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Changing HIV Clinical Knowledge and Skill in Context

The Impact of Longitudinal Training in the Southeast United States

Culyba, Rebecca J., PhD1; McGee, Blake Tyler, MPH2; Weyer, Dianne, RN, MS, FNP-BC3

Author Information
Journal of the Association of Nurses in AIDS Care: March-April 2011 - Volume 22 - Issue 2 - p 128-139
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The Southeast region of the United States bears a disproportionate burden of the HIV epidemic, with an estimated rate of new AIDS cases being approximately 27% higher than the national average in 2007 (Kaiser Family Foundation, 2009). In addition, the HIV-infected population in the Southeast experiences greater barriers to accessing HIV care compared with the general U.S. population (Andersen et al., 2000; Reif, Golin, & Smith, 2005), partly because of the high proportions of African Americans and inhabitants of rural areas (U.S. Census Bureau, 2010). Previous studies have shown that rural locales tend to lack health care providers who are experienced in managing patients with HIV (Heckman, Somlai, Kalichman, Franzoi, & Kelly, 1998). In the South, delayed HIV diagnosis and care are more common among rural, uninsured residents, and increasingly among African American females (Krawczyk, Funkhouser, Kilby, & Vermund, 2006). In addition to the higher proportions of African Americans, women, uninsured, and rural residents infected with HIV, the South also has higher rates of diabetes, stroke, infant mortality, sexually transmitted diseases, poverty, and unemployment than other regions of the United States (Reif, Geonnotti, & Whetten, 2006). States in the South have lower tax-bases than other regions of the country, resulting in inadequate health care infrastructure (Whetten & Reif, 2006). Indigent HIV-infected patients often rely on small, federally funded outpatient programs, such as Ryan White clinics, which are funded by the Ryan White HIV/AIDS Treatment Extension Act of 2009 (Ryan White Program [RWP], Health Resources and Services Administration [HRSA], 2010); Federally Qualified Health Centers; free clinics; or other safety net programs (Reif et al., 2006). Given the demands on the regional health care system, the authors hypothesized that an onsite, multidisciplinary, longitudinal training program would increase the capacity of HIV care and service providers in the Southeast to provide quality care to existing and newly diagnosed patients.

The Southeast AIDS Training and Education Center (SEATEC) is one of the 11 federally funded regional AIDS Education and Training Centers that provide targeted, multidisciplinary HIV education for health care providers (Health Resources and Services Administration, 2008). The primary mission of SEATEC is to meet the training needs of health care providers in Alabama, Georgia, Kentucky, North Carolina, South Carolina, and Tennessee who diagnose and manage patients with HIV, with a special focus on racial or ethnic minority and minority-serving providers, rural providers, and providers working in Ryan White-funded programs. Physicians, nurse practitioners (NPs), physician{L-End} 's assistants (PAs), nurses, dental professionals, and clinical pharmacists are targeted for training, and SEATEC specializes in tailoring trainings to meet the specific needs of these clinicians and their supporting staff. In response to the observed needs of the HIV health care workforce described earlier, SEATEC implemented a longitudinal training and evaluation program at selected HIV outpatient clinics across the Southeast to increase the knowledge and skills of multidisciplinary HIV care teams.

In addition to being attentive to the real-world context of HIV care and service provision in the Southeast, the SEATEC longitudinal training intervention is grounded in the rationale of adult learning theory using active learning methods (Silberman & Auerbach, 2006), which include clinically integrated teaching opportunities for health care professionals that have real-world application, are communal to facilitate peer support and generalization, and involve follow-up to support training transfer (Das, Malick, & Khan, 2008). The training program was implemented at each clinic site, with an aim to improve the HIV-related knowledge and skills of clinical and nonclinical service providers at community-based health centers. Clinical faculty had observed at the clinic that the work environment could affect the ability of trainees to apply new knowledge and skills, and this has been supported by literature on training transfer (Burke & Hutchins, 2007). Thus, under the SEATEC longitudinal model, the entire clinic team participated in didactic, skills-building, and case-based training sessions on a regular basis at the clinic site for at least 1 year.

Participating clinics used a multidisciplinary team approach to provide HIV care in the context of resource scarcity and therapies that have increased life expectancy for patients. Although multidisciplinary care teams are not new to HIV care, this approach is increasingly acknowledged as central to effectively managing chronic disease and general primary care practice (Rodriguez, Marsden, Landon, Wilson, & Cleary, 2008). Sherer et al. (2002) found a significant relationship between receipt of transportation (p = .001), mental health care (p = .0005), and chemical dependency counseling (p = .036), and receipt of any care or regular care in an urban, hospital-based HIV program. There was also a significant relationship between the receipt of case management and both an increased number of patient visits (p = .005) and improved retention in primary care (15%-18%).

Cheever, Lubinski, Horberg, and Steinberg (2007) described how a specialty model of HIV care that includes a multidisciplinary care team with an HIV specialist, case manager, clinical pharmacy support, social worker, benefits coordinator, mental health support, and health educator allowed for more efficient, comprehensive, and cost-effective HIV care. Although teams are susceptible to decreased individual efforts and suboptimal use of member skill and knowledge when member roles are redundant and not clearly defined, the team approach in chronic care has been shown to improve self-management, motivation, and treatment adherence in patients by including team members with these skills, leading to improvements in the quality of chronic care itself (Rodriguez et al., 2008). As organizations increasingly move from individual-based work to team-based work, evidence suggests that expert teams are developed best through training that is focused on teamwork competencies as well as task work competencies (Salas, DiazGranados, Weaver, & King, 2008; Weaver, Wildman, & Salas, 2009).

A typical multidisciplinary HIV care team includes physicians who share primary responsibility for patient care with NPs and PAs (Cheever et al., 2007; Rodriguez et al., 2008; Sherer et al., 2002). However, in regions such as the Southeast where there is a lack of primary care physicians specializing in HIV (McKinney, 2002), NPs and PAs often serve as primary care providers for patients and may operate independently from physicians (Rosenblatt, Andrilla, Curtin, & Hart, 2006; Wilson et al., 2005). Although NPs and PAs have been known to provide as high a quality of care as physicians and even higher quality of preventive HIV care in Ryan White settings (Wilson et al., 2005), their ability to participate in continuing medical education events and professional conferences is limited by time and funding constraints (SEATEC, 2008). Furthermore, nonclinical staff members, such as social workers, health educators, and administrators, although critical to the multidisciplinary HIV care team, encounter such professional opportunities even more rarely than clinical staff. Locating professional health education in rural areas can address challenges to the quality of health care and workforce retention issues (Committee on the Future of Rural Health, Care Board of Health Care Services, 2005; Daniels, VanLeit, Skipper, Sanders, & Rhyne, 2007). In addition, Rosen et al. (2005) described a multidisciplinary, longitudinal HIV clinical training model that removed barriers to professional training and updates by bringing training sessions onsite to strategically located facilities within HIV-affected communities. These and other precedents for overcoming obstacles to continuing education for health professionals in rural and/or publicly financed health care facilities provided additional support for the rationale that HIV care and service providers in the Southeast would benefit from onsite, multidisciplinary, longitudinal training. Evaluation data from six longitudinal sites were collected to identify any measurable increases in provider knowledge, skills, and capacity to meet patient care needs. The results of this evaluation are discussed in the following paragraphs.


In the beginning of 2009, six active longitudinal training sites in Georgia, Alabama, Tennessee, and North Carolina completed participation in the longitudinal training and evaluation study. When this study was initiated in 2002, sites were purposefully sampled from newly funded RWP Part C (formerly Ryan White Care Act Title III) clinics. Organizations that were eligible to receive Part C funding under RWP to provide early intervention and primary care to HIV-infected patients included Federally Qualified Health Centers, rural health clinics, and community-based organizations such as health centers or faith-based agencies that provided services to populations infected with HIV or at risk of HIV infection. Although none of the clinics discussed here were newly-funded Part C clinics, participating sites in our study were selected using a purposeful sampling technique with these organizational criteria in mind to ensure that the sites were currently providing HIV primary care or expanding existing services to include primary care for HIV-infected patients. Clinics met this criterion, less so because of new RWP funding than because of the formation of a new HIV care team, which was often because of staff turnover. Sites in this analysis included three RWP-funded clinics, a faith-based AIDS service organization, a walk-in free clinic, and a Federally Qualified Health Center. All six sites completed 1 year of bimonthly or quarterly training, and three of the sites received a second year of training.

Training content was informed by results of pre-training needs assessments, which included an organizational assessment by the clinical trainer who administered a modified HRSA Primary Care Assessment Tool (PCAT; Health Resources and Services Administration, 2003) walkthrough and reviewed a convenience sample of patient charts. The training curriculum was standardized to ensure coverage of a wide spectrum of topics, including clinical disease progression and opportunistic infections, laboratory and diagnostics, antiretrovirals and adherence, motivational interviewing, mental health and substance abuse in HIV, and team-building. The needs assessments revealed areas for trainers to emphasize but did not change the overall content of the training curriculum. In addition to participating in didactic lectures, skills-building workshops, and intensive case discussions at their sites, learners were given numerous topic-specific training handouts, the medical text Clinical Manual for Management of the HIV-Infected Adult (Coffey, 2006), and updated Department of Health and Human Services treatment guidelines.

A multimethods approach was used to evaluate the effect of the training program on the long-term knowledge of participants on topics essential to care of HIV-infected patients. For measuring knowledge and skill change resulting from the training intervention, SEATEC developed a Provider Assessment Tool (PAT), consisting of 18 or 28 multiple-choice questions administered to each group of learners at either the start or about 1 month in advance of the first training session, and repeated approximately 3 months after the completion of each year of training. Clinical and nonclinical versions of the PAT were developed for both first- and second-year training series. In the first year, clinicians completed the 28-item version and nonclinicians responded to the 18-item version. In addition to knowledge and skills change, the first-year PAT asked learners to report the extent to which their clinic environments enabled them to apply new knowledge and skills in their clinical care contexts. Finally, a focus group was conducted with the learners 3 months after training using a standardized interview schedule developed by SEATEC to collect qualitative data about how providers applied the training in practice, with real-world examples from the clinic. The interview schedule included the following three questions: (a) Which training session was most helpful to you—either personally or as a group—and why?, (b) Please give an example of how you have changed the way you work with HIV patients as a result of our trainings, and (c) Looking forward, what ideas do you have about how we can add to or improve our trainings for your clinic? Although chart reviews were most often used solely as part of the pre-training needs assessment, results from a post-training convenience sample of patient charts at one clinic site were also collected to assess change in quality of care that may have resulted from the training. Other factors that might have affected the quality of care delivered included the addition of more experienced providers to the care team and/or improvements in components of primary care, including accessibility, comprehensiveness, continuity, and coordination, which have been associated with better patient outcomes (Ding et al., 2008; Hecht, Wilson, Wu, Cook, & Turner, 1999).

Demographic and employment data were collected using the Health Resources and Services Administration Participant Information Form, which asked learners about gender, race and ethnicity, professional discipline, employment setting, and patient population. Participant evaluation data were collected using the SEATEC training evaluation form administered immediately post-training at each session during the year. This form collected data on training satisfaction, self-rated knowledge before and after training, and intent to change behavior as a result of the training using a 5-point Likert scale. The change in scores on the knowledge and skills items of the PAT was analyzed according to cluster sampling methods, in which each clinic site was considered a primary sampling unit, accounting for the design effect of the relative homogeneity within clinic sites. To establish validity of its content, the PAT was developed and reviewed by SEATEC training staff, with extensive HIV clinical practice expertise in contexts similar to that of these learners. PAT data were managed and analyzed using SPSS v16.0 and SAS v9.1; data from the participant information and evaluation forms were cleaned in SAS and analyzed with SPSS, and qualitative data from focus groups were organized using Atlas.ti v5.2. The study was approved by the Emory University Institutional Review Board (IRB #145-2003), with a waiver of written informed consent.


Population Information

From 2006 through 2008, a total of 144 unduplicated learners attended at least one longitudinal training event at one of the six clinics. On average, learners attended 3.2 training sessions in a given year, with 42 learners completing both pre- and post-PATs. Of the 144 learners, 18.8% were nurses, 18.1% were social workers, 9.0% were midlevel clinicians (mostly NPs), and 2.8% were substance abuse or mental health professionals. Physicians made up an additional 2.8%. Administrative assistants, office and program managers, and pharmacy technicians constituted most of the other responses to the professional discipline question (43.8%), an illustration of the diversity of participants and a reflection of the program objective to reach the entire clinic team. Similarly, a mix of clinical and nonclinical learners took part in the longitudinal training events: approximately 35% of the participants identified themselves as care providers or clinicians, whereas the other 65% reported nonclinical roles. Approximately 80% of the participants were females. The majority (52.1%) of the providers was black or African American and 46.5% were white; 4.2% identified themselves as being of Latino or Hispanic ethnicity, in addition to their race (Table 1).

Table 1
Table 1:
Longitudinal Training Participant Profile by Site, 2006-2008

According to the senior full-time clinician at each site, most of the HIV-infected patients served by the longitudinal training participants belonged to racial or ethnic minorities. At two sites, at least 75% of HIV-infected patients were persons of color, and at three additional sites at least 50% of patients were persons of color. At only one site the proportion of minority HIV patients was below 50%, but it was still greater than 25%, and that clinic served a predominantly rural area. Therefore, the longitudinal training reached its intended beneficiary population. Of note, a majority of HIV-infected patients seen by the senior clinicians at two sites were reported to be females. Most HIV-infected patients at all six sites were prescribed antiretroviral therapy, and half of the senior clinicians reported that they cared for at least 50 HIV-infected patients in an average month.

Quantitative Impact Data

Overall, participants at the six clinic sites who completed 1 year of longitudinal training improved their scores on the first-year PAT by a mean of 4.33 (95% CI: 2.64-6.03). In other words, the 42 participants (30 clinical and 12 nonclinical) who completed both pre- and post-testing answered an average of more than 4 additional questions correctly after the training series as compared with before. This mean change in score was highly statistically significant (p = .001), and it retained this level of significance even when stratified by clinical and nonclinical learners (Table 2). Similarly, the mean score increased measurably at both facilities that specialized in HIV care and services (sites 1, 2, 4, and 5) and facilities that had less day-to-day experience with HIV (sites 3 and 6). In addition, the scores of the 23 learners who completed a second-year PAT at the start and end of the year increased by a mean of 1.96 (95% CI: −.67-4.58). This result approached (but did not achieve) significance at the .05 level (p = .085), partly because of the smaller sample size. The clinical and nonclinical versions of the PAT were analyzed together as one measure because stratified analysis revealed no remarkable difference between clinicians and nonclinicians in terms of knowledge change, with mean clinical and nonclinical knowledge score changes of +5.0 (p = .003) and +4.1 (p = .006), respectively.

Table 2
Table 2:
Mean Pre- and Post-Training Scores on the First-Year Provider Assessment Tool (PAT)

In addition to the pre- and post-training provider assessment, longitudinal participants were asked on the participant evaluation form about their own knowledge and skill changes and intent to change their practices as a result of the training. Participants rated their own knowledge and skills before and after the training on a scale of 1 to 5 and responded to a dichotomous question about whether the training would in any way change how they work with HIV patients. Across all training events at all six clinic sites, the 144 learners completed approximately 600 event-specific training evaluation forms. Of the 555 responses with valid data on knowledge and skills change, 454 (81.8%) indicated an increase in self-rated knowledge and skills, whereas another 92 (16.5%) indicated no change. Similarly, of the 444 responses with valid data on intent to change practice, 374 (84.2%) indicated the learner would change how she or he worked with HIV-infected patients, whereas 41 (7.3%) indicated the learner would not change, and 29 (6.5%) designated the question as not applicable. However, no significant correlation was observed between average change in self-rated knowledge and change in PAT score in any year of training, corroborating the findings by Cook, Friedman, Lord, and Bradley-Springer (2009) that self-reported knowledge change may not be a reliable predictor of objectively measured knowledge change.

Because clinical context may mitigate the application of new knowledge and skills, the first-year PAT also asked participants to rate the presence of enabling factors in their clinic environments. Specifically, the PAT asked to what extent providers experienced encouragement from others, opportunity to apply learning, and support for making changes at their clinics. The pre-training results from all six sites formed an internally reliable scale (Cronbach's alpha = .792), with a theoretical range of 3 to 15. The mean pre-training score for all participants was 11.5 (n = 50); at year-end it was 10.5 (n = 41), with values as low as 3.0, indicating a potential lack of environmental support for training transfer among some learners. Moreover, participant score on this scale was not correlated with change in PAT score during either year of training: for year 1, r = −.23 (p = .16), and for year 2, r = .20 (p = .35). This finding suggests that learners with substantial knowledge gains were among those who reported a lack of enabling factors in their clinics. However, more research may be needed to determine whether a perceived lack of enabling factors at the clinic level truly inhibits the application of new knowledge and skills in practice.

Qualitative Impact Data

Despite potential barriers to training transfer described earlier, post-training focus groups with participants and responses to open-ended questions on the PAT offered qualitative evidence that substantive behavior change resulted from the longitudinal program. During focus groups, participants were asked which training topics were most helpful to their practices and what, if any, changes they had made to their practices as a result of the longitudinal training series. At both pre- and post-training, participants were asked on the PAT what they thought were the top three challenges to providing HIV care at their clinics. Qualitative analysis of these data was carried out using thematic content analysis, where participant responses were aggregated and open-coded by two reviewers to determine the dominant themes described in Table 3.

Table 3
Table 3:
Overview of Qualitative Responses From Group Discussions and Provider Assessment Tool (PAT)

Comments related to the clinical progression and management of HIV disease occurred most often in the focus groups, and both clinical and nonclinical providers verbalized benefits they had gained from this subject matter. Clinicians appreciated the opportunity to clarify certain treatment guidelines and discuss how to apply them in real-life situations. For example, one NP, who provided primary care to HIV-infected patients, stated that the training helped her identify which antibiotics she should prescribe in light of a patient's antiretroviral drug regimen and how to interpret the significance of laboratory values in HIV-infected patients beyond standard CD4+ T-cell counts and viral load tests. Nonclinicians also found the information on clinical management of HIV “very helpful” and expressed enthusiasm for clinical images at most sites. For example, one program manager stated she had more appreciation for the work that clinicians did inside the examination room after viewing detailed images of clinical manifestations of some opportunistic infections and sexually transmitted diseases during a training presentation.

Nearly as often, participants mentioned the training they had received about special populations, such as patients with substance abuse and/or mental health problems or transgender concerns. Some learners expressed that their previous education had been inadequate to deal with these challenging areas, which is notable given the overlap between these areas and HIV. For example, the HIV Costs and Services Utilization Study found that mental illness and substance abuse were more prevalent among people living with HIV than in the general population, and persons struggling with mental health and substance use problems are the least likely to adhere to their antiretroviral treatment (Beckett et al., 2007). Therefore, HIV service providers stood to benefit from more complete training on the needs of these groups, and longitudinal participants provided examples during focus groups that demonstrated their improved capacity to serve patients individually and as a team. For example, one learner noted that a patient had recently confided to her that he had been “clean” for 6 months after years of substance abuse, which the clinic knew nothing about. She speculated that he might have felt he could discuss his substance abuse because of the clinic's increased competency with this issue. Learners at another site noticed an increase in suicidal ideation among their patients in conjunction with the economic recession, and they stated that they felt better prepared to handle this challenge while also acknowledging that they could not “take care of everyone” and needed to refer these patients to appropriate mental health professionals.

In addition to special populations, participants frequently cited improved communication and teamwork as consequences of the longitudinal training. In some cases, just having a specified time and space to come together as a group and discuss matters openly, as with the intensive case discussions, was itself a team-building exercise. In other cases, improved knowledge of each other's job responsibilities allowed for better coordination of services and a more multidisciplinary approach to meeting patient needs. For example, one nursing assistant credited the team-building sessions with helping to reduce redundant or inconsistent actions, such as when a patient who was dissatisfied with the response of one care provider to his request “worked the room” by making the same request of other providers in the clinic until he obtained what he wanted. In the example she described, the nursing assistant decided first to approach the medical assistant, who already had seen the patient, to learn what action had been taken and why, which allowed her to further serve the patient without undermining her colleague. This example paralleled the remark of an NP at another clinic site who said of her team, “We have each others' backs now.” These findings suggest that the longitudinal trainings provided by SEATEC resulted in the development of teamwork competencies, specifically a clearer understanding of member roles, which reduced duplication of effort and optimized the use of team members' knowledge and skills.

However, enhanced provider capacity may be attenuated by systems-level barriers to improved patient outcomes. An analysis of responses to the open-ended question on the first-year PAT about the challenges of providing HIV care revealed two dominant themes both pre- and post-training: the first theme was nonadherence of patients to medical care, and the second concerned lack of staff support and resources. Patient adherence concerns revolved around patients not keeping their appointments or taking their medications as prescribed, whereas staff support issues ranged from inadequate funding to understaffing to lack of community resources for referral. Both types of challenges fell at least partly outside the scope of a training intervention at the provider level, but the frequency of articulation implied that the potential of longitudinal training participants to change their behavior is constrained by contextual factors in the clinic environment. Further research is needed to assess the extent to which these factors impede the application of new learning in clinical practice.

Capacity Building

Despite evidence of potential system-level barriers to improved patient outcomes, changes in organizational capacity were documented at the 1 clinic site from which pre- and post-training modified PCAT walkthrough and chart review data were available. The PCAT review found notable changes in some areas of primary care service delivery, including the expansion of types of staff members who carried out risk assessments and directly observed therapy; increased collaboration with a partner clinic on perinatal care; increased client use of dental services; and facilitated adoption of a streamlined infection control plan. Among the 10 patient charts reviewed, there was a 75% improvement in documentation of allergies and a 20% improvement in documentation of tetanus/diphtheria vaccination in the previous 5 to 7 years. Increased attention to organizational and quality of care measures is planned for future evaluation activities to better understand the extent to which knowledge, skill, and behavior change among HIV care teams leads to improved health outcomes despite the existence of environmental constraints, such as insufficient funding, inadequate workforce and staff turnover, and ineffective referrals to community resources.


The long-term goal of this longitudinal training intervention was to increase capacity among providers of publicly funded, HIV-related care and services to improve outcomes for predominantly minority and/or rural HIV-infected populations in the Southeast United States. The quantitative evaluation data show that participation in the SEATEC longitudinal training series increased HIV-related knowledge and skills. Furthermore, data from focus groups and PCAT and chart reviews suggested that positive changes in provider capacity and behavior were also consequences of the longitudinal training despite the potential lack of enabling factors in the clinics. These improvements were observed in a wide array of service providers and a diversity of clinic sites, suggesting that a team-based approach to longitudinal training with content that is informed by needs assessments and responsive to the priorities of individual sites is well suited to the HIV care system in the Southeast United States. On the basis of this evidence, a clinic-based, longitudinal training intervention is an effective intervention for improving knowledge and skill, and it is a promising means of improving the quality of care and services that marginalized HIV-infected communities receive, especially when that care is delivered by multidisciplinary teams in which midlevel clinicians, such as NPs, play leading roles. Results of this study warrant further research aimed at measuring the effect of the training on quality of care and the factors that enable members of multidisciplinary care teams to change their behaviors as a result of team-based, longitudinal training.

These evaluation data are subject to several limitations. First, although specialists in program evaluation and HIV clinical care developed the PAT, it has not been validated outside the context of this particular training program. In addition, other factors may have contributed to increased HIV-related knowledge and skills. For example, learners may have attended other workshops or conferences, and staffing changes may have enhanced clinic capacity. In the absence of a comparison group, it is not possible to conclude that longitudinal training was the sole source of these improvements. Also, the trainers themselves were present at the focus groups, which may have influenced the content of participants' responses about the effect of training. Finally, the absence of pre- and post-training PCAT and chart review data from 5 of the 6 sites complicated the assumption that increased provider knowledge and skills necessarily lead to improved care and services for patients. In an effort to strengthen the measurement of the extent to which longitudinal training builds clinic capacity and improves quality of care, the study protocol has been modified to include a more rigorous pre- and post-training chart review and the addition of standardized and more detailed questions to the post-training PAT, which ask participants about behavior changes and barriers and enabling factors for those changes.

As mentioned above, there may be a discrepancy between what a service provider learns at training and how effectively she or he is able to apply that learning in practice. When participants were asked to rate the presence of enabling factors in their clinic environments after 1 year of longitudinal training, the average response was just 10.5 on a scale of 3 to 15, with responses as low as 3.0. Furthermore, no statistical correlation existed between the score on this scale and change in knowledge as measured by the PAT, suggesting that some learners with extensive knowledge acquisition face clinic environments that are not conducive to implementing what they have learned.

In light of the frequent enumeration of patient adherence and staff resources as the most substantial challenges to providing HIV care, it is clear that change in individual knowledge and skills will not by itself sufficiently improve the quality of services that rural and minority HIV-infected patients receive. Nonetheless, the focus of the longitudinal training on teamwork rather than just task work may help providers overcome organizational barriers through better understanding of each others' roles and collaborative use of work-arounds (methods to circumvent problems without actually eliminating them), as exemplified in the qualitative results described earlier. These results suggest a need for future research that focuses on developing measures of teamwork competencies more systematically among multidisciplinary HIV health care teams.

Despite these limitations, we cannot dismiss the gains in knowledge and skills among providers who served this vulnerable population, especially given the evidence suggestive of changes in provider behaviors and clinic practices. Indeed, Cook et al. (2009) demonstrated that objective change in knowledge and skills, measured by pre- and post-testing, is predictive of behavior change in HIV clinical training of health care professionals. Our evaluation did not measure behavior change more thoroughly in an effort to balance the rigor of optimal program evaluation methodology with real-world evaluation priorities, such as limiting interference with clinical training and operating within resource constraints. However, we did go one step further than previous studies by measuring knowledge change rigorously and identifying specific changes to service delivery (Rosen et al., 2005). Our study also underscores the relevance of the principle of teamwork training identified by Salas et al. (2008), which states that learning should be guided by the desired outcomes and organizational resources of the target audience and illustrates the importance of onsite training in HIV clinical care, particularly in the rural Southeast where midlevel clinicians are often the primary care providers in multidisciplinary team environments. For these reasons, the SEATEC longitudinal training program continues to be implemented regionally, serving as a model for improving the capacity of multidisciplinary teams to provide quality care for HIV-infected patients in the Southeast. Models such as this will become increasingly important with the advent of health care reform, national focus on workforce development in primary care in general, and increased attention to the early identification of HIV-infected individuals.

Clinical Considerations

  • Longitudinal, clinic-based training of multidisciplinary health care teams results in significant gains in HIV-related knowledge and skills that are retained over time across a wide spectrum of service providers and clinic sites.
  • The longitudinal format, which uses needs assessment and outcome evaluation data, allows trainers to better tailor the content of trainings to the unique challenges and available resources that potentially affect the standard of HIV care at any given clinic site.
  • Onsite training is particularly important for the many clinicians and support staff who have limited ability to travel to offsite educational offerings; nonclinical personnel especially are seldom offered continuing education and updated HIV information. Training onsite also facilitates the tailoring of training content.
  • Training sessions that include all members of the health care team and address team-building and communication skills appear to facilitate transfer of specific patient information and improve coordination of patient care.
  • Systemic challenges to providing HIV care, such as inadequate resources for staff and nonadherence of patients to treatment, may complicate the application of new knowledge and skills in practice. These challenges may be compounded by clinic environments that potentially lack elements conducive to training transfer.


Financial support for this evaluation was received from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), HIV/AIDS Bureau, Grant No. H4AHA00067.

The authors report no real or perceived vested interests that relate to this article (including relationships with pharmaceutical companies, biomedical device manufacturers, grantors, or other entities whose products or services are related to topics covered in this manuscript) that could be construed as a conflict of interest.


The authors thank Felicia Guest, Debbie Isenberg, John Blevins, Elizabeth Dial, Sinafikish Sahlu, Tracy Graham, their graduate student assistants, and especially the participating clinic staffs who made this study possible.


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health education; HIV clinical care; HIV training; provider training evaluation; rural population

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