Perspective Chapter: Enhancing the Nurse-Initiated Management of Antiretroviral Therapy Training and Implementation – A Conceptual Framework

Abstract

Task shifting of nurse-initiated management of antiretroviral therapy (NIMART) rather than doctors is crucial to meet the increasing demand for antiretroviral therapy (ART) in primary health care in low and middle-income countries with limited healthcare resources. This chapter will furnish cooperation between the NIMART conceptual framework, National Department of Health policies and guidelines, and empirical findings regarding the management of ART and tuberculosis (TB) in South Africa and globally through pre-service and in-service training and continuous professional development (CPD). It will also include regulations and WHO guidelines on task shifting, application in a healthcare setting, the HIV continuum of care use in identifying gaps, and the development of appropriate interventions to improve patients and population health outcomes. The training and health care systems or structural challenges or barriers and strategies or enablers to enhance effective training and implementation, including the role and responsibilities of NIMART nurses, will be explored and discussed in detail. The focus will mostly be on the primary health care (PHC) setting as the first level of care and entry into the healthcare system to decentralize healthcare services and facilitate access to HIV services by the community.

1. Introduction

The dual burden of Human Immunodeficiency Virus (HIV) and tuberculosis (TB) are global public health of concern and demands integrated TB/HIV services collaboratively to manage and control the dual epidemic as well as Prevention of Mother to Child Transmission (PMTCT). According to WHO and UNAIDS [1], there were approximately 37.7 million people living with HIV (PLWH) worldwide in 2020, of which 19.3 million are women, 16.7 men above 15 years, 1.7 million children and adolescents less than 15 years old. Furthermore, an approximately 680,000 deaths from Acquired Immune Deficiency Syndrome (AIDS) have been reported from low and middle-income countries and reported a total of 190 million people who tested and receive results for HIV in 2018.

According to the UNAIDS [2] report, sub-Saharan Africa is the worst affected by HIV globally. It is home to the most significant number of PLWH, with an HIV prevalence of 6.7%, 730 00 new HIV infections, and 300,000 AIDS-related death. Young women, men who have sex with men, transgender people, sex workers, prisoners, and people who inject drugs are at an increased risk of acquiring HIV infection (UNAIDS, 2020). South Africa has the largest HIV population globally, with 8.2 million PLWH, HIV prevalence high at 20.4% in 2021, 200,000 new HIV infections, and 72,000 AIDS-related deaths. South Africa has the most extensive ART programme globally, with 3.4 million PLWH on ART because of the adoption of WHO task-shifting.

As a result, nurses rather than doctors initiate ART in the primary level of care, and it is crucial to train nurses in nurse-initiated management of ART (NIMART). Task shifting was adopted in South Africa, and training on NIMART was introduced in 2009 to improve access to ART. Therefore, it is crucial to enhance the NIMART training and implementation in South Africa by making all role players and stakeholders aware of the conceptual framework that can strengthen and optimize training and implementation to improve patient and HIV programme outcomes. The framework should cooperate with the national Department of Health policies and guidelines, including empirical studies on HIV management to enhance the quality of care, achieve the UNAIDS 95–95-95 target by 2030 and end the HIV and TB epidemic. The increasing number of PLWH in need of ART continues to exert excessive pressure on the health care system, which is already experiencing a dire shortage of resources and high staff turnover. This chapter will focus on the description of concepts related to enhancing NIMART training, education, and implementation, the objectives of NIMART training, the methodology of the conceptual framework, barriers and enablers of NIMART training and implementation, the HIV continuum of care, and the role and responsibilities of NIMART-trained nurses.

2. Definition of concepts

WHO defines education as the process of giving or acquiring knowledge, skills and developing attitudes and values at school or university, while training aims at improving the level of a trainee’s competence in a specific area and may be defined as the process of developing, changing or strengthening the knowledge, skills, and attitudes of a target group [3].

NIMART training is a short course on essential HIV clinical management that tackles the fundamentals of HIV management and includes prevention, diagnosis, treatment initiation, management, control, referrals, monitoring and evaluation of treatment success. NIMART was developed in response to the call for action by the South African government to adopt WHO recommendations for task-shifting to strengthen the response to HIV and TB epidemics. It was specifically developed and aimed at professional nurses working in the primary health care (PHC) setting [4].

The NIMART-trained nurse is a professional nurse (PN) or midwife trained in nurse-initiated management of antiretroviral therapy or treatment and has undergone a clinical mentorship programme and assessed for competency in managing HIV and TB [4].

Clinical NIMART mentorship is an HIV programme that focuses on enhancing the skills, competencies, attitudes, and values of trained NIMART concerning HIV prevention, diagnosis, treatment initiation, and linkages to care and treatment, referrals, and monitoring of treatment success for children, adolescents, pregnant women, adults, co-infected with TB and the management of opportunistic infections. Upon completing the programme, the nurse is assessed and receives a competency certificate [5].

Pre-service training or pre-service education refers to any structured activity aiming at developing or reinforcing knowledge and skills before a health care professional joins service or takes up a job that requires specific training in addition to those of undergraduate courses either from the public health service or private practice, to provide competence needed to perform new services [3].

Continuous Inservice training refers to training provided to health care workers already employed in the public or private sector to acquire practical work experience and can be provided after one or two years of the theory are completed to enhance the performance of the health care workers or nurses [3].

Continuous professional development (CPD) is a term used to describe the learning activities in which healthcare professionals engage to develop and enhance their skills, knowledge, competencies, and abilities to perform their jobs [3].

According to WHO [3], task-shifting involves rational distribution or delegation of tasks among health workforce teams with a highly specialized or qualified workforce to less specialized health workers with shorter training and fewer qualifications to use valuable human resources for health efficiently. It is a great option or method to enhance efficiency in delivering health care services, especially HIV and TB services in low and middle-income countries with a high shortage of skilled human resources.

3. The objectives of NIMART training

The objectives of NIMART training are to upskill nurses’ capacity in HIV and TB management. The training also seeks to cultivate positive attitudes among nurses dealing with PLWH and those affected by the diseases. NIMART training facilitates the decentralization of HIV services to the PHC level, thereby:

• increasing access to HIV and TB services to meet the growing demand for ART and improve the country’s socioeconomic status through the provision of early ART initiation to PLWH,

• reducing complications and death related to HIV and TB,

• improving patient health outcomes, and increasing life expectancy,

• facilitating the optimal use of human resources for health,

• improving monitoring and evaluation of the HIV and TB programme,

• identifying strengths, gaps or weaknesses, or challenges and opportunities to guide policy and decision-makers on strategies to improve and end the HIV and TB epidemic [6].

4. Methodology of the conceptual framework

The conceptual framework (CF) was developed by conceptualizing the two stages of the study—The impact of NIMART training on HIV management and barriers to NIMART Training and Implementation. An explanatory sequential mixed method (QUAN-qual) was used [7]. Mixed methods refer to a research strategy in which a researcher combines qualitative and quantitative methods to comprehensively understand the phenomenon under study to produce a more complete and validated conclusion [8, 9, 10]. In order to develop a conceptual framework that will provide direction, strengthen NIMART training and implementation, and improve patient outcomes, a descriptive and explorative program evaluation design was used. Retrospective data were gathered from the District Health Information System (DHIS) and the three integrated electronic registers (TIER.NET), of the selected PHC facilities, including interviews with purposively selected NIMART-trained nurses and program managers directly involved in managing TB/HIV coinfection until data saturation was reached. Programme evaluation research refers “to an applied system scientific method used to measure or assess the implementation, conceptualization, design, utility and outcomes or impact of social programs for decision making purpose”, and is very useful in mixed methods [11, 12].

The Donabedian structure-process-outcome (SPO) model and Dickoff, James, and Wiedenbach’s practice-oriented theory were two models that were crucial in the creation of the theoretical lens through which this conceptual framework was developed. The Donabedian’s SPO model gave the researcher a framework to assess and enhance the application of HIV management following NIMART training [13]. The structure of the fixed PHC facilities providing ART or health care system and the process of NIMART training to professional nurses greatly influence the achievement of the health outcomes. Furthermore, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, a thorough review of the literature was conducted in studies conducted in Africa and around the world from January 2012 to February 2017 from various databases. The results were analyzed using the quality assessment research instrument created by the Joan Briggs Institute in 2014 to obtain a broader perspective of factors that can enable and those that can be a barrier to NIMART training and implementation and play a major role in the development of the conceptual framework. Studies consulted for the thorough literature review revealed positive and negative factors affecting NIMART training and implementation. These will be discussed in detail in section five as barriers and enablers to efficient NIMART training and implementation, together with study findings.

The final conceptual framework was developed following Dickoff et al.’s POT, with six elements presented as questions and integrated into Donabedian’s SPO model [14], as presented in Figure 1. The six elements questions addressed include:

Figure 1.

Conceptual framework for strengthening NIMART training and HIV management implementation.

4.1 Who is expected to implement the NIMART conceptual framework? (the agent)

According to Dickoff et al. [14], the agent refers to the persons or things that implement the framework. According to Donabedian’s SPO model, this refers to the structure that enables the implementation of the CF, including the recipient and the context [13]. The department of health provincial and district regional training centers (RTCs), Higher education institutions ((HEIs), partners supporting the department of health, the South African nursing council (SANC), Health and welfare Seta (HWSETA), and other stakeholders are regarded as the agents of the NIMART training process and has the responsibility to facilitate effective quality training to PNs and student nurses including patients that are receiving care from such nurses.

4.2 Who is the recipient of HIV management after NIMART training? The recipients

A recipient is a person or thing receiving action from the agent [14]. In this framework, the recipient is any health care worker receiving NIMART training. These can be PNs, facilitators, student nurses, nurse educators, or programme managers. The agent should provide comprehensive quality training to improve the skills, competence, and confidence of the NIMART nurse in providing quality care to the patients and facilitators and educators to transfer the skills to the students. In addition, the patients indirectly benefit from the NIMART training as they receive care from the NIMART nurse equally.

4.3 In what context is the NIMART training implemented? (the setting)

The context refers to resources, activities, and environments which enable or facilitate the implementation of the NIMART conceptual framework [14]. A combination of organizational resources and a conducive, safe and comfortable environment in the district primary health care system can facilitate implementation. Having adequate, independent, experienced, skilled human resources for health (HRH) with positive attitudes toward PLWH and HIV programmes facilitates robust implementation. Again, the development of a standard integrated NIMART curriculum and effective interactive strategies that stimulate critical thinking and facilitate the integration of theory and practice can influence implementation. Moreover, the provision of NIMART/HIV management pre-service training to student nurses, continuous professional development (CPD), and in-service training on HIV changes can facilitate NIMART implementation. This also includes the availability of good communication and relationship skills, compliance to HIV/TB and PHC policies, guidelines, protocols, and standard operating procedures (SOPs) to facilitate implementation. In addition, treating patients and nurses with respect and attending to their concerns or challenges can also facilitate implementation. Furthermore, maintaining the physical infrastructure of the PHC facilities, having enough space, re-organizing the facility in line with the ideal clinic integrated clinical services management (ICSM) standards, and reducing waiting times can facilitate implementation and quality. Prioritizing the PHC in budget planning is necessary to deal with the overt challenges influencing implementation. Provincial and district management team support, flexibility, coaching, and supervision are necessary to influence and facilitate discipline and meaningful implementation.

4.4 What are the support systems to strengthen NIMART training and implementation? (dynamics)

The dynamics refer to the sources of power or energy among the activities [14]. According to Donabedien [13], this refers to the process that facilitates the implementation of the CF, including the guiding principles. Provision of motivation, acknowledgement, and recognition of NIMART nurses for rendering services under difficult conditions substantially influences and facilitates implementation. Intrinsic and extrinsic recognition is necessary to motivate and enhance performance. This would invariably boost their self-esteem, build confidence, and improve their sense of responsibility and feeling worthy to the department. Again, the Department of Health should meet NIMART nurses’ needs and deal with their frustrations. Furthermore, avoiding negative criticism and blame–punishment feedback would greatly influence successful implementation.

4.5 What are the guiding approaches, rules, or procedures to improve NIMART training and implementation? (the principle/s)

The guiding principle refers to the rule, technique, protocol, and routine governing the activities to achieve the terminus [14]. According to the Donabedian SPO model [13], the recipient, agent, and principles that guide NIMART training and implementation are referred to as the structure. Providing quality training, mentoring, support, and compliance to policies, guidelines, SOPs, and protocols are the guiding principles that facilitate achieving patient and framework outcomes. Again, monitoring, reporting, and evaluation facilitate the identification of gaps, signs of danger & success in arriving at the terminus. Another principle to facilitate and influence implementation is the involvement of all internal and external stakeholders, which includes district clinical specialist teams (DCST), facilitators, RTC managers, the province and district leadership, developmental partners, HEI, SANC, and HWSETA in implementation.

4.6 What is the outcome of the implementation of the NIMART training conceptual framework? (terminus)

Terminus refers to the outcomes or end results of the activity [14], while [13] describes a terminus as the end product or outcomes of the structure and process. The outcomes of effective and efficient implementation of NIMART training facilitate the production of confident, competent, and skilled NIMART nurses who comply with policies and guidelines. This will also facilitate the improvement of patient health status by increasing linkages to ART, improving adherence and retention to care, reducing loss to follow-up (LTFU), enhancing viral suppression, and decanting of the stable patients, and relieving pressure on NIMART nurses. Furthermore, this reduces complications and death rates, thus increasing life expectancy. Dickoff et al.’s six elements questions and Donabedian’s SPO described above were categorized and classified with the characteristics and activities from the study findings to develop a conceptual framework that can facilitate and influence the improvement of NIMART training and implementation in the district health system, thus improving patient and HIV programme outcomes as represented in Figure 1.

5. Barriers and enablers to effective NIMART training and implementation

A study conducted by Mboweni and Makhado [15] in South Africa revealed structural or health care system, environmental, patient, human resource, training, and mentoring factors as challenges influencing NIMART training and implementation and supported by various studies in Africa and globally. Such barriers should be dealt with decisively to enhance the effectiveness of NIMART training and implementation, improving the quality of care and HIV services.

5.1 Health care factors

Health care system or structural factors plays a significant role in the effectiveness and efficiency of delivering HIV services and health care services in general, including achieving universal health coverage (UHC). According to Mboweni and Makhado (2019), several challenges are influencing NIMART training and implementation in South Africa and other African countries, which includes:

• lack of NIMART training regulation,

• shortage of staff,

• poor work schedules and processes,

• inadequate systems for data management,

• drug stock-outs,

• poor integration of services,

• poor clinical supervision and management support,

• insufficient leadership role model,

• stigma and discrimination.

5.1.1 Poor leadership role model

The success of the HIV programme and ending the HIV and TB epidemic lies in the commitment of the district, provincial and national leadership with clear political will and leadership strategy. Therefore, poor leadership affects the implementation of the NIMART programme. All internal and external stakeholders should have clear roles and responsibilities to avoid duplication and overlapping of functions and facilitate the integration of HIV and non-communicable disease as they are both chronic diseases.

Supportive supervision by district and local management is key to dealing with gaps in training and implementation at facility levels, such as shortage of medication, equipment, and supplies as soon as possible. There is no district clinical mentorship programme; if available, it is mostly partner driven. Partners are HIV and TB communities or non-profit organizations mostly funded by donors. The United States President’s Emergency Plan for AIDS Relief (PEPFAR) supports the government in preventing, controlling, and managing HIV and TB. Their existence is based on funding, meaning HIV management can collapse when they are unavailable and create dependency as most nurses working for government no longer render HIV services and rely on NIMART nurses from NGOs. Patient care is delayed as some patients are referred to another facility or have to wait for a partner NIMART-trained nurse.

5.1.2 Inadequate integration of service

The high shortage of skilled human resources for health requires better planning through integrating HIV, communicable and non-communicable services. Vertical integration might allow underutilized resources to remain and contribute to inefficient operations, excess capacity and duplication must be removed from the system. Health service integration is defined as the “managerial or operational changes to health systems to bring together inputs, delivery, management, and organization of particular service functions.” Integration improves access, facilitates services, and addresses what has brought together inputs, delivery, management and organization of particular service functions.” Integration improves access, encourages the use of services, and addresses what has been referred to as the four ‘D’s’ – duplication, distortion, disruption, and distraction. A health facility should be a one-way stop where the patient can receive all services without moving from one consultation room to another. However, adequate staff allocation is key to ensuring quality, reducing long waiting hours, and improving patient satisfaction. Such staff needs to be provided with appropriate training to provide quality care and be integrated during NIMART training, where adult care 101 can be integrated and continued within the facility level during clinical mentorship support visits.

Integrating health services improves multiple healthcare outcomes among HIV-infected people who inject drugs. This can be relevant to managing other key population groups eye marked to reduce new HIV infections. A mind shift set from vertical programmes to context-specific equitable access to integrated services is crucial to achieving the 95–95-95 and 10–10-10 plus 90% targets by 2030 by dealing with issues related to:

• human rights,

• gender inequality,

• violence,

• preventing and addressing gender-based violence,

• intimate partner violence,

• stigma, discrimination,

• access to sexual reproductive health,

• mental health,

• communicable and non-communicable services,

• eliminate vertical transmission,

• stop criminalization and punitive laws and policies of key populations, especially people who inject drugs and sex workers.

All stakeholders should speak in one voice and put PLWH and communities at risk at the centre, with a non-judgmental attitude and embracing diversity [7]. Key populations in the HIV programme refer to a group of people who are vulnerable and disproportionately affected by HIV owing to risk behavior and marginalization and frequently lack access to health care services and include: lesbians, gays, bisexuals, transgender, sex workers, men who have sex with men, people who inject drugs, prisoners or inmates, and people in intergenerational relationships with older men or women groups and adolescents.

5.1.3 Inadequate information systems and processes

The healthcare process refers to interrelated or interacting healthcare activities transforming inputs into outputs. The processes and systems are essential in improving the quality and performance of the healthcare environment and can help providers with reliable, cost-effective, and sustained healthcare processes and enable them to achieve their goal of improving care delivery and enhancing patient outcomes. Therefore, inadequate information systems and the process can affect quality and decision-making.

5.1.3.1 Inadequate patient information systems and processes

There are inadequate information systems and processes for follow-ups and tracing of patients. It became difficult to provide continuous quality care to patients, especially those working in farming, mining, and industrial areas, as they are highly mobile and migrant workers. Facilities ended up with a high loss to follow-up and missed appointments, and systems and processes should be developed to address such. There should be one system nationally to track patients’ movements as they visit other facilities using ID as a unique identifier.

5.1.3.2 Inadequate viral load management systems and processes

Viral load management is critical in managing and monitoring the effectiveness of treatment or treatment outcomes in HIV management. It is currently lacking or not implemented effectively in most health facilities. If no systems and processes are in place, it will affect patient outcomes. Most patients’ blood for viral load is not collected per cohort. Either they are missed, or patients did not visit the facility, and there are no effective systems to identify such on time for tracing or tracking the patients. Viral load management is also crucial in monitoring the 95–95-95 UNAIDS target by 2030 to ensure that ART patients adhere to treatment and are virally suppressed. Quality improvement is key to identifying gaps and developing processes and systems that can be followed to improve VL monitoring in all health facilities. Patients, key populations, and the community should be educated on the slogan of undetectable equals untransmissible (U=U), to reduce new HIV infection through early ART initiation and adherence to lower the HIV viral load in the blood and by reaching that level where the transmission will be low and should be emphasized that this only applies to the transmission through sexual intercourse and not through other methods transmission; therefore they need to continue to implement relevant preventatives measures [16].

5.1.3.3 Poor data management systems and processes

Data management is collecting, keeping, and using data securely, efficiently, and cost-effectively. Managing digital data in an organization involves various tasks, policies, procedures, and practices. Data are critical to HIV programme management as it identifies gaps and monitors progress. Management should be data-driven to direct planning and allocation of resources. Therefore, the whole programme will lack direction if data are not managed well. The study revealed poor adherence to data management SOPs, incomplete clinical records, inconsistent clinical records quality audits, and lack of data verification. The facility manager’s responsibility is to ensure that data are well managed in the facility. However, it is not happening in some facilities or is inadequate. Health care providers, including NIMART nurses, mostly do not accurately complete clinical records or registers. Such gaps make it difficult for the data team to capture quality data in the DHIS and TIER.NET. They also do not comply with the SOPs and HIV guidelines, compromising quality. Clinical records quality audits are not conducted consistently. Hence, gaps in clinical records are not attended to until data capturing. This is the responsibility of the clinical nurse mentor, HIV programme manager, and NIMART-trained nurse with the support of and under the leadership and guidance of the facility manager. The data team should ensure that the facility or institutional data is always verified, cleaned, timely, and ready to use. Access to timely and accurate facility data is vital for decision-making and planning. There should be a data collection system, processes, and equipment with a well-trained data or information team. A proper and highly effective ICT infrastructure is also necessary to collect real-time data from the facility or community level. The programme also needs well-trained staff to conduct data cleaning and verification process to ensure quality.

5.1.3.4 Stigma and discrimination

HIV was labeled as a gay disease from its beginning around the 1980s, which had the foundation of stigma and discrimination and has remained to the present. The failure of the HIV programme is owing to stigma and discrimination. Most PLWH are not accessing health services owing to stigma from community and health care workers. Stigma and discrimination become barriers that delay PLWH’s early access to ART leading to complications and death. Suppose the world has to end the HIV epidemic. In that case, the focus will be on ending stigma and discrimination, especially among key populations such as adolescents, young women, LGBTQI–а common abbreviation for the lesbian, gay, bisexual, transgender, queer, and intersex community. Countries should end criminalization and punitive laws against LGBTQI and people who inject drugs and develop strategies to enhance access to health services. This will help deal with behavior that exposes them to HIV, reducing new HIV infections. Inequalities should be confronted to end the HIV epidemic [17].

5.2 Environmental factors

NIMART-trained nurses continuously reported poor infrastructure, that the health facilities are poorly maintained, small, and cannot accommodate the growing number of patients needing health services. They work in an overcrowded and congested environment, worsening infection during the COVID-19 pandemic. The consultation rooms are small and not well ventilated despite implementing ideal clinic initiative standards for quality care. Some patients have to wait outside for a long time and are exposed to heat or cold to implement infection control measures. Such small facilities do not have enough space for supplies, equipment, and medicines. Therefore, proper planning and budgeting is need to refurbish or extend the health facility.

5.3 Health care providers’ factors

Health care providers can play a major role in ensuring that HIV services are accessible, efficient and effective. However, various factors must be considered to ensure quality, such as staff attitude, shortage, and scheduling.

5.3.1 Staff attitude

Some health care workers have negative staff attitudes toward patients and are a barrier to accessing health services, which has to change. Nurses must comply with their pledge and work according to SANC regulations and Batho Pele or customer care principles in line with the South African Constitution Act 108 of 1996 regarding human rights and patients’ rights charter. Training should be provided to sensitize nurses on these legislations, including stigma and discrimination and key populations.

5.3.2 Shortage of skilled healthcare workers

Low- and middle-income countries like South Africa still experience a high shortage of skilled human resources for health, making those available staff overworked or overburdened and suffer from exhaustion and stress. This requires better planning, budgeting, and allocation of work schedules by the healthcare leadership. Some staff members resigned or transferred to work in other areas as they no longer cope with the workload, especially in rural provinces. Those left continue to be overworked, dissatisfied, and experience burnout, affecting the quality of HIV management and other programmes. Some form of intrinsic and extrinsic incentives is necessary to motivate nurses trained on NIMART. Despite task shifting, there is still high staff turnover, and more needs to be done. Nurses still perform non-clinical roles, and there is a need for task shifting in other roles like ordering and dispensing medication by assistant pharmacists rather than pharmacists, administrative work to administrators, and collecting specimens for phlebotomists or laboratory technicians as it delays actual management of patients. Nurses cannot become all-rounders as it compromises their clinical skills.

5.3.3 Confidence in HIV management

NIMART training should be aimed at providing knowledge and skills and building confidence and a positive attitude to manage PLWH. The districts should prioritize the establishment of the Department of Health district clinical mentorship teams and avoid reliance on partners to build the confidence of NIMART nurses at a facility level where patient care and management are taking place than at a classroom level where theory and simulation take place. On-job support to conduct the physical assessment, staging, interpretation of guidelines and results, selecting the correct regimen, drug interactions, and management of complications and opportunistic infections is key to improving the clinical competence of NIMART-trained nurses to the acceptable level of providing quality HIV management.

5.3.4 Clinical supervision and support by management

Management support is key to achieving the organizational goals and objectives, and once it is lacking, the HIV programme is not going to perform as expected. Management should manage by identifying gaps and be more proactive than reactive. Most challenges experienced by NIMART nurses and other health care providers might be minimized through the support of national, provincial, district, and local management. They will plan better and prioritize resources effectively where it is needed most.

5.4 Patient factors

Patients’ social, psychological, physical, and financial factors need to be consider in HIV management. Failure to consider these factors might lead to poor clinical and virologic outcomes. Poor clinical outcome refers to a situation where the patient’s condition is not improving despite taking antiretroviral treatment, while virologic outcomes refer to a situation where the viral load remains high or does not improve despite the patient starting on treatment.

5.4.1 Social factors

Patients need to modify their lifestyle, stop or reduce smoking, and alcohol consumption, eat a healthy diet, and exercise. Patients need treatment and scheduled appointments and avoid over-the-counter medication or traditional herbs that may interfere with treatment. Continuous patient self-care management education is key in every visit, including the importance of adherence to medication through health education and counseling. There is a need to modify a lifestyle that interferes with appointments and adherence to treatment because missing appointments interfere with the regular taking of medication, resulting in poor clinical and virologic outcomes. Some clients experience intimate partner violence (IPV) or gender-based violence (GBV), especially women when they have to disclose their HIV status and end up hiding and not taking medication as prescribed or missing their appointments.

5.4.2 Psychological factors

Stigma and discrimination also play a significant role in lack of disclosure, stress, anxiety, and depression, and loss of follow-up and should be dealt with decisively by NIMART nurses and the healthcare system. Factors leading to stigma and discrimination should be identified and addressed appropriately, including prevention. Sensitization of health care providers and the community about stigma and discrimination can be integrated into training and education and during community education and awareness campaigns. All stakeholders should be involved and sensitization, including PLWH, traditional and religious leaders, CBOs and NGOs. Mental health services should be provided to PLWH to reduce stress, anxiety, and depression. Enhanced adherence counseling (EAC) should be provided to all patients who missed appointments and did not adhere to treatment. Lack of support also results in poor adherence to treatment and lack of disclosure; patients need to identify a friend and family support and be referred to psychosocial counseling to help cope, accept the diseases, and move on with life. Community support groups can also be used to refer patients so that they have an opportunity to share their experiences with other people. Some do not have money to access health facilities monthly and can be registered for home or community medication distribution if they qualify or are assisted by community health workers. Some are physically disabled or very ill and need support with daily self-care management.

5.4.3 Financial or economic factor

Patients with financial difficulties or lack of support might miss appointments due to a lack of transport money to visit a health facility or pay for treatment in a private health facility or pharmacy. Some patients are unemployed without any government grant to support themselves, especially immigrants and those living with a disability or mental illness who need support. ART is available free of charge in South Africa’s public health services. Stable patients on ART and the communities should be made aware of the minimum package of interventions to support linkage, adherence, and retention in care and differentiated models of care for stable chronic patients on treatment, which include repeat prescriptions (RPCs) collection strategies after six months on treatment through facility pick point (FAC-PUP), adherence clubs (AC) within the facility or community, external pick up points (EX-PUP) from the local shops, pharmacies or NGOs (National Department of Health AGL, 2021).

5.5 Inadequacy in NIMART training

South Africa has the largest and most high-profile ART programme globally, with 7.7 million initiated on treatment. However, quality is still a challenge and should be addressed through proper training, including standardization of the curriculum, use of strategies that can stimulate critical thinking, competency-based education, training and assessment, and application of the conceptual framework to enhance NIMART training and implementation.

5.5.1 Standardization of NIMART curriculum

The literature review and the study findings revealed that the NIMART curriculum was not standard and partner-driven, and recommendations were made to standardize the curriculum. The National Department of Health in South Africa did not have a standard curriculum to guide the country and train providers. The content covered and even the period offered differed. Some offer it in five days while others in ten days. The curriculum is a standards-based sequence of planned experiences where students practice and achieve proficiency in content and applied learning skills. The curriculum is the central guide for all educators as to what is essential for teaching and learning so that every student can access rigorous academic experiences. The disruption of onsite training by the COVID-19 pandemic has propelled the department to develop a standard training programme. It is now being attended to and offered online through the national knowledge and training hub and is accessible to all professional nurses either from m private or public sector and allocated CPD points. However, it is unclear which curriculum was followed in developing the training materials.

5.5.2 The use of strategies that stimulate critical thinking

Facilitators or educators should use interactive teaching strategies to stimulate critical thinking, including problem-based, reflective, case studies, and seminars. Health workers play a major role in learning and teaching by active participation based on their experience and knowledge of managing PLWH. Facilitators and educators should be adequately trained to facilitate NIMART and should be carefully selected during the recruitment process. Moreover, they should possess skills like nursing education or health sciences education with computer and good presentation skills, not just pick anyone to facilitate learning and teaching. In addition, experience in HIV and AIDS management is also necessary. They should do away or eliminate traditional strategies or didactics of the presentation without active participation or involvement of participants.

5.5.3 Use of competency-based education, training, and assessment model

Integrating theory with practice is key to improving health workers’ competency levels and performance. Clinical mentoring and competency tools were developed to assess the competency of nurses after training and can be certified as competent than being presented with a certificate of attendance. All health workers trained should undergo a clinical mentoring process by allocating an experienced mentor for 6 to 12 months to support the trained health workers onsite or virtually through SMS, WhatsApp, and telephonically. Final assessments are conducted through OSCE or simulated case studies and onsite job assessments while managing the patients in the health facility to determine the competency of the trained health workers. NIMART-trained nurses should complete the logbook or portfolio of evidence with stipulated cases needed to manage children, men, women, ANC pregnant women, HIV/TB Co-infected cases, and adults. They need to show the integration of adult primary care in managing chronic diseases and integrated management of childhood illness when implementing NIMART or managing PLWH. Other education and training strategies that can improve NIMART implementation include pre-service, continuous in-service training, and CPD.

5.5.3.1 Pre-service training

Introduction or strengthening of NIMART as pre-service training to nursing students can help facilitate capacity building of new nurses before they can enter or join the health care system and prepare them to work effectively and efficiently in providing quality services to the community and PLWH. According to WHO (2014), pre-service education or pre-service training is used interchangeably and refers to any structured activity aiming to develop or reinforce knowledge and skills before a health care professional enters public health service or private practice. “Pre-service” refers to activities before a person takes up a job requiring specific training, i.e. before a person ‘enters service. This also includes courses for graduates and undergraduates, which are ‘pre-service courses’ if they provide the competence needed to perform new services. Pre-service training is the training nurses receive before they begin managing patients in a health facility after completing formal training. This stage is vitally important as it lays the foundations for motivation and ensures that new nurses are competent before entering the consultation room.

Pre-service coordination is meant to increase efficiency for patients and office staff. Patients know upfront what their service will cost before they arrive, and they have the opportunity to pay for that service in full, in part, or to make payment arrangements. Nurses should be exposed to HIV and non-communicable and communicable disease guidelines, policies, and protocols before they start working as part of induction and orientation to their new roles in health facilities to provide integrated, comprehensive quality care to their clients or patients. This will also reduce time spent orientating the new nurses and be used effectively for patient clinical management. Again, training will reduce stress and anxiety as the new nurses will be familiar with such guidelines and confidently manage the patient. Unnecessary referral to other professionals or facilities will be reduced, facilitating access to services in the first or primary level of care. This can be designed through stakeholder coordination by the national, regional, or district training centres together with higher education institutions offering training and education to nurses and partners supporting the Department of Health, and can be offered through staggering the content every academic year or allocating weeks specifically for NIMART and Adult Primary care (APC) 101 like how Integrated Management of Childhood Illness (IMCI) is being integrated into HEIs learning and teaching programmes. Adult Primary Care (APC) is the new name for Primary Care 101 (PC 101). APC is a symptom-based integrated clinical management tool using a series of algorithms and checklists to guide the management of common symptoms and chronic conditions.

In adults, a clinical tool is a comprehensive approach to the adult’s primary care for 18 years or older. APC has been developed using approved clinical policies and guidelines issued by the national Department of Health and is intended for use by all healthcare practitioners working at the primary care level in South Africa as a clinical decision-making tool. This tool accompanies a training package consisting of short onsite sessions using simulated case scenarios. APC is being implemented as part of the Integrated Clinical Services Management (ICSM), a key focus within the Ideal Clinic Realization and Maintenance (ICRM) initiative to improve the quality of care delivered and is complemented by the health for all health promotion tool to promote healthy lifestyles and health education. Therefore, APC 101 is a step-by-step training provided to health workers for the integrated management of communicable, and non-communicable diseases in the primary level of care with limited resources and facilitates the provision of integrated management of NCDs and communicable diseases, including HIV.

5.5.3.2 Continuous in-service training

Providing continuous or ongoing in-service training is key to keeping health workers updated on the current development and changes in national HIV policies, guidelines, and protocols to provide appropriate services to the community and PLWH. According to WHO, in-service training refers to training persons already employed, e.g. health providers working in the public or private sector.

In-service training refers to practical work experience during studies and usually, after one or two years of the theory are completed. In-service nurse training enhances the performance of a nurse. A nurse feels enriched with additions of ideas, concepts, and activities. In-service training improves the overall personality of a nurse. Sometimes it is called in-service education and training (INSET), and it improves various aspects of the overall performance of a nurse. This has to be planned periodically and facilitated within the facility to access all staff members and encourage discussion of real cases within the facility. Online nursing is a dynamic profession subject to rapid changes, like the HIV programme hence the need for in-service training for nurses. In-service training can be described as training that has been systematically planned, is carried out by a trainer within an institution, and takes place during normal working hours. Nurses are essential in transforming healthcare and health systems. Being educated to degree-level ensures nurses are well equipped to provide high-quality care. It also prepares them to take the lead, inform and design health services delivery, decision making, and policy development.

5.5.3.3 Continuous professional development

CPD is the term used to describe the learning activities professionals engage in to develop and enhance their skills. Health workers are expected to keep themselves abreast of the current trends and development in research to provide quality services. NIMART should be registered and accredited as one of the CPD programmes with SANC or HWSETA that must attend annually to accumulate points. CPD enables learning to become conscious and proactive rather than passive and reactive. Furthermore, CPD is professionals’ holistic commitment to enhancing personal skills and proficiency throughout their careers. CPD combines different methodologies for learning, such as training workshops, conferences and events, e-learning programmes, best practice techniques, and ideas sharing, all focused on helping an individual to improve and have effective professional development. This can be managed by professional bodies such as SANC and HWSETA.

5.5.4 NIMART training and implementation regulation

NIMART training is not yet registered and accredited as a formal pre-service or CPD programme. It is not recognized as an expert in government even though it is recognized by non-governmental organizations (NGOs) supporting the government with HIV management. There are no incentives for providing an additional expert role as a NIMART nurse or clinical mentor, which demoralizes NIMART nurses. This delays the implementation of WHO recommendations for task shifting of creating an enabling regulatory environment for implementation, sustainability, and quality care. This requires all stakeholders, guideline developers, decision, and policymakers to fast-track engagements to register and apply for accreditation of the NIMART training with all relevant education and training quality assurance bodies such as SANC, HWSETA, and Department of Higher Education and Training as vocational training and consider as expert skills with additional remuneration for scarce skills or other forms of incentives can be implemented to motivate nurses.

5.5.5 Development of a conceptual framework to strengthen NIMART training and implementation

According to Mboweni and Makhado (2020), there was no conceptual framework to guide the training and implementation of NIMART, and this study developed a framework that needs to be implemented and reviewed before adoption. A further study can be conducted to upgrade the framework into a model that can be tested and approved for use. A framework is a particular set of rules, ideas, or beliefs that you use to deal with problems or decide what to do, and it can guide how to conduct training and implementation of NIMART. According to Adom and Hussein (2018), a conceptual framework is a structure that the researcher believes can best explain the natural progression of the phenomenon to be studied. The application of NIMART training and implementation was discussed in section five of this chapter.

6. The HIV continuum of care

The HIV continuum of care is a public health model that indicates steps or stages people living with HIV take from diagnosis until they achieve and sustain viral load suppression. The stages include diagnosis of HIV infection, linkage to treatment or ART, management of a patient on ART, retention to care and achievement, and maintenance of viral suppression, as illustrated in Figure 2 [18].

Figure 2.

HIV continuum of care.

The HIV care continuum is useful as both an individual and population-level tool or framework to assess care outcomes, and analyzing the proportion of PLWH in a given community, helps policymakers to plan and make a decision about the allocation of resources, and service providers can identify gaps in service delivery and develop interventions to improve the quality of care to PLWH to achieve the treatment goal of viral suppression. Achieving viral suppression has health and prevention benefits. Health benefits to PLWH as the viral load becomes low and can live healthy and longer, increasing life expectancy. The prevention benefit is that PLWH who take treatment as prescribed and have undetectable viral load have no risk of transmitting HIV to their HIV-negative sexual partners. However, these patients need continuous engagement in HIV care with support, and knowing where the problem helps develop targeted intervention to break the cycle of HIV transmission. Therefore, it requires the involvement and collaboration of all stakeholders such as local health departments, community-based organizations, traditional and religious leaders, traditional healers, health care providers, public health officials, and PLWH to develop and implement quality improvement systems to support all PLWH to navigate the continuum and achieve and maintain viral suppression successfully. NIMART nurses play a major role throughout this continuum.

Diagnosed HIV infection can measure the percentage of the total number of PLWH whose infection has been diagnosed and measures prevalence, and NIMART nurses achieve this by conducting provider-initiated counseling and testing (PICT) to all patients coming to their care and confirming those without documented HIV status. This ensures that no one is left behind. Linkage of people who tested HIV positive to quality care is one of the crucial roles of NIMART nurses as clinicians and continues to ensure that PLWH receives effective and efficient care through follow-up, management of OIs, complications and provide adherence counseling messages, thereby keeping PLWH in care until they are viral suppressed, which indicates treatment or failure if the viral load is high while on treatment. It is very easy to lose PLWH if this continuum is not implemented properly. A combination of preventive interventions is also very important in reducing new HIV infections.

7. The role and responsibilities of NIMART nurses

The NIMART nurse plays an expert role and responsibilities in managing HIV and TB and includes the following [19, 20]:

Promote universal prevention and control of infection

• Prevention of Transmission of Communicable infections across all age groups and key populations, including from mother to child (HIV, Hepatitis, Listeriosis, Malaria, Syphilis, COVID-19, and TB) through education, community awareness, and campaigns and provide combined preventions strategies or refer clients for Voluntary Medical Male circumcision (VMMC), Pre- Exposure Prophylaxis (PrEP), Post Exposure Prophylaxis (PEP), including condom distribution.

• Strengthening antenatal and postnatal care for both HIV-negative and positive mothers through the PMTCT programme.

• Confirm the HIV test for those without documented HIV status and conduct provider-initiated counseling and testing for all clients under their care, including HIV index and recency testing services for partners and children.

• Conduct History taking and physical examination: To identify potential risk, baseline assessment, and identify conditions that need urgent attention and referral, the physical examination also helps to identify contradictions, OIs, and staging of the patients, which helps to understand the severity of the client’s clinical condition, associated risks of mortality and determine the urgency and timing of ART initiation.

Conduct Screening of the following

• Conduct screening for TB to identify clients with a positive TB screen who requires further investigations such GeneXpert, and identify those with negative TB screen who may be eligible for TPT.

• Symptoms for meningitis to diagnose and treat clients with cryptococcal and other forms of meningitis and reduce associated morbidity and mortality.

• Mental health: Active depression and other mental health issues such as psychosis and substance abuse to identify potential adherence risks and side effects.

• Non-communicable Diseases (NCDs) such as hypertension, diabetes, and epilepsy to identify and manage major chronic diseases or co-morbidity and prevent drug interactions or contraindications.

• Pregnancy: Ask if not pregnant or planning to conceive for early referral to ANC, and measures to prevent mother-to-child transmission, assess fertility and contraceptive needs if not pregnant, and assess eligibility for ART regimens.

• Screen STIs, especially in sexual active clients, to identify and to provide early treatment.

• Neurodevelopmental screening among children for early referral and follow-ups.

• Cervical screening to identify women with cervical lesions and manage them appropriately.

• Nutritional assessment – to identify recent weight loss that may indicate active opportunistic infections or other conditions, also identify under/overweight clients that require nutritional and lifestyle support. Promoting breastfeeding and counseling the mother on feeding options is key to improving and maintaining the nutritional status of infants and children exposed to HIV, as it strengthens the immune system.

• Facilitate the collection of baselines clinical specimens- CD4 cell count to identify eligibility for CPT, cryptococcal antigen screening, to identify asymptomatic clients that need pre-emptive fluconazole treatment, Creatinine and Estimated glomerular filtration rate (eGFR) to assess renal sufficiency, HB to identify and manage anemia and eligibility for some ART where necessary such as Zidovudine (AZT), Hepatitis B, to identify those co-infected with hepatitis.

Interpretation of National Health Laboratory Services (NHLS) results and reports and develop appropriate interventions.

7.1 ART initiation and managing clients on ART

Fast track linkage to ART initiation, determine eligibility criteria and reason to defer ART, select the correct regimen, and provide key adherence messages for adults, children, and adolescents, including lifestyle modification.

• Re-initiating ART in clients who have interrupted treatment.

• Managing clients with TB/HIV coinfection.

• Switching stable clients on ART between first-line regimens and clients not responding well to the first-line regimen with confirmed virologic failure to a second-line regimen.

• Early referral of complicated cases for expert management.

• Management of opportunistic infection and complications related to HIV and TB.

• Provide routine integrated care to other conditions, including sexual reproductive health such as contraceptive and mental health services, identify and address stigma and discrimination, intimate partner violence, and gender-based violence.

• Care for HIV-exposed infants and children.

Identify eligibility for prophylaxis such as TB preventive therapy (TPT), and cotrimoxazole preventive therapy for infections (CPT).

Monitoring clients on ART.

Quality care at the follow-up visits promotes adherence, achieves and sustains viral suppression, minimizes side effects and toxicities, and promotes quality of life.

Viral load monitoring and management – to determine clinical, virologic, and immunological response to ART, management of viral load results in infants, children, adolescents, ANC pregnant women, and adults and conduct routine viral load monitoring.

Implement interventions to suppress viral load, including enhanced adherence support.

Provide clinical support to staff – experienced NIMART nurses in the health facility are expected to provide support to pre-service trained nurses, those newly trained, and staff on interpretation of guidelines, results, and ART initiation, and interventions and can be trained as clinical nurse mentors through the district clinical mentorship programme to transfer skill, knowledge to newly trained nurses thus improve clinical competence in the management of PLWH. They can also provide in-service training to keep staff and NIMART-trained nurses up-to-date with current development and research.

Data management and quality improvement – NIMART nurses are responsible for documentation of clinical findings, results, and interventions, and this should be legible, signed, and dated as per record management policy. Data management requires systems and processes, including clinical records audits to identify gaps and develop a quality improvement plan and projects to improve such gaps.

8. Conclusion

Enhancing NIMART training and implementation is key in HIV management to improve the quality of care and achieve the goal of ending new HIV infections and ending the HIV epidemic in low and middle-income countries through proper training, clinical mentorship, leadership, and management support, and dealing with structural challenges influencing the implementation of NIMART in healthcare services. The HIV continuum should continue to provide direction on managing the programme and identify individual and population gaps that require appropriate action by policy, decision-makers, health care providers, PLWH, community, and other stakeholders to end the HIV epidemic.

Acknowledgments

The authors also want to acknowledge the Department of Health in North West Province, South Africa, Regional Training Centre, and NIMART trained nurses for participating in the study.

Conflict of interest

The authors declare no conflict of interest.