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.
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.
Papers of particular interest, published within the annual period of review, have been highlighted as:
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.