.0% 3 15.0% 0 20

5. Listen to what the client has to say.

18 90.0% 2 10.0% 0 20

HISTORY (ASK/LISTEN) 1. Ask the client her name,

age, marital status, address, occupation of self and partner, and religion.

16 80.0% 4 20.0% 0 20


16 80.0% 4 20.0% 0 20

3. Ask the client about her family medical problems.

6 30.0% 14 70.0% 0 20

4. Ask the client about previous medical conditions.

8 40.0% 12 60.0% 0 20

5. Ask the client about general health problems.

20 100.0% 0 0.0% 0 20

6. Ask the client about HIV status.

11 55.0% 9 45.0% 0 20

7. Ask the client about medications.

19 95.0% 1 5.0% 0 20

8. Ask the client about alcohol use and smoking.

3 15.0% 17 85.0% 0 20

9. Ask the client about tetanus immunization status.

0.0% 6 100.0% 14 20

10. Ask the client about social support.

11 55.0% 9 45.0% 0 20

11. Ask the client about other problems or concerns.

17 85.0% 3 15.0% 0 20



NOT OBSERVED TOTAL

PHYSICAL EXAMINATION (LOOK/FEEL)

1. Ask the client if she needs to empty her bladder. Save and test urine, if necessary.

2 10.5% 17 89.5% 1 20

2. Observe the client’s general appearance.

19 95.0% 1 5.0% 0 20

3. Explain each step of the physical examination.

15 75.0% 5 25.0% 0 20

4. Take the client’s blood pressure, pulse, respirations and record findings.

20 100.0% 0 0.0% 0 20

5. Help the client on to the examination table.

11 55.0% 9 45.0% 0 20


1 5.0% 19 95.0% 0 20

7. Check the client’s conjunctiva, tongue, nail beds and palms for pallor.

17 85.0% 3 15.0% 0 20

8. Check the client’s face and hands for edema.

18 90.0% 2 10.0% 0 20

9. Perform all steps of chest examination

12 60.0% 8 40.0% 0 20

10. Perform all steps of abdominal examination

10 50.0% 10 50.0% 0 20

11. Perform all the steps for a lymph nodes examination

15 75.0% 5 25.0% 0 20

12. Perform all steps for examination of the skin.

15 75.0% 5 25.0% 0 20

13. Perform all steps for a heart examination

9 45.0% 11 55.0% 0 20


2 10.5% 17 89.5% 1 20

15. Ask the client if she has questions. Help her from the table and offer her a seat.

14 70.0% 6 30.0% 0 20


20 100.0% 0 0.0% 0 20

17. Discuss findings with the client.

19 95.0% 1 5.0% 0 20


2 11.1% 17 88.9% 2 20



NOT OBSERVED TOTAL

19. Record the results on the client’s record/antenatal card and discuss them with her.

19 95.0% 1 5.0% 0 20

20. Refer client for HIV screening, if the client chooses.

19 95.0% 1 5.0% 0 20

IDENTIFY PROBLEMS/NEEDS

1. Identify the client’s individual problems/needs, based on the findings of the history, physical examination and screening procedures.

12 60.0% 8 40.0% 0 20

PROVIDE CARE/TAKE ACTION

1. Treat the client for syphilis if the RPR test is positive, provide counseling on safer sex, and arrange for her partner to be treated and counseled.

0 0.0% 9 100.0% 11 20

1a. Provide counseling on safer sex, arrange for her partner to be treated and counseled.

2 18.2% 9 81.8% 9 20


7 35.0% 13 65.0% 0 20

3. Provide tetanus immunization based on need.

N/A N/A N/A N/A N/A N/A

4. Dispense necessary medications.

9 45.0% 11 55.0% 0 20

5. Provide counseling about necessary topics.

18 90.0% 2 10.0% 0 20

6. Develop a plan for complications with the client.

11 55.0% 9 45.0% 0 20

7. Record the relevant details of care on the client’s record/antenatal card.

18 90.0% 2 10.0% 0 20


16 80.0% 4 20.0% 0 20


19 95.0% 1 5.0% 0 20


APPENDIX I: CLIENT SERVICE DATA FOR SITES WITH AND WITHOUT MEDICS

NAME OF SITE MONTH # CLIENTS RECEIVED

HIV CT

# NEW ART

CLIENTS

# NEW ART CLIENT WHO

ARE ART ELIGIBLE

MONTH PRIOR TO INITIATION OF HIV MEDIC

PROGRAM

# CLIENTS RECEIVED

HIV CT

# NEW ART

CLIENTS

# NEW ART CLIENTS WHO

ARE ART ELIGIBLE

M Chikankata Mission Hospital

March 2007 108 56 12 July 2005 151 21 21

C Mazabuka District Hospital

March 2007 6 54 37 N/A N/A N/A N/A

M Choma General Hospital

February 2007

653 200 90 May 2006 586 150 82

C Kalomo Hospital March 2007 214 75 30 April 2006 500 100 82 M Macha Mission

Hospital March 2007 325 200 20 July 2005 47 47 15

C St. Lukes Hospital

February 2007

78 35 11 June 2006 57 28 11

M Mpongwe Mission Hospital

March 2007 101 95 50 August 2005 94 77 39

C Luanshya Thompson Hospital

March 2007 145 N/A 59 October 2005 78 59 27

M Mtendere Clinic March 2007 95 82 67 March 2005 91 45 38 C Kanyama Clinic March 2007 387 187 92 March 2005 301 148 87 M Masaka

Healthcare Centre

March 2007 450 197 112 May 2004 600 600 370

C Villa Maria Hospital

March 2007 120 70 N/A May 2004? 308 48 44

M Mbale Health Facility

March 2007 55 30 15 January 2005 30 30 12

C Tororo District Hospital

March 2007 N/A 33 5 February 2005 N/A 22 5


NAME OF SITE MONTH # CLIENTS RECEIVED

HIV CT

# NEW ART

CLIENTS

# NEW ART CLIENT WHO

ARE ART ELIGIBLE

MONTH PRIOR TO INITIATION OF HIV MEDIC

PROGRAM

# CLIENTS RECEIVED

HIV CT

# NEW ART

CLIENTS

# NEW ART CLIENTS WHO

ARE ART ELIGIBLE

M Monze Mission Hospital

April 2007 322 109 96 February 2006 250 100 80

M Lyantonde Health Center

March 2007 488 106 32 May 2004 264 33 20

M Gombe Hospital March 2007 1789 1107 40 April 2005 7800 284 26 M UCOM Hospital M Kalisizo

Healthcare Hospital

March 2007 291 41 5 June 2005 247 40 17

M Rakai District Hospital

March 2007 390 54 31 August 2004 383 7 7

M Soroti Healthcare Facility

March 2007 13 6 April 2004 26 10

M Kampala market clinic

March 2007 462 114 42 June 2005 521 51 20

M = Site with HIV Medics C = Comparison site


APPENDIX J: STAKEHOLDER INTERVIEWS Twenty-one stakeholders were interviewed—11 from Zambia and 10 from Uganda.

QUESTION RESPONSE

1. Name of stakeholder institution • ECSAION country Rep – Member of Nursing and Midwifery Counsel

• MOH • MOH • ZNA • Macha Mission Hospital • Medical Council • Chisoha Farms • CHAZ • National Aids and TB Council (NAC) • Chikankata Health Services • Allied and Health Professionals Council • Butabela Hospital • Masaka Regional 1 • Kalisizo Health Centre • Gombe Hospital • Rakai Hospital • Medical Superintendent/Director Health Services • ART Clinic • ART/NAC • Choma General Hospital • General Nursing Council


3. What is your age range? Less than 25 years: 0 25 – 34 years: 0 35 – 44 years: 9 45 years or more: 12

5. What is your position at this site/institution?

Includes Director Clinical Care and Diagnostic Services; Acting Senior Nursing Officer

6. Before today, were you aware of the HIV Medic program?

Yes: 14 No: 7


QUESTION RESPONSE

7. If yes, what did you know about it? • A cadre trained by MOH through CHAZ

• Due to the HR crisis. This cadre is supposed to operated at the ART clinic to enable doctors, nurses and clinical officers to concentrate on the more technical aspects of care and are not doing basic nursing skills

• Help ART clinic • I had meeting with AHF and the ZNA (Zambia Nurses Association) came to complain about

the program • I have been working with them • I heard about it from my friends while attending a conference in Southwest Africa.

Something to do training • I just heard about this HIV Medic from Dr. Biemba/CHAZ who explained that this cadre was

being developed as a leak with community. This cadre was presented as a treatment supported at the CCM-Global fund meeting to support the request for the community funding. Round 6 of the Global Fund was requesting for funds to try and solve the HRH crisis

• I was in Kalisizo and RaKai where the HIV Medic program was well established before I came here

• It’s started. Been involved since it began—4 station • Participated in their interviews for selection • These staff help in the ART clinic by doing the following: Take TPR weight; Talk about

AIDS; Adherence Counseling; Side effect of drugs; Follow-up clients • To teach about HIV • Trained to assist in the running of clinic (ART) • When the training started we gave consent


QUESTION RESPONSE

8. What is your opinion about the HIV Medic program? • Multi-purpose HIV/AIDS, ART field/community worker

• They have helped in nursing ART clinic; HRH crisis has been evaluated, e.g., Kampala • Progressive idea as HIV/AIDS is a full-time job but there are people who can help so that

professionals concentrate on the technical issues. • Very helpful. Clinic began in 2004 with few clients and now there are 1,300 clients. We have

now started integrating staff. Before the HIV Medic was managing the clinic on her own with doctors increase in patient has led to integration

• I need to really understand the concept well before I can tell you about it. I need a little more time to understand

• I think it’s a good program as they are training counselors and these will be good. Most donors now realize that the community is the key and are putting funds to support initiative that will ensure that the funds reach the community. We as NAC are now being given funds for the districts

• Very good exercise. It has added additional staff to our institution. It has provided expertise labor, currently there are so many programs at the hospital and few staff, at least these have ensured that staff focus on other critical areas

• Beneficial, relieves pressure on health care staff • From the description I feel should be integrated into the other programs • It is difficult to make an opinion of a program that few are aware of • In the event of shortages if they are not given technical jobs they are now a problem. They

can be given supportive work, e.g., clients’ adherence • I think it would be rejected as I just returned from Kenya where the Ecsacon was meeting.

There everyone was against the idea of another cadre. Only Zambia and Zimbabwe are accepting it. Right now there are too many nurses on the streets who have no jobs. Why can’t government employ them

• It is too early for me to comment as I have only heard about this and I have not seen how they work

• As there is not medical people I would prefer that this course was added to people with medical background

• Good if appropriate person selected • It is an important program because they have an idea of what the clinic is all about and able

to manage work with little supervision • It is going fine. Visit, training • It has been useful up to a limit. Some things they can do, some they cannot do • A good idea. HRH crisis we thought we could use them like nursing assistants using the

policy that exists for nursing assistants. They are a good cadre, quite useful. Initially we had lay people who wanted to participate in the care and it was easy to allow them so that they could do the simple things that help the clinic to flow well: Manage patients; Organizing files; Vital signs

9. Do you think this program is one that would be acceptable to doctors/clinical officers, country-wide? Why or why not? Please explain.

Yes: 16 No: 5


QUESTION RESPONSE

9a. • As long as we understand the context that they are working in. There was a problem initially with them as they to use to move around with a stethoscope. This made everyone uncomfortable. The difficulty was also with the remuneration—who would pay them. In the AHF sites it has been easy as they are paid by Uganda Cares but in the other sites they are sometimes given an allowance by the hospital and this is very little money and it has not been easy for the Medics

• The program would be accepted because it gives relief to nurses, CO, doctors • Shorten waiting time for patients • It helps • Both the doctors and CO would be relieved of doing basic things such as weighing patients,

vital signs, taking of blood, etc. • Doctors would not support because they have a problem accepting people who are not

trained. Look at the counselor’s course—doctors don't accept it. We have spent 10 years accepting that a nurse can be employed as a full-time counselor

• We need qualified health professionals to assist with the many health facilities • Assist in so many ways, e.g., blood taking; weighing clients; examine wards pharmacies • I think so as long as they are trained • I see no reason [why not]; people see values in programs as long [as they]are set • As there are in most, in clinics are manned by Uganda Cares • No problem working with them • This helps strengthen the quality services and doctors can focus on other areas • An extra help is welcome in understaffed clinics • Because it is a public health issue and should be acceptable to all health professionals • This is because doctors are a very conservative group and don't like anyone who is not a

trained clinical officer will accept this group • It will not as it might create a depleting in the resources. Currently there is a debate about

the health care assistant training which is being developed • Because there are too many unemployed • As they have no medical background and would be difficult to accept • Not as professionals they will not be developed

10. Do you think this program is one that would be acceptable to nurses, country-wide? Why or why not? Please explain.

Yes: 15 No: 5


QUESTION RESPONSE

10a. • Just as we accept nursing auxiliary the nurses should. They are there to help nurses focus on the more technical issues instead of focusing on simple things like pulling out cards, patient lines

• They would gain knowledge and practical experience • Reduce workload • It helps to educate and to stop spread of disease • Due to the pressure of work, nurses would focus on their core competencies, e.g., at Menga

Hospital the cadres are performing the basic skills while nurses focus on technical skills • Nurses are too busy protecting the profession and feel that their core functions are being

taken away • They have assisted the nurses in the clinic but looking at time they spend at training they

would need updates twice a year • As long as they are trained. The example of the mental attendant who is currently working

here and they are not trained. The mental attendant is only given a week’s orientation and these are absorbed into the system and are each in payroll. They are currently being absorbed and go for nurses having psychiatric (sentence not completed)

• The key is to keep the boundaries set • As they are currently developing a program for health care nursing assistant • Working closely with them and she has been training the nurses in medication • Same, give a hand/recording/giving results • This helps strengthen the quality services and doctors can focus on other areas • It’s public health, it’s affecting everyone • It will not as it might create a depleting in the resources. Currently there is a debate about

the health care assistant training which is being developed • Difficult as the nursing council are not happy due to the closure of some enrolled in nurses’

schools. Nurses are also protecting their profession • We rejected this idea at the nursing meeting because right now people/nurses are not

employed • This is because the nursing auxiliary program has not been accepted. The enrolled nurses

program has been scraped and I do not think people will accept this program • Only if they are in the communities; even HCA have been rejected by the nurses


QUESTION RESPONSE

11. Do you think this program is one that would be acceptable to clients, country-wide? Why or why not? Please explain.

Yes: 20 No: 1

• Yes, clients accept anything as long as they get treated. At the ECSAION meeting a debate was held on the impact the volunteers have had in the community and have patients appreciate them. This is because they live and work there. We have to acknowledge the fact that at community level these cadres are much appreciated by the community although us at policy level are against them

• Initially clients would be skeptical but would be won over when they see how the HIV Medic is working

• Clients need services and are tired of the long queues. It’s better that they are looked after by a provider that is trained than one that is not. Currently some of our health centers are being manned by untrained classified daily employees

• Clients would welcome this cadre. This is because all clients want to see is a provider and they would like to spend less time in the queues It would reduce the waiting time

• These staff have already been accepted by the community and the instructors • If the MOH explained who these people are and they are/have been created • As he is teaching them and helping them. They like him • The patients would accept them as long as they are part of a team and can be identified

and the knowledge is not beyond their units. They would help as patients would realize that their waiting time is greatly reduced

• The communities are looking for care and support. The resistance is with the health workers • People that are chosen are from communities. No, if they do not process the right skills • Clients would accept them. This is because patients don't know the difference between

health workers. As long as they get care and support, clients don't min d who provides the care

• It reduces the waiting time, clients will accept anything that helps them to spend less time at the health facility

• They have no choice as they don't know what is going on. The problem with developing countries people don't know who they are dealing with as they come in medical coat. So they will accept anyone who comes in a coat to provide a service. An example I have is that when I refer a patient to a pediatrician clients refuse as they say we are all doctors

• See health workers providing services • Clients don't know the difference; all they want to see is a quality service. It doesn't matter

who is providing it • They have been helping them around even taking their particulars • As they are part of an integrated team—HIV response • Patients may not need skills to deal with HIV/AIDS


QUESTION RESPONSE

12. What problem is this new cadre meant to solve? Are there other factors causing the problem a new cadre will not address?

• The crisis of human recourses • Nurses are doing too much reactive work, making beds, bathing patients and this is taking

too much time. They have less time for professional work • I suppose it’s meant to solve the congestion at the health facilities. The lacking of health

providers but it will not solve the problems as who will pay them and who will supervise them

• To assist in ART clinic, manpower; To track lost clients in the community; Meant to remind clinicians about their abnormal results on progress

• Reduce patient waiting time • I do not know • This new cadre is meant to solve the current HRH crisis and insure the client care is not

affected by this crisis. Basic activities, which are time consuming for the nurses can be undertaken by this group such as: 1. Vital signs; 2. Adherence support, which is consuming. No there are not other special factors that are causing this problem except the HR areas in the health sector

• The human resources crisis • Reduce workload on frontline health workers in relation to basic nursing skills • Medics come in touch with many patients they should have knowledge to advise patients • The crisis with human recourses • HRH - understaffing and the work overload, also the management of data. Instead of nurses

focusing on record keeping it eases their work • They are specialized in a small field, now societies people go beyond the scope of work that

the Medics do. My concern is that the HIV Medic will begin to go beyond their scope of practice and into areas they are not trained

• HIV is a new disease for HCW. At first HCW were not willing to work there • HRH; Understaffing in ART; Overwhelmed • Should have basic medical knowledge • The HR crisis; The health providers • To be answered by originals of the program • Elementary tasks that put pressure on tasks • Handling of P/WHA at community level and providing ART services. The last part (I am not

sure)


QUESTION RESPONSE

12a. Can it be solved by other skill mix changes in existing professions?


• Give additional training to the nursing • Providing all nurses with HIV training and strengthen in-service departments would be a

better way of solving this problem • Nurses can solve if they are in numbers but because constraints it becomes difficult • Maybe by involving all cadres like nurses, clinical officers and EHT • The existing professionals showed focus on technical things. NCT should begin as a point

of entry at community level. This is why NAC has developed guidelines for community counseling where the community counselors will do finger picks testing and then send clients to ART center

• Not by skill mix but if we increase the output the money used to train these people can be used to hire other nurses

• Two months ago I attended a meeting in Geneva where we talked about task shifting for this task shifting they were looking at the various cadres and how they can be trained including PLWHA. They said since HIV is a global program they were thinking of developing a similar cadre to what you are talking about. I deal with regulation and we thought it would be difficult to regulate these people without then undergoing formal training

• When ART began we had assumed that we would have between 6–8 health care provider but we found out that they couldn't manage the clinics well as they had other responsibilities at the hospital, so we realized it was not going to work and needed someone who would focus on HIV care

• Get the N/A Nursing Assistants, Nursing Aids to do the job • Litigation • I don’t think so • No t really. Non-medical personnel should not do medical work • Not really as the current professions, nurses, doctors, clinical officers need to focus on their

core technical competencies • We are short staffed


QUESTION RESPONSE

13. How could this cadre be integrated into the existing system? • By ensuring that the current nurses who are on the street are employed and trained and

employed as HIV Medics to help allay the unemployment of nurses • This should be done by the health service itself. The ministry should look at how they

worked with dressers and medical assistants and how these were integrated into the system

• This cadre is best left in ART clinic TB clinic • N/A • There is a need to bring/share the current curriculum with the stakeholders so that all can

have an input into it; standardize training; Certification and good M&E system. • They can work as CDES and then from there select these that should go for training of

nurses • It would be difficult to regulate and integrate this cadre without ongoing formal training • There is a need to understand where exactly that they fit. Like nursing assistant who are

trained for three months. The training could be integrated into school of nursing • There are already NA who study on job training and they could as well do the job • Health care assistant/ward attendant level • MOH is already training the senior 4 school level who passed and training. They have now

increased the entry for the medical attendants to senior 6. These are now enrolled if they have the science subjects they then progress to the nursing school

• No – If the people had a medical background. They should not be integrated into the system as we would not be able to monitor the work that they do. They would also be over their scope of practice and undertake tasks for which they are not trained

• Here a busy days – Be integrated on non busy days Tuesday and Friday • Ensuring that we used the existing people who are there in the system, the dressers cadres

by giving them: 1. Training; 2. Putting them on the payroll • It would be difficult to integrate this because government does not have the findings.

Looking at the CHW and the history of the CHW - it would be difficult. Government could support the cadre the same way as annual staff. Government does not have incentives. One option could be that the community contribute a levy like the health center schemes. This find could then be used to pay this cadre. Government could also make it uniform in that a certain % of the scheme, e.g., 2% goes to supporting this cadre

• Due to their level of education they could be a lower level than the enrolled nurse. We could then have a pyramidal system where after a while they enter school of nursing

• The man works for the farms and he is a farm clinic worker, he is helping • With more training, the HIV Medic can integrated into the system and moved on to

becoming Zeno • It needs consultation wit the MOH and public • Lobby with government as this cadre has to be accepted by government as it does not have

such a cadre


QUESTION RESPONSE

14. What changes would have to be made in the infrastructure to support the development, deployment and support of this cadre?

• None – expand • Not much change • If their cadre could be given a status of helpers in this clinic and have updates two times in

this year; They can also work in the TB clinic • It depends how many of these cadres are we intending to train if it is a national program,

lessons should be learned from the TB program • No • The way of integrating is different. The idea itself is good that is if there was a way of

regulating them • Have bigger clinic to ease the flow of patients • Nursing Assistants/Aids are being phased out by the ministry, then why this new cadre • Recruitment criteria • They would be able to make changes as government is phasing out nursing auxiliaries and

so wanted not to do anything to accept these • No – planning • There would be no change in the existing structure • There would be no changes to the infrastructure • No change in infrastructure. There should be an increase in the equipment for vital signs.

This cadre should be strictly deployed where there are nurses to supervise them • He is already part of the farm employees and has been here for a while now • No changes • Create bigger space and due to the increase in the number of patients • The current establishment consist 13k health providers and we would like to increase to

41K. However we are hindered by the HIP completion points ceiling of 8.2% for PE of our GDP. We would like to recruit more health professionals so that we can improve our health services but this is not possible due to this ceiling. The only changes that would have to be made would be to the establishment and the pay roll. Otherwise currently we have clients being looked after by the relatives, so it would not be a new thing


QUESTION RESPONSE

15. Do you think this new cadre should be registered/licensed

Yes: 17 No: 4

15a. What professional association will supervise the curriculum, licensure, continuing education of this new cadre?

• I think this will be a problem as these people don't have basic medical and nursing skills. • Medical Council • These would be a big challenge as the nurses would be willing to register this new cadre • In the past we had dressers and dispensary they were not licensed or registered. They

should be supervised and monitored. The ZNA can be part of the training of this new cadre. This is important as nurses have to supervise them as they are in the majority. This would also help nursing to provide the supervision that will be needed for this new cadre if is developed

• Let the medical association treat them as affiliates • Medical Council of Zambia • Doctors/Medical Council • As these people will be puncturing people’s veins and they should have annual license

renewals. Nurses should supervise them as they would be working directly under them • It takes a lot to license a cadre. This will defeat the purpose. Certification of this cadre would

be better. This would have to be supervised by the MOH as the doctors and nurses would not do it. Lessons can be learned from what we have gone through with the National Guidelines for HIV Counseling and Testing. In the beginning we wanted to license them and we had great difficulties with the Medical Council due to the issue of drawing blood. The licensing process we were advised would take too long as it would need a licensing body. We then opted for certifying these people. If HIV Medics are drawing blood you will have a long challenge in the community

• It would be difficult to supervise them and they will dilute the professionals that are under the MOH – No professional association should supervise public perception if the existing cadres would be?

• Professional councils; HRH MOH; within the professional acts it would be difficult to regulate them as their regulation cannot be contained with the existing statutory acts. However, ministries still have that mandate to control the cadre and the HR and personnel diffusion of the MOH

• MOH structure • Nursing and the MOH. However, we would need to ensure that the curriculum and training

persons are accepted by the nursing and allied workers. • There would be great resistance. They would not be accepted, e.g., nursing aids • Nurses as it is part of the nurses cadres • Nurse/Midwife • Nursing Council • I don't think so because most regulatory bodies, e.g., GNC and MCZ can only register

courses above six months. As the training is less than six months they should not be licensed. Nurses – GNZ/ZNA as they would be working directly under a nurse

• This would be hard but as they work under nurses they could be supervised by nurse • Nurses • Medical Nursing


QUESTION RESPONSE

16. What changes in professional development of other cadres may occur if this new cadre is created?

• This would be a problem with the professionals. They are even refusing to accept nursing auxiliary. They don't want to even have anything to do with them. Who will supervise them is my question. There is need for a sense of ownership of this program, by either the government or the professional bodies. To achieve this, the curriculum must be designed, developed, implemented by either one of the various regulatory bodies. Who designed the curriculum, who is supervising them

• Nurses and clinical officers should focus on highly skilled activities to improve quality care. I see a change in the qualification of the nurse

• The nurses and clinical officers just need more orientation and still need to look into anatomy and physiology

• For now = no professional adjustment advocated • I don't know • Various stakeholders including government • None • Public perception of the existing cadres would [need to] be qualified. [There would be] worry

of falsification of the qualifications. • Nothing really • None • The curriculum should be accepted by all • None, as this cadre will not be supported by government • I don't think so • Accreditation points could be given to the people supervising this cadre • There would be no changes as they have no basic training • I don't think it can affect the nurses in any way • Focus on technical


QUESTION RESPONSE

17. Who would fund the development, deployment and salaries of this new cadre? • Right now there are nurses on the streets as government says it can’t employ them. There

are no funds, don't really know but for it to be sustainable let government fund it • Initially the NGOs and then the government. • This is the greatest problem facing this HIV Medic cadre. The government does not have

funds • If there is funding the development of this new cadre should be channeled to developing

and strengthening of nursing. We hear there is money from doctors for human resources. These funds should be channeled to the re-opening of enrolled nursing schools, increasing the number of teachers in schools, increasing intakes in nursing schools

• CHAZ - for churches; GOVT - for GOVT institutions • NGO to begin with, later MOH • Donors • Government should take the leading role and NGOs should come in • For long-term development and sustainability the government should fund with support from

our cooperating partners • Cooperating partners • If the government is initially involved, the government and of late we are having some

assistance from development partners. It would be good if the government and development partners should fund

• Hospital funds and part of the professional development. The funding for mental health is from hospital funds and is one for one week, using local facilities. This program could learn from these

• It's expensive - Our NAC program is currently training people for two weeks. We could attach these people to institution and the funding

• The government would have been the best to fund them but like the nursing aids they are not accepted

• As they are helping Ugandans the government should fund them • Problem/told reached ceiling, no routine of newer cadre • MOH • Government • Government • The Government • MOH – In the meantime external organization WHO, who can begin the initial processing

funding and then government take over


QUESTION RESPONSE

18. Are there sufficient funds to do so?


• With Cooperating (did not complete sentence) • Funds could be made available from WHO and government • I think so. If the government has money to help other countries with wars then they have

more money • If we plan well we can have enough • The government has money • Since we are talking about Human Resources constraints then we need this cadre very

much so funds should be budgeted • Funds such as the Global Fund can be used after all we are being encouraged to make use

of them • All those nurses/CO/doctors who have migrated what has happened to their salaries. These

salaries should be taken to pay for these people • I think so • I don't think so because of ART P/E ceiling of 8% • No recourses. I am not sure • Currently we need donor funding • As government is now no longer training nursing aids

19. Are there any data that can be used to assess potential costs?


• The curriculum for nursing overall areas but these just have on-the-job trainers • They could use the data from the nursing training • Our partners AHF are paying this cadre K600,000.00 at the moment • May be training cost for the period covered • As I have the budgets that we used to have these people • We could look at the cost of the lay counselors and the current cost of the HIV Medic

training • We could use the nurses costs – 5,000.000 from government and 4,000.000 from the

students • Other volunteers who are paid ; Volunteers help 1/2 general • None at the moment • As most cost has been borne by donors • Not exactly, I don’t want to give you a figure while I am not sure about it. It would depend on

length of training, resource person for training, detailed curriculum and when all these are it would give you a tough estimate on the cost of training


QUESTION RESPONSE

20. How will the effectiveness of this cadre be measured? • By the effectiveness of how they could help improve the work of the nurse

• By seeing the reduction in patient loads • Need for monitoring them on a quarterly basis and report to the relevant body; Evaluation

like this one to see their impact • By monitoring performance through reports and their participation and being accepted by

stakeholders • Based on performance; Patient waiting line; What they are able to do • There is need to endure that there is proper monitoring and evaluation. We could use what

we have learned from TB supporters • The outcome will be difficult to measure as these are multi-functional. It will depend on

individual and hospital human recourses to supervise them • Perception of clients toward the people; Immediate supervision/nurses • I think and I am only guessing with the increased number of clients accessing and adhering

to ART: 1. Waiting line; 2. Defaulter rates and how clients feel; 3. As a result of this cadre • The reduction in patient lines/queues and waiting time at the health facility • Increased number of clients on ART; Increased number of adherence rates; Reduced

number of people who are sensitive to drugs; reduced resistance and reduce number of clients with relapses

• Are a lot people being tested; Getting people medicine; VTC; Community • We could measure the effectives of this cadre against what the nurses are doing • Set targets what you want them to achieve and the competencies that they should have;

Job description • I don't know • We could do evaluation at district, regional and country levels • Appraisal forms by immediate supervisors • Through the job descriptions, annual confidential reports • On the farm we are seeing people get better and go back to work • By in-service training • From the work they are doing, the patients are seeing


QUESTION RESPONSE

21. Do you think that the MOH should certify this cadre of HIV Medic? If not, why not Explain your response.

Yes: 15 No: 4

• Who will supervise them • Yes there is a big gap in service delivery since medical orderlies were removed • This is because it will dilute the nursing image • Since we have human resource brain drain it is important that this cadre is supported as

scaling up of ART clinics comes along. A lot of people want to be in urban areas • I think the cadre has potential to do a lot • They are helping • These need to be certified as they will be working with people’s lives • They are contributing to the HRH crisis • Because it’s bringing self value for them; Ongoing development professional • The authorities in the MOH must be involved right from the beginning so that they are in the

know. As the professional bodies are set by acts of parliament but according to me when there is necessity a criteria cadre can be trained to solve a critical problem and there the MOH can still come in

• It would help them approved by the system. They could be absorbed into the system and they could be recognized and accepted

• Lobby for them to be recognized • Like N/A MOH • They are providing a good service; They have assisted the clinics and like the nursing

auxiliary who is certified by the MOH they should also • To make sure right people are in the right place • There are dilemmas which are their doing and this is cause of more confusion in the health

service. Right now the nursing auxiliary is being phased out and are not on the payroll. Although they are needed we have now placed them on the hospital as volunteers. I don't think MOH will license them

• These are auxiliary staff, if you certify them you are setting very high standards. They don't certify nursing auxillaries or CHW - why should they certify these?

• I think there is a great need to protect the client. But as CDEs are not licensed and medical assistants/dressers were not licensed it would cause a problem

• Right now the nursing auxiliary program has been phased out, why bring on another cadre


QUESTION RESPONSE

22. Please share any other thoughts or comments on the HIV Medic program. • Let them cost what it takes to train and convert that into the training of nurses and bond

them. Let us train more health professionals. Let the community support workers still be trained and left to work in the community and funding found

• Challenges: 1. There is need to have a well-structured course; 2. All efforts should be made to make the HIV Medic accountable to the nurse/clinical officer; Legality of the cadre should be a priority

• This would be a good program but should be integrated. They need to expand nursing schools and government to support post basic nursing. The following could be done: (a) pre service curricula to include HIV; (b) strengthen the in-service departments; and c) nursing association to be used in capacity building and training HIV Medics

• More HIV Medics to be trained – rural areas after scaling of ART; To have updates and make sure grade 12 are picked for the course; The training should have four weeks of class, three weeks of practical; Training manuals should also be looked into so that it becomes a sizeable document which is easily carried around

• Seems a good program and we need more people to be trained • It’s beneficial for him being on the farm as he is teaching and educating client • There is a need to scale up the program. It’s been created to relieve the over burdening of

the health workers. However, the following steps should be done: 1. Continuous capacity building; 2. Uniformed for easy identification; 3. Motivation and government recognition

• The HIV Medic should be used as a part of the entry for VCT. They need to include in their training the finger prick testing and should be part of the DCT – diagnostic counseling and testing. As these are community covers testing should be done at point of care

• Community linkages and linking to health work well as community cadre; having a CHW is important

• Create more awareness about it as I don’t think many people are aware of it • This program should be funded and expanded: More work needs to be done to ensure that

they get absorbed into the system; They should have access to the other training to ensure that they develop professionally

• Lobby for them to be accepted by government. As right now they don't know their future • A cadre who is training focus ART; Handle issue pertinent to clinic • The HIV Medic training should be upgraded; pioneers of this should be provided with an

opportunity to be upgraded to ZENS; They should remain in service and be part of the payroll

• Not enough consultation was made on how this staff will be handled • I would prefer they undergo further training in the medical field. Today we have HIV

tomorrow we will have another problem • MOH should not do this. They should get all stakeholders involved. Government should

take the lead with this initiative. It should be sensitized to all stakeholders. There is a need to seriously think of patients’ rights, observe confidentiality; there is also a need to get them into a proper well-structured training with clearly defined rates and responsibilities: 1. This should be a six-month course; 2. Recognized; 3. Good and well-trained teaching staff; 4. Proper entry qualifications. There should also be well structured supervisory mechanism

• Only people with basic medical knowledge in the program, e.g., there are nurses on the streets

• I can’t - What are arguments for and against, who is pushing this agenda is it demand led on supply. These are cultural issues. We need to think of the fact that our PE personnel comments as a nation cannot exceed 8.0% of our GDP. There is need to think of other ways to fund this and improve the motivation of our health providers. I don’t think creating another cadre would help. Let’s improve the enrolled nurses’ output.

• Where will this cadre fall if they are the full cadre, nursing is to be involve in the design, development of the curriculum – Nursing; Allied Health Workers


QUESTION RESPONSE

• For this program to be effective they will need additional training apart from HIB as they will meet various other diseases which are not HIV related like a flu . They also need more training so that they can provide love – comprehensive care, mental, physical, social, medical care. This because mental health is such a critical issue. There is also need to put in place a long-term plan for this cadre. How will they be integrated into the system? How will the structure be, who will they report to? Should this course be a foundation course for those who are aspiring for higher education? Can they qualify to get into nursing, social work, counseling? What percent will be trained every year? These are my thoughts


APPENDIX K: REVIEW OF HIV MEDIC CURRICULA FOR UGANDA AND ZAMBIA

General:

Provide a job description that clearly outlines the expectations after completion. The learning objectives are useful, but the specificity of a job description is important.

Include learning objectives in the course syllabus (Preface 01A) , as well as participant selection criteria, which is already outlined in the student agreement form

Clarify exactly what is expected in the objectives. It is not clear on their role related to ARV management from the objectives (are they only to “describe” it, or should they be able to “demonstrate” it?)

The course syllabus should be more specific in the clinical requirements. How long is the clinical component? How many days per week is it? What specific objectives will be met in clinical? A logbook for tracking their clinical skills as completed is important to add. The clinical forms are focused on patient interactions or overall student assessment of performance rather than the skills performed—it would be useful to track overall skills as they are accomplished using a logbook.

Provide reference manual other than PowerPoints. New providers may want more information. Use a nationally (or internationally) approved manual to give them more information. Consider something like “Medical Management of HIV Infection” by Bartlett and Gallant, if there are no local resources available.

Didactic:

Revise body system presentations to have a clearer focus on HIV and ARV management. If the primary goal is producing providers who can manage ARV therapy, it is essential that each presentation on a body system includes slides on how that system may be impacted by HIV and ARV treatment, then follow each with a case study to highlight the clinical picture. The presentations on diabetes, pancreas and liver (all of which can be affected by ARV therapy) did not include any info on how those systems are affected by ARV therapy. While there are presentations on HIV, OIs and ARV management later—even if you add just a few slides to each body system presentation it will help reinforce how the body system may be affected. In general, it is recommended to reduce the emphasis on general anatomy/physiology and clarify the focus on the impact of ARVs, and follow with exercises and case studies to apply the knowledge to clinical simulations.

Each presentation should include objectives. This relates to the first point. This objective: “Describe the basic function of the pancreas” is much less useful for this group than: “Describe the basic function of the pancreas and how it may be affected by ARV therapy.” There are no objectives, so the purpose of the presentation is not clear. Be specific and focus more on the impact of HIV or ARV on the body system. Even the exam questions focus more on biology of system functions than on the impact of ARV treatment.


Remove OI presentations to allow more time for clinical decision-making skills. The objectives do not mention OIs at all, so if there is no role for this provider related to OIs—just do an overview and remove the detailed information on management of each. Then you can do more clinical simulations to better develop decision-making skills.

Start with general concepts and then get specific. Move infection prevention, counseling, general HIV information, taking a history and physical exam to the beginning of the course. Then get into body systems, how impacted by HIV/ARVs, and then ARV management. In fact, you could offer “testing out” of the basic HIV information—do a quiz and if everyone performs well, reduce time spent reviewing this information.

Include history-taking documentation. At some point they should be trained in note-taking and documentation as appropriate for their settings.

Clinical:

Please note that there is not much specific information about the clinical portion, (how it is structured, specific clinical objectives to be met, numbers of students at each site, etc.) so some general recommendations have been made to apply as appropriate.

Specify their role related to ARV management and revise curricula accordingly. The learning objectives mention they should be able to “Demonstrate an understanding of when to start the therapy and what to start with, when to change and what to change to and when to actually stop the therapy.” If they are meant to manage patients on ARVs, please change to “Demonstrate initiating, changing therapy and stopping therapy with a client in a clinical setting” or provide other specific instructions such as “Demonstrate initiating treatment with a client in a clinical setting and demonstrate changing or stopping therapy in clinical simulations if no opportunities arise with patients.”

Emphasize clinical decision-making skills in clinical practice and increase use of case studies/simulations in didactic portion. In ARV management, the physical skills (taking BP, drawing blood, etc) are not as difficult or important as the ability to properly assess and manage ARV treatment. If managing ARV treatment is part of their job description, I would emphasize this throughout the curriculum.

Do not wait until the end for clinical. This puts too much emphasis on didactic and does not give students the opportunity to practice skills as they are learned. Go through the introductory presentations, basic body systems and then start rotating some students through clinical sites. A logbook to track skills will be helpful. The emphasis on clinical decision-making should start early, and being in the clinic over a longer period of time will give more opportunities for reviewing cases and seeing more patients. Especially given that many clinics have shorter hours—you can stagger clinic rotation to maximize experience with clients.

Ensure adequate clinical experiences. If there is more than one trainer, be creative about clinical rotation in order not to overload sites and give students more time working with clients. For instance, you can split the class in half so that one trainer does a morning session while the other trainer takes the other half of class for clinical. It takes some juggling, but will provide more clinical experience.


Provide more specific clinical guidance. Provide a clinical overview form or syllabus for clinical instructors that outline specific clinical objectives, the proposed schedule, how to provide feedback and how to assess and report on student performance in clinical. A logbook that outlines specific skills to be performed is important to add. Also suggest finding some way to also include an assessment of clinical decision-making skills in simulation in their clinical skills practice and assessment, even if that occurs in the classroom.

Assessment:

Assuming that the objective “Demonstrate an understanding of when to start the therapy….” means you want providers who can manage ARV therapy. If, however, you mean that you want them to understand normal and refer abnormal, and not directly manage ARV clients, you should consider these recommendations in that context. These recommendations are for producing providers who can manage ARV therapy—not just refer.

Include more activities for formative assessment. Students receive an exam every week and a final exam. The presentations seem very biology focused and not focused enough on impact of HIV and ARVs. I would add exercises and case studies (unless they exist elsewhere) that help students apply clinical decision-making skills to the biological function of the system.

Revise exam questions to be more consistent with objectives. While the objectives speak to the ability to provide and manage ARVs and assess clients—the exam questions are very basic and focused on biological function. Revise them to focus on applying the knowledge to clinical situations and use multiple choice more than short answer.

Review and revise weekly exam questions and final exam questions to be more consistent. This is related to the point above—there should be a clean line from objectives to practice to final assessment. The objectives speak to managing ARV therapy, but the weekly exam questions are focused on biology and the final exam questions are more focused on HIV/ARV impact on systems. Please review and revise the weekly exam questions to be more consistent with the final exam questions.

Provide clear guidance on how to assess participants clinically. There’s no specific instruction on how they are assessed as competent in clinical. If it is using the evaluation form provided, please note that. How will you ensure they have been able to do all the skills you are teaching without documenting them using a logbook?

Please specify how they will be either qualified/certified/approved to practice and which professional body will provide the approval. The overview presentation notes participants will receive a certificate of participation, not certification. Perhaps they are certified after a clinical examination and additional didactic exam? That should be clearly explained at some point.

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