South Africa-The Co-INFECT Study: Nursing Models of Care for HIV and MDR-TB to Improve Treatment Outcomes
Mycobacterium tuberculosis (TB) remains the leading cause of death among persons living with human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) in southern Africa. This co-infection has resulted in an overwhelming burden for healthcare workers and the healthcare system. Drug-resistant TB remains a growing threat to public health despite advances made in treatment and diagnosis over the past decade. South Africa has the world's highest rate of TB/HIV co-infection and ranks fourth worldwide for both multi-drug resistant (MDR) TB incidence1 and HIV prevalence. Treatment of MDR-TB, defined as resistance to isoniazid and rifampin, remains challenging and complex. Prospective cohort studies from South Africa report less than 50% treatment success (i.e. cure or completion) and significant differences in patients with and without HIV are noted. In addition to the complexity of treating MDR-TB/HIV co-infection, systems level factors such as access to care and healthcare capacity also contribute to poorer treatment outcomes. Complicating the clinical situation is the insufficient number of trained healthcare providers capable and clinically competent to manage the challenges of integrated MDR-TB/HIV care. Nurse case management (NCM) models in which a registered nurse facilitates treatment plans to ensure that appropriate and timely care are given have been shown to be safe and improve treatment outcomes. In this research program we are evaluating such models including models with nurses prescribing treatment for MDR-TB/HIV as well as case management approaches.
My month in South Africa was an incredible experience, both personally and professionally. While I have traveled internationally quite a bit, this was my first trip to Africa and my first time doing public health research in the global setting. After three years of nursing and public health education I was struck by how much more I noticed in my surroundings that tie into health. I was fortunate to step into a project that is already fairly well developed. Dr. Jason Farley and colleagues have completed much work in the past few years that has helped move the decentralized health care initiative to where it is today. These existing connections, time to see the different pieces of the healthcare system, and ability to see patients from a nurse’s eyes all made my experience in South Africa a very rich one.
It is a bit overwhelming to arrive in a foreign country with the intent of helping assess and evaluate their health care system. Who am I, on my first visit to this continent, to report on the well being of the nation’s health? There is so much to learn and thankfully I had ample opportunity to learn from amazing mentors and from personal experience. Our trip was planned to start with the third South African tuberculosis conference in Durban, South Africa. This conference was a wonderful introduction to the healthcare structure of South Africa, as well as new research and key players in the MDR-TB research/management scene in country.
With this academic introduction our group moved on to the site at which our research work would be done. Murchison Hospital, in Port Shepstone, KwaZulu-Natal, would be our home base for the remaining weeks in South Africa. It was at this point that I was able to form a better understanding of the personal side of the MDR-TB problem, in addition to its medical complexity. Speaking with current healthcare providers and seeing the conditions of patients brought the necessity and importance of our work to the forefront. I saw the benefits, discussed at the conference in Durban, of moving MDR-TB management to the primary health care setting. They are many: more immediate initiation of treatment, improved infection control, improved patient care and increased adherence to treatment. The personal side of the disease made me so grateful for my health and family. Joining the mobile injection team and rounding at the hospital brought me directly in touch with patients, very sick patients.
The most valuable part of this experience for me was the exposure to multiple levels of the health care system; from the administrative department of health level, to the specialty hospital, to the clinic level, down to the home visits. To see the intersection of primary care and public health and the general health system was an amazing way to put my combined degrees of nursing and public health together. I hope to keep this experience with me in the various settings I will practice in the future. As a newly graduated nurse practitioner, I am excited to solidify my clinical skills in the next few years. I can also see myself returning to international work in the future.
The support of Dr. Jason Farley, Jeane Garcia-Davis, and Kaya Mlandu, the first nurse in South Africa to initiate and manage MDR-TB care for patients, was vital to the success of my experience. Their expertise, knowledge of the local systems, dedication to teaching and compassion towards the patients made my time in South Africa an excellent learning environment. The presence of other students made the experience more engaging.