Continuing education and support for providers is critical in light of periodic changes in guidelines for HIV care and treatment, coupled with mandates for rapid scale-up of care [1,2]. This is particularly true in remote areas and for primary care cadres without infectious disease or HIV subspecialty training. Traditional in-service training, such as centralized workshops with ongoing support, may not be feasible in some settings; in addition, expert input may be needed urgently at times, and case acuity or other access challenges obviate the ability to refer for specialist care. These variables highlight the need for an effective strategy to build providers’ capacity.
Electronic health (eHealth), defined by the WHO as the use of information and communication technologies (ICT) for health , offers novel approaches to provider training, records-based clinical guidance, and proxy actions to extend care for people living with HIV (PLHIV). eHealth comprises several domains, including mobile health (mHealth), health information systems/electronic medical records (EMR), telemedicine, and eLearning, and the various formats have been utilized across different health areas in recent years. We aimed to review and synthesize recent eHealth (with particular focus on telemedicine) and other approaches to provider training and client care improvement for HIV with a critical analysis of gaps in the literature and recommendations for potential next steps.
REVIEW APPROACH AND PROCESS
The current review was based on search of peer-reviewed literature published between 1 April 2016 and 13 April 2017, conducted on 14 April 2017. PubMed, Global Health, Academic Search Premier, and Cochrane databases were searched using the terms: (eHealth OR telemedicine OR mobile phone* OR cell phone* OR SMS OR mhealth OR mobile health* OR m-health OR electronic health* OR ehealth OR e-health OR text messag* OR mobile messag* OR smart phone* OR smartphone* OR social media* OR mobile technolog* OR computers, handheld) AND (training OR education OR teaching OR delivery of healthcare) AND (HIV OR HIV infections), producing 207 unique references. Of these, 65 full text articles were assessed by one author (C.S.T.), with 29 included in this review. Inclusion criteria were based on content including eHealth, telemedicine, or innovative provider training or support interventions for HIV care, including ICT or other technology descriptions relevant to provider-targeted interventions.
HUMAN RESOURCE INTERVENTIONS FOR HIV CARE & RELEVANCE OF ELECTRONIC HEALTH
In considering education and support for HIV care providers, we extended our review scope to include: traditional in-service training for health professionals without eHealth modalities; training of alternate HIV care providers, a broad cadre of health workers in less resourced settings who often complement or substitute for certified professionals; and non-eHealth approaches to extend reach of services (Table 1). Our rationale for including these publications is to lay a foundation for available and potentially successful care models to which eHealth technologies may be applied to streamline or further extend care. Ultimately, the performance of health providers will depend on quality improvement methods, coaching, mentoring, and supportive supervision that maximize impact. Vasan et al.[7▪▪] summarized evidence for these methods on the performance of healthcare workers in primary healthcare settings in a systematic review. The authors found that many (57.5%) studies addressed ‘supportive supervision’ and found generally positive results, with seven of the 40 reviewed studies being randomized controlled trials (RCTs). Despite this volume and rigor, they noted little clarity about the most effective features of supervision, as well as the design, implementation, and monitoring of supervision programs. The same was true for the other dimensions of interventions for improved healthcare worker performance, for example, mentoring, coaching, and quality improvement. Next steps should include reaching a consensus on a systematic definition of supportive supervision and mentoring, to be followed by establishing standards specific to HIV care for each of these activities.
Specific interventions focusing on training for health professionals found positive impact on HIV patient care for stigma and rights-based care and influenza guideline training,[4,5] and, within a review assessing approaches to improve prevention of mother to child transmission, on maternal antiretroviral treatment (ART) use .
Alternate HIV care providers, cadres typically serving as community outreach workers, peer navigators, or frontline primary healthcare providers, may be able to reach clients who would otherwise be left without HIV care and treatment and, most importantly, make services more cost-efficient and client-friendly. As part of building evidence on task shifting to lower-level and lay providers and associated positive benefits, Ma et al.'s [11▪] systematic qualitative review found that task shifting reduces the shortage of medical professionals in lower and middle-income countries, improves the psychosocial well being of PLHIV, and strengthens the relationships between PLHIV and health providers by building trust. With implications for the training and capacity building of providers, the authors present evidence that essential knowledge and problem-solving skills were more useful than disease-specific treatment literacy in training for lay health workers. However, the best strategy has not yet been identified to effectively build capacity in and sustain the quality of these alternate providers. A targeted nutrition training intervention for frontline providers was found to have some improved weight gain among pediatric HIV patients with wasting as compared with control clinics in a cluster-randomized trial but follow-up was too brief to determine impact on stunting .
Last, interventions using novel approaches to HIV care provision with human resources were included. A program report with a two-phase intervention of training traditional birth attendants and other community-based cadres for counseling and providing mobile care units with both health professionals and frontline providers in India reported considerable patient reach but had no comparator group . Bassett et al.'s [8▪] RCT is, as stated by the authors, the first published study to evaluate the effectiveness of patient care ‘navigators’ to optimize treatment for HIV and tuberculosis (TB). Even with this study's robust methodology and outcome measures to evaluate the efficacy of the navigator intervention for combined HIV and TB treatment, the authors found no difference in treatment outcomes between the intervention and standard care group. Although the authors note that intervention intensity – in this case, the performance of the navigators – was perhaps insufficient to improve outcomes, the study demonstrates the value of a rigorous evaluation design to indicate an intervention's effectiveness, weaknesses, and potential modifications for improvement.
ELECTRONIC HEALTH INTERVENTIONS
eHealth can encompass a variety of technological approaches, and 13 articles were included within this group (Table 2). Articles in this section were diverse, ranging from design or results of trials studying provider-centered interventions, project development and pilot studies, reviews of eHealth interventions partially or exclusively focusing on HIV, and evaluations of enhanced EMR or human resources information systems (HRIS) that included components to facilitate delivery of HIV care by providers. A single cluster-randomized intervention trial assessed the efficacy of an EMR enhanced with an embedded clinical decision support system on HIV treatment failure outcomes [16▪▪]. In that study, intervention facility providers received alerts via EMR for two types of notifications: when patients had a critical CD4 value or missed lab and to suggest clinical actions in response to lab results and recorded medications. Control facility providers only received a standard monthly patient report. Patients with immunologic treatment failure at intervention facilities were three times more likely to have treatment changed and had significantly shorter times from alert to action and from ART initiation to first laboratory monitoring. The evidence was high quality with analyses adjusted for potential confounding of differences in baseline disease stage at entry, and the results suggest that EMR systems to prompt provider action should be considered for scale-up. These systems are increasingly present in public-sector facilities and their functionality becomes more robust over time. However, the inability to eliminate article-based records as the initiating step and need for data clerks with the associated staffing and training burden should be improved in future iterations of EMR-based interventions. Three articles also provide insight into potential for merging provider-targeted interventions with EMR. Kang’a et al.[14▪] reviewed EMR platforms in Kenya against national standards in 2012 and found that few of the evaluated EMR systems incorporated any integrated clinical decision-making aids. Two other program reports describe EMR and HRIS systems that incorporate provider-targeted components to improve care [18,19▪]; these systems work to integrate different databases to ensure comprehensive data are available to providers. Rettler et al. describe software that merges clinical site EMRs with the public health department's system to ensure HIV patients are retained within the cascade through notifications to field epidemiology personnel. Waters et al.[19▪] report on an innovative system in Mozambique that merges data on provider skill sets, determined by in-service training and certification, and clinical sites needing personnel with those skills in areas the providers prefer, increasing likelihood of provider retention. However, efficacy data using patient outcomes and provider knowledge and satisfaction measures are needed before these demonstration models can be recommended at larger scale.
Mobile-platform-based interventions are described in several articles and address a variety of HIV care areas, but efficacy data are lacking or data suggest no intervention impact [13,23]. A Kenyan review called for greater evaluation of mobile-based interventions generally; two recent systematic reviews found few HIV eHealth interventions targeting providers overall [22▪,23], and it is hoped that planned interventions will incorporate rigorous evaluation into design . Internet-based interventions comprise models that act as provider proxies in a high-resource setting [20,21] or more directly supply information to health providers [15▪,17▪]. These interventions all assume a certain knowledge of and access to electronic media and, while smartphone use is expanding, interventions of this type may not be feasible for providers in some settings. Social media or an Internet platform to extend sensitization or care activities are promising in a high-resource setting and would benefit from efficacy data specifically for HIV care, patient input on user friendliness and confidentiality, and care outcomes [20,21]. Confidence in quality and reliability of information was also relevant to program assessments for provider learning where Wikipedia (Wikipedia.org), an open database with no internal validation, was provided as a potential electronic resource for health information with mixed reviews. From that study, rural providers identified the need for accessible, curated content specific to national guidelines and information to be made available in urgent situations [17▪]. An innovative approach to controlled content to supplement eHealth initiatives was also presented, linking program-generated video of scripted patient encounters through YouTube (LLC, San Bruno, California, US) [15▪]. This model holds promise and should be considered for augmentation of in-service training and support; formative studies are in process to determine best host sites (e.g., YouTube, WhatsApp Inc, Mountain View, California, US, Skype; Communications SARL, Luxembourg) in areas with variable connectivity, and cost-effectiveness in settings where smartphone use and connectivity are expanding. Larger sample sizes and rigorous trial design will be required to measure efficacy.
Telemedicine interventions (Table 3) were more homogeneous than those identified for eHealth. Primary programs/studies included evaluation of four provider-focused telemedicine interventions,[26▪▪,27▪,28▪,29▪▪] and two telephone-based care extension interventions in which providers called HIV patients with depression for consultation and symptom monitoring [25▪,30]. We also included a review [32▪] and a technology and study protocol description [31▪▪] that featured technology relevant to telemedicine intervention design and programming considerations.
The Extension for Community Healthcare Outcomes (ECHO) model offers rural providers access to a multidisciplinary care team at an academic center and to other rural providers to create a community of practice with weekly online sessions. This program was evaluated by two separate implementing groups,[26▪▪,29▪▪] with differing experiences between the two. The Washington group had providers joining from four other states; these providers rated the program highly and may have self-selected due to their and their patient populations’ greater isolation from HIV specialty referral sites as compared with the population in the second study [26▪▪,29▪▪]. The second study described ECHO super-imposed on the Veterans Administration system in the United States, in which referrals are possible but often require long-distance travel that is inconvenient for PLHIV in rural areas [26▪▪]. Moeckli et al.[26▪▪] considered this factor, noting that specialty providers were often reluctant to relinquish care and believed PLHIV preferred to stay with providers with whom they had already developed rapport, whereas primary care providers felt more comfortable referring care to established specialist teams. The publications eligible for review inclusion for the two US projects did not analyze key patient outcomes, such as viral suppression or annual viral load monitoring, so we cannot comment on program efficacy at the patient level.
In Malawi and Botswana [27▪,28▪], two studies describe systems analogous to ECHO that worked effectively in settings in which referrals are not possible or feasible. One potential weakness in a low-resource setting, however, is the reliability of Internet connection for meetings with a team of experts. In a tertiary facility in the national capital of Malawi, a pathology telemedicine intervention resulted in successful pathology team consultations, achieving high concordance in cytologic and histologic diagnosis. But Montgomery et al. did not comment on connectivity issues and their potential impact on consultative meetings [27▪]. A study in Botswana used a smartphone-based consultation service for dental cases, which may be a better paradigm as providers used smartphones to send data and photos to experts in the capital, Gaborone. However, more data are needed on differences between expert management recommendations and course of care, particularly on biopsy access and follow-through [28▪]. This smartphone model may be more practical due to popularity and widespread use of applications like WhatsApp that allow low-cost text/file transmission and calls through subscriber Internet coverage while avoiding mobile network charges. As Internet coverage and smartphone ownership increase in low resource settings, this approach may gain traction. In Botswana, another solution is being explored that may resolve connectivity issues by using underutilized television bandwidth. Chavez et al.[31▪▪] describe plans to extend the current national telemedicine model to this ‘white space’ band and assess whether connectivity and expansion of expert clinical guidance across primary care fields make a measurable impact on provider access, knowledge, and quality of care. We recommend that the team also evaluate how specialists manage competing demands for guidance in urgent situations with their usual work and whether compensation becomes an issue. Other countries may wish to implement this model and, in doing so, may grapple with human resource issues on how to convene a consistently available expert panel.
The current review of recent publications on HIV service provider training and performance enhancement evaluates mobile technology, telemedicine, and other innovative provider-targeted interventions utilizing eHealth for HIV-related care. Review articles and service assessments illustrated functionality of mobile phone and EMR platforms and highlighted best features to make the technology more robust for provider-targeted applications. Similarly, reviews on interventions to improve provider performance, both specific to HIV and for primary care generally, identified successes as well as the need for greater standardization of models for provider support, particularly following in-service training with supportive supervision and mentoring. New applications of technology show potential, including using YouTube to broadcast scripted educational videos, sending clinical case information through smartphones and mobile apps, and using ‘white space’ frequencies to improve connectivity and access to content. Despite the promise of these interventions, firm evidence is needed to determine how feasible eHealth programming is in low resource and rural settings where connectivity remains limited, serving as a key limitation among many of the articles reviewed. Approaches to maintaining patient confidentiality, particularly in telemedicine and EMR-based systems, were explicitly considered by some but not all of the interventions described in this review. Going forward, patient confidentiality protections within the program are a necessary component that should be given the same weight as ethical review board approval for formal evaluations and standard minimum protection guidelines developed for nascent eHealth projects. Evaluations of feasibility and efficacy must be done rigorously to optimize the power of technology for telemedicine and preservice/in-service training and to ensure success at scale-up. Given the rapid pace of technologic development and expansion of both Internet coverage and HIV prevention and treatment modalities, we anticipate substantive change over the next few years in provider training and service extension to meet the needs of clients living with HIV.
We would like to thank Carol Manion, Allison Burns, and Tamara Fasnacht for their assistance with the literature searches.
Financial support and sponsorship
The current work was supported by the United States Agency for International Development (USAID) through Cooperative Agreement OAA-A-14-0045 to FHI 360 for the management and implementation of the LINKAGES Project. Views expressed do not necessarily represent the views of USAID nor FHI360.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
1. Joint United Nations Programme on HIV/AIDS (UNAIDS). AIDS update 2016. Geneva: UNAIDS; 2016.
2. World Health Organization (WHO). Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection, recommendations for a public health approach. 2nd ed.Geneva: WHO; 2016.
3. WHO; International Telecommunication Union. National eHealth Strategy Toolkit. Geneva: WHO; 2012.
4. Duque J, Gaga S, Clark D, et al. Knowledge, attitudes and practices of South African healthcare workers regarding the prevention and treatment of influenza among HIV-infected individuals. PLoS One 2017; 12:e0173983.
5. Geibel S, Hossain SM, Pulerwitz J, et al. Stigma reduction training improves healthcare provider attitudes toward, and experiences of, young marginalized people in Bangladesh. J Adolesc Health 2017; 60:S35–S44.
6. Sunguya BF, Mlunde LB, Urassa DP, et al. Improving feeding and growth of HIV-positive children through nutrition training of frontline health workers in Tanga, Tanzania. BMC Pediatr 2017; 17:94.
7▪▪. Vasan A, Mabey DC, Chaudhri S, et al. Support and performance improvement for primary healthcare workers in low- and middle-income countries: a scoping review of intervention design and methods. Health Policy Plan 2017; 32:437–452.
This comprehensive review article focuses on approaches and outcomes for provider posttraining support and performance improvement for various healthcare areas, which is critically important as many projects include this approach but there is little guiding evidence on best practices. The article's conclusions are critical for further research in the field based on lack of standard definitions and approaches to mentoring and supportive supervision and paucity of provider performance improvement intervention evaluation to provide guiding evidence.
8▪. Bassett IV, Coleman SM, Giddy J, et al. Sizanani: a randomized trial of health system navigators to improve linkage to HIV and TB care in South Africa. J Acquir Immune Defic Syndr 2016; 73:154–160.
The first randomized controlled trial assessing impact of health system navigators on HIV and tuberculosis outcomes in South Africa. Though findings showed no measurable impact on primary outcomes, study provides high-quality evidence on a care extending cadre with little prior evaluation data.
9. Kojima N, Krupp K, Ravi K, et al. Implementing and sustaining a mobile medical clinic for prenatal care and sexually transmitted infection prevention in rural Mysore, India. BMC Infect Dis 2017; 17:189.
10. Ambia J, Mandala J. A systematic review of interventions to improve prevention of mother-to-child HIV transmission service delivery and promote retention. J Int AIDS Soc 2016; 19:20309.
11▪. Ma Q, Tso LS, Rich ZC, et al. Barriers and facilitators of interventions for improving antiretroviral therapy adherence: a systematic review of global qualitative evidence. J Int AIDS Soc 2016; 19:21166.
This systematic review article is important as it summarizes provider perspectives surrounding task shifting to extend HIV care. This article is important as it is a review of qualitative evidence and portrays a high degree of acceptability of HIV care task-shifting to lay workers in low-income and middle-income countries.
12. Claborn K, Becker S, Ramsey S, et al. Mobile technology intervention to improve care coordination between HIV and substance use treatment providers: development, training, and evaluation protocol. Addict Sci Clin Pract 2017; 12:8.
13. Gupta RS, Yewale K, Hegde AS, et al. Use of technology in follow-up of HIV positive pregnant women and their babies till 18 months of age- an innovation by Maharashtra State AIDS Control Society (MSACS), India. Curr Opin HIV AIDS 2016; 11 (Suppl 1):S46–51.
14▪. Kang’a S, Puttkammer N, Wanyee S, et al. A national standards-based assessment on functionality of electronic medical records systems used in Kenyan public-sector health facilities. Int J Med Inform 2017; 97:68–75.
This review article critically assesses different electronic medical record platforms used in Kenya and provides insight into key technological features. The article highlights considerations to guide further platform development and is relevant to all countries adopting medical records systems.
15▪. Kuehne J, Keiller L. African answers to African problems using mobile technology. Med Educ 2016; 50:571–572.
This brief project report describes using smartphone-produced video posted to YouTube to augment preservice training. The article is important because it highlights tools (e.g., Internet) increasingly available to all levels of health provider and creative approaches to increasing scripted content access to bolster in-service and preservice training efforts.
16▪▪. Oluoch T, Katana A, Kwaro D, et al. Effect of a clinical decision support system on early action on immunological treatment failure in patients with HIV in Kenya: a cluster randomised controlled trial. Lancet HIV 2016; 3:e76–e84.
This is one of few randomized trial results included in the review, assessing the impact of a provider-targeted alert and decision support system within an electronic medical record (EMR) system on actual patient outcomes. This article is important because it provides high-quality evidence for provider electronic health (eHealth) interventions merged within EMR to guide scale-up efforts.
17▪. Park E, Masupe T, Joseph J, et al. Information needs of Botswana healthcare workers and perceptions of Wikipedia. Int J Med Inform 2016; 95:8–16.
This article is among the first to describe use of widely available electronic reference sites by medical professionals for clinical advice. This article is included because it emphasizes provider recognition of need for open-source site with accurate, vetted information and resources for acute consultations.
18. Rettler H, Klevens M, Haney G. Building health IT capacity to improve HIV infection health outcomes. Am J Manag Care 2016; 22:821–825.
19▪. Waters KP, Mazivila ME, Dgedge M, et al. eSIP-Saúde: Mozambique's novel approach for a sustainable human resources for health information system. Hum Resour Health 2016; 14:66.
This article is important because it describes provider-targeted information and resources that can be used to track in-service training and better match trained providers to clinical sites. As human resources databases become more robust and incorporated with EMR, the potential for in-service training and support within larger electronic systems is present, as exemplified in this article.
20. Bath R, O’Connell R, Lascar M, et al. TestMeEast: a campaign to increase HIV testing in hospitals and to reduce late diagnosis. AIDS Care 2016; 28:608–611.
21. Gibbs J, Sutcliffe LJ, Gkatzidou V, et al. The eClinical Care Pathway Framework: a novel structure for creation of online complex clinical care pathways and its application in the management of sexually transmitted infections. BMC Med Inform Decis Mak 2016; 16:98.
22▪. Njoroge M, Zurovac D, Ogara EA, et al. Assessing the feasibility of eHealth and mHealth: a systematic review and analysis of initiatives implemented in Kenya. BMC Res Notes 2017; 10:90.
This review summarizes all eHealth and mobile health (mHealth) interventions in Kenya and is important for three key observations. There is a paucity of eHealth programming targeting providers, there are few eHealth programs in underserved counties/rural regions, and there are few data evaluating program/approach efficacy.
23. Posadzki P, Mastellos N, Ryan R, et al. Automated telephone communication systems for preventive healthcare and management of long-term conditions. Cochrane Database Syst Rev 2016; 12:CD009921.
24. Yah CS, Tambo E, Khayeka-Wandabwa C, Ngogang JY. Impact of telemonitoring approaches on integrated HIV and TB diagnosis and treatment interventions in sub-Saharan Africa: a scoping review. Health Promot Perspect 2017; 7:60–65.
25▪. Drummond KL, Painter JT, Curran GM, et al. HIV patient and provider feedback on a Telehealth Collaborative Care for depression intervention. AIDS Care 2017; 29:290–298.
This article provides qualitative results and insights to telephone-based care for HIV patients with depression and is important for guiding aspects of telemedicine programming needed to form a therapeutic alliance with patients.
26▪▪. Moeckli J, Stewart KR, Ono S, et al. Mixed-methods study of uptake of the extension for community health outcomes (ECHO) telemedicine
model for rural veterans with HIV. J Rural Health 2016; doi: 10.1111/jrh.12200. [Epub ahead of print].
One of two important articles presenting data from an HIV telemedicine program targeting rural providers and patients in the United States. This study details qualitative inputs from providers and patients within a system with an existing referral network to HIV specialists on why the telemedicine program was underutilized over time.
27▪. Montgomery ND, Liomba NG, Kampani C, et al. Accurate real-time diagnosis of lymphoproliferative disorders in Malawi through clinicopathologic teleconferences: a model for pathology services in sub-Saharan Africa. Am J Clin Pathol 2016; 146:423–430.
This article describes a pathology telemedicine approach utilizing video conferencing and imaging with fairly high diagnostic accuracy for lymphatic neoplasms between Malawian and US-based teams. The importance of this article is demonstration of how biopsy-based diagnosis can be made more available and reliable in limited resource settings, though with substantial initial investment.
28▪. Tesfalul M, Littman-Quinn R, Antwi C, et al. Evaluating the potential impact of a mobile telemedicine
system on coordination of specialty care for patients with complicated oral lesions in Botswana. J Am Med Inform Assoc 2016; 23:e142–e145.
This article describes a telemedicine program utilizing resources available to rural providers, predominantly smartphones. This study is important as it describes a viable approach for many settings and areas where diagnostic and management discordance between consultant and local provider can arise and how to manage the issues.
29▪▪. Wood BR, Unruh KT, Martinez-Paz N, et al. Impact of a Telehealth Program that delivers remote consultation and longitudinal mentorship to community HIV providers. Open Forum Infect Dis 2016; 3:ofw123.
The second of two articles describing a telemedicine approach for rural HIV providers and patients, in this instance in settings without established referral networks. This study provides quantitative and qualitative inputs from rural provider participants over time and can guide design and implementation for similar scenarios.
30. Reynolds NR, Satyanarayana V, Duggal M, et al. MAHILA: a protocol for evaluating a nurse-delivered mHealth intervention for women with HIV and psychosocial risk factors in India. BMC Health Serv Res 2016; 16:352.
31▪▪. Chavez A, Littman-Quinn R, Ndlovu K, Kovarik CL. Using TV white space spectrum to practice telemedicine
: a promising technology to enhance broadband internet connectivity within healthcare facilities in rural regions of developing countries. J Telemed Telecare 2016; 22:260–263.
This article describes a new, planned application of available and underutilized telecommunications bandwidth to an existing telemedicine program in Botswana. Although the article is limited to program design, it represents a detailed description of a potentially feasible and sustainable approach to telemedicine programming in resource-limited settings.
32▪. Iribarren SJ, Brown W 3rd, Giguere R, et al. Scoping review and evaluation of SMS/text messaging platforms for mHealth projects or clinical interventions. Int J Med Inform 2017; 101:28–40.
This review article assesses technical aspects of various eHealth programming platforms and is important for guiding platform choice and features when designing mHealth/telemedicine programming.