Seung, Kwonjune J. MD; Bitalabeho, Akiiki MD; Buzaalirwa, Lydia E. MD, MDC; Diggle, Emma RN; Downing, Moher MA; Bhatt Shah, Mona MD, MPH; Tumwebaze, Benon; Gove, Sandy MD, MPH
In many resource-poor countries, the HIV/AIDS epidemic poses serious challenges to already stressed health systems. This is particularly true in countries of sub-Saharan Africa, where HIV prevalence rates are in the double digits, but also in many other countries where there is limited access to HIV care and treatment. Throughout the world, doctors and nurses are struggling to care for HIV-infected patients under conditions barely imaginable to health care providers in developed countries.1
Recent global aid initiatives mean that HIV testing, antiretroviral therapy, and other HIV-related interventions are slowly becoming accessible for many poor countries. In developing countries, these interventions are new for many of the doctors and nurses. Even those who have recently graduated from medical and nursing school may have had only a cursory introduction to HIV/AIDS. Despite their lack of training, these health workers are expected to provide complex clinical interventions. In contrast to developed countries with low rates of HIV infection, primary care doctors and nurses in high-burden countries are increasingly required to perform many tasks previously in the realm of infectious disease specialists, such as diagnosis and treatment of opportunistic infection, or initiation of antiretroviral therapy.
In developing countries, the responsibility for training in HIV/AIDS care and treatment generally falls to the ministry of health, which is the primary employer of doctors and nurses in the public sector. As with other new interventions, training generally takes the form of short “in-service” seminars, where health workers are taken away from their posts and brought to a central location, typically for one to two weeks. The seminars generally consist of traditional, classroom-based lectures and do not include more innovative teaching methods.
The use of standardized patients (SPs) in medical education was pioneered in the 1970s. By 1989, a study concluded that 70% of U.S. and Canadian medical schools used SPs in the curriculum.2 There has been extensive research on the validity and effectiveness of SPs for training and evaluation,3,4 and SPs have been used for training on a wide variety of subjects, including physical examination, interviewing skills, and patient counseling and education.5
In contrast, reports of SPs in developing countries are much sparser in the medical literature. “Simulated clients” have been used to assess provider behavior in different environments (e.g., private practitioners, family planning services), but this is a third-party quality-assessment method rather than an educational tool.6 A number of medical schools, mostly in middle-income countries, have reported the use of SPs as part of objective structured clinical examinations (OSCEs). Several of these reports have been frank about the difficulties of organizing SPs in resource-poor settings.7–9
This article presents a unique approach to HIV/AIDS training in resource-poor settings that incorporates the use of SPs as part of in-service training provided by ministries of health. We interviewed course facilitators and SPs about their experiences to determine the feasibility and effectiveness of this approach.
Integrated Management of Adolescent and Adult Illness
Integrated Management of Adolescent and Adult Illness (IMAI) is a World Health Organization (WHO) health systems strengthening initiative with a strong emphasis on training health workers in the management of common diseases and conditions. Because of the seriousness of the epidemic in many developing countries, HIV/AIDS is a high-priority area for IMAI.10 IMAI provides ministries of health with tools to integrate HIV-related interventions into primary care services. Chronic HIV Care With ARV Therapy and Prevention is an IMAI guideline module based on general principles of chronic disease management, and, like all IMAI modules, it contains clinical protocols designed to be used in resource-poor settings with limited laboratory services.11,12
There are two main IMAI HIV/AIDS training courses that have been developed around the management protocols in Chronic HIV Care. The WHO Basic Antiretroviral Therapy (ART) Training Course is aimed at “medical officers” (typically medical school graduates with one year of postgraduate training) and nurses of varying levels of training, and it includes such topics as WHO clinical staging, prophylaxis of opportunistic infections, and initiation of first-line antiretroviral regimen therapy. The WHO ART Aid Training Course is aimed at lay counselors and includes such topics as HIV education, posttest support, and adherence counseling. Both training courses are intended to provide basic skills necessary for health workers to start caring for HIV-positive patients and are to be followed by regular supervision and mentoring.
The IMAI Chronic HIV Care guideline module and associated training courses were first used to train health workers in Uganda in 2004.13 Since then, IMAI has been adapted by a number of other countries in Africa, Latin America, and Asia. Although countries adapt the generic training materials to suit their needs, one common format is a one-week in-service training for staff working in primary care clinics (Table 1). Participants from district hospitals and health centers are typically selected by the ministry of health and attend the training at no cost to themselves. Given the very short duration of the trainings, there is a strong emphasis on efficient, skills-based learning that is facilitated by the use of SPs.
SPs in IMAI
SPs were incorporated into the first IMAI training at Masaka Regional Referral Hospital in Uganda in 2004. Masaka Region has a total population of about 1.2 million and an HIV seroprevalence of about 10% to 12%.14 A small number of people living with HIV in the local community were recruited by the training team to be SPs, and they work closely with the course facilitators to train Ugandan doctors, nurses, and counselors. SPs have subsequently been used in all other countries that have adapted IMAI.
In IMAI, SPs are called Expert Patient–Trainers (EPTs) to emphasize their role in the training of health workers. In the medical literature, the use of SPs includes simulated patients (non-ill people who have been coached to portray specific illnesses) and actual patients (who have been trained to portray their own illnesses).15 IMAI has taken the latter approach, with the idea that people living with HIV are best qualified to train health workers in the communication and counseling skills that are crucial to chronic management of HIV. Furthermore, in countries where many HIV-related interventions are new, people living with HIV often have more clinical knowledge and firsthand experience with these interventions than health workers do. Finally, direct interaction with people living with HIV is the best way for health workers to examine their own attitudes and prejudices.
IMAI training is divided into traditional classroom-based learning and multiple-station assessments (“skill stations”). EPTs are integrated into both. During classroom-based learning, EPTs explain what it is like to live with HIV, and they help participants understand HIV as it affects patients. For example, at several times during the class for clinicians, the facilitator and the EPT may act out a clinician–patient interaction and then discuss with the class whether the clinician interacted with the patient in a caring and communicative manner. During the class for counselors, the EPT speaks about his or her experience with HIV and the medical system.
Course participants spend approximately two hours per day in “skill stations,” a multiple-station assessment that consists of one-on-one encounters with EPTs. In each encounter, the health worker is expected to interact with an EPT portraying a standardized case. This generally takes place in a large room or outdoor area where participants can quickly rotate to an “open” EPT after each encounter. Course participants are given some leeway in how long they take to interact with each EPT; generally, participants complete three to four encounters during a two-hour session.
Cases include common HIV/AIDS-related clinical and counseling scenarios in the setting of a primary health clinic, such as a patient with a new opportunistic infection or a patient who is noncompliant with antiretroviral therapy. After each encounter, the EPT gives feedback based on a checklist that is modeled after the 5As conceptual framework for behavioral change (Appendix 1).16 Course facilitators observe participants during the skill stations and provide additional feedback. The cases are designed to correspond to the classroom content, and they become increasingly difficult as the course progresses. It is important for the course facilitator to supervise the multiple-station assessment closely. The facilitator can pick up much valuable information about the skills of health workers that is not evident in the classroom, and he or she can intervene quickly before an error becomes a bad habit. If many students are making the same error, it can be addressed in the classroom immediately after the skill station.
Selection and Training of EPTs
EPTs are usually recruited from groups of people living with HIV/AIDS (PLHA) or through nongovernmental organizations that work closely with these groups. In most countries, criteria for the selection of EPTs have been minimal, with the only common requirements being HIV-positive status and the willingness to discuss that status openly. EPTs are not required to have a high level of education. Semiliterate PLHA with little formal education have been able to become competent EPTs with good training and close supervision.
All EPTs are expected to undergo a three-day preparation, which includes training in the 5As and practice time for one or more specific cases. Instructions on how to portray each case provide only broad outlines of the major clinical or counseling points, and the EPT is expected to use his or her own life experiences to fill in emotional details. This allows EPTs to portray cases in a realistic manner after a relatively short training (Figure 1). EPT competence improves with experience, but there are some who never fully grasp the concept of playing a role. Course facilitators closely observe EPTs to identify those who are having difficulty and to provide them with additional instruction or replace them.
It is important to address the social and ethical issues involved in training EPTs. For clinical realism, it is important to recruit EPTs from a wide variety of backgrounds, including poor and vulnerable groups. But, members of these groups have often experienced past discrimination from the health care system. EPTs may not feel comfortable discussing certain issues directly with course facilitators. Working closely with PLHA groups can be very helpful in this regard. By communicating with EPTs collectively and through identified PLHA group leaders who are experienced in dealing with such issues, problems can be identified and addressed in a timely fashion.
On the most basic level, IMAI is often implemented in areas where HIV care and treatment is still limited, so EPTs themselves may not be receiving adequate medical care. Course facilitators may be able to provide some simple medical care to some EPTs. EPTs that require more complex interventions should be referred to local clinics or hospitals; PLHA group leaders should also be involved in promoting care and treatment, as they often have an interest in advocating for better medical care for group members, EPTs and non-EPTs alike.
In some countries, EPTs were already living openly with HIV, were confident in their knowledge and skills, and were overenthusiastic in their feedback to health workers. In other countries, where stigma and discrimination were stronger, the EPTs needed to be coaxed to point out obvious clinical errors made by health workers. After each day, it is important that the course facilitator hold an EPT debriefing session to discuss these issues and ways to improve feedback given to the health workers.
Benefits for Health Workers
After the first positive experience in Uganda in 2004, EPTs quickly became an integral part of IMAI training throughout Uganda and other countries that adopted the IMAI strategy (Table 2). We interviewed IMAI course facilitators and EPTs in several countries about their experiences.
Course facilitators reported that health workers generally found the EPT skill stations to be an efficient use of training time and very helpful for reinforcing clinical and counseling skills learned in the classroom sessions. Several health workers who already had extensive experience in working with HIV patients and were participating in the IMAI training to evaluate its effectiveness reported that they still found the EPT feedback to be useful.
Course facilitators noted that health workers were often initially quite skeptical about EPTs, having never experienced anything like this method before. Skepticism, however, generally turned to enthusiasm after participating in the skill stations. However, this does not mean that every health worker found it easy to receive feedback from a patient. There were several reported incidents where the course facilitator had to intervene and instruct health workers, both doctors and nurses, how to behave respectfully with an EPT, a lesson that hopefully was retained during clinical practice with real patients. Finally, EPTs helped doctors and nurses examine their attitudes about PLHA and their responsibility to provide psychosocial support. In several countries, the EPTs were the first PLHA living openly with their disease that health workers had met.
Benefits for EPTs
EPTs in many countries felt that they were an effective part of the training team and took great pleasure in imparting their knowledge and experience to health workers, whom they often felt to be in great need of training.
At first we did not know that there are things we could contribute in the fight against HIV/AIDS. Now I can see that we can do a lot. Now I feel personally that I am helping and contributing to the improvement of the health care system.
Several noted the mutual benefits of PLHA involvement in the training of health workers on HIV/AIDS.
The fact that a person living with HIV/AIDS was involved as a trainer inspired our spirit. If the training was given without the presence of a person living with HIV/AIDS, the outcome would have been different.
Similar to the experience of SPs in other countries,17 EPTs benefited from the sense of being part of the training team, the satisfaction of improving the skills of health workers, and learning more about their illness. Meeting other EPTs was also a valuable experience, as this allowed them opportunities to support and learn from each other.
Very educative . . . exciting . . . improved my positive attitude to my status.
As an expert patient–trainer, I have learnt a lot how to take care of myself and I think I am able to help others who are like me . . . most nurses and clinical officers learnt a lot from my experience.
An improvement in self-esteem was a common response, exemplified by this quote from a Ugandan EPT:
When I knew that I had HIV/AIDS I felt that I had a lot of stigma. My husband left me and my child. I was not able to disclose my status to my employers, but they then found out and I lost my job through discrimination. I did not know what to do and felt very low. I lost so much weight through worry; I felt that no one wanted me. Then a friend of mine informed me about the role of the Expert Patient-Trainer. I applied and was accepted and I joined. I did the training, have done workshops. I now have courage. I have since gained weight. I have no fear because you meet people in the same status as you and you feel quite okay. I feel that I am in the right place, and I feel happy to encourage others. As a result I am now also a peer educator and we help others. We help the health practitioners because they told us they didn't know how to handle HIV/AIDS patients and they didn't know how to access our emotional status and general care, but through this they have gained a lot. I think this has helped me to fight my stigma, and accept my status. Before, I felt so shy, I felt bad. This training has made such a difference. I can speak out and I feel motivated. I can live a better and more positive life. I rejoice for it, and I am now a very happy person.
EPTs in most countries were generally paid for their services, but, in several countries, they were asked to volunteer. Several EPTs noted that it was important to receive financial compensation.
The effort or participation of EPTs in the training sessions would be appreciated in the form of a money incentive for the time they spent in these sessions.
Many EPTs went on to become lay counselors working at HIV clinics after receiving additional formal training in counseling. After this transition, the term “Expert Patient–Trainer” was often replaced by “lay counselor,” “ART Aid,” or some other label that emphasizes full-fledged membership in the clinical team.
For this study, we interviewed a convenience sample of IMAI course facilitators and EPTs, as many continue to be active in IMAI trainings. Health worker course participants, however, were not interviewed. Further research on the use of EPTs in IMAI training is needed, particularly regarding health worker attitudes, reliability, and cost-effectiveness. Nevertheless, this experience shows that the use of SPs can be implemented successfully into HIV/AIDS training for doctors, nurses, and counselors in resource-poor settings. Working with SPs allows health workers to practice in a controlled environment, avoiding potential harm to real patients. Course facilitators are able to observe the health worker in action and adjust the didactic part of the course in order for the health workers to meet their educational goals. Finally, the SPs themselves learn from training and teaching health workers and are able to provide a valuable resource to the training of health workers in chronic illness. They see themselves as important members of the training team, and they feel more empowered about their own illness.
As global efforts continue to expand in-service training efforts for HIV/AIDS, we believe that the use of SPs can expand as well. One of the lamentable results of the HIV epidemic is that in almost all countries, there is an ample supply of people living with HIV/AIDS. Many of them are intelligent, underemployed, and genuinely enthusiastic about participating in the training of health workers. The cost of using SPs differs from country to country, but it can be expected to be much lower than in developed countries because wages are generally much lower. Already, in many of the countries adapting IMAI, local pools of trained EPTs have been organized and can be called on to prepare for training in a particular zone or province. As the number of EPTs increase, maintaining the quality of EPT training and supervision will become more important. One possible solution that has not been explored is EPT certification, which could be possible in countries that have incorporated IMAI into the national in-service training program coordinated by the ministry of health.
The need for in-service training in HIV/AIDS care and treatment in many resource-poor countries is expected to continue for some time. In the long term, however, HIV/AIDS training needs to be shifted into preservice training—the medical and nursing school curricula—preferably in a manner that allows graduates to enter the workforce with a running start. Some African countries have already begun efforts to integrate IMAI and SPs into medical and nursing school curricula. Hopefully, this will facilitate the wider use of SP methodology, because it has great potential for improving medical and nursing school curricula in a wide variety of subjects.