Botswana National Botswana National Program: Nurses Program: Nurses Dispensing ARVsDispensing ARVs

Tendani Gaolathe M.DTendani Gaolathe M.DDirectorDirector

Botswana-Harvard Partnership Botswana-Harvard Partnership /PEPFAR Master Trainer Program/PEPFAR Master Trainer Program

HEALTH INDICATORSHEALTH INDICATORS

HIV prevalence per health district, among pregnant women aged (15-49)

years, Botswana, 2005

HIV prevalence among pregnant HIV prevalence among pregnant women aged 15-49 years is 33.4%* women aged 15-49 years is 33.4%*

HIV is more prevalent among HIV is more prevalent among Botswana aged 25-34 yearsBotswana aged 25-34 years

Infant mortality (per 1,000): 56Infant mortality (per 1,000): 56 Maternal mortality (per 100, 000): Maternal mortality (per 100, 000):

326326 Under five mortality (per 1 000): 74Under five mortality (per 1 000): 74 Life Expectancy at birth: 33.74 Life Expectancy at birth: 33.74

years years

Health Statistics-CSO 2003Health Statistics-CSO 2003

Non-hospital sitesNon-hospital sites Clinics 257Clinics 257 Health Posts 336Health Posts 336 Mobile Posts 761Mobile Posts 761Staffing (country-level)Staffing (country-level): : Nurses 26.1/10 000Nurses 26.1/10 000 Doctors 3.1/10 000Doctors 3.1/10 000 FWE* 5.2/10 000FWE* 5.2/10 000

*family welfare educator

Patients on HAART in Botswana: July Patients on HAART in Botswana: July 20072007

Total on HAART in Botswana – 90,478Private Sector – 9,514 (approx.)

0

10000

20000

30000

40000

50000

60000

70000

80000

Jan-0

2

Apr-

02

Jul-02

Oct-

02

Jan-0

3

Apr-

03

Jul-03

Oct-

03

Jan-0

4

Apr-

04

Jul-04

Oct-

04

Jan-0

5

Apr-

05

Jul-05

Oct-

05

Jan-0

6

Apr-

06

Jul-06

Oct-

06

Jan-0

7

Apr-

07

Jul-07

Time period

Nu

mb

er

of p

atie

nts

Currently on HAART in Public Sector

Cumulative deaths

Out-sourced under PPP Project

74,348

7,755

6,616

ARV site roll-out in BotswanaARV site roll-out in Botswana

0

5

10

15

20

25

30

35

Jan-02 Jul-02 Jan-03 Jul-03 Jan-04 Jul-04 Jan-05 Jul-05

Period

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er o

f A

RT

sit

es

32 hospitals & over 100 satellite clinics

Hospital

Satellite Clinics

ARV SiteARV Site

IDCC

ARV Pharmacy

ARV Laboratory

Clinic Rollout PlanClinic Rollout Plan 128 clinics to go to full prescribing and 128 clinics to go to full prescribing and

dispensing capabilitydispensing capability 64 clinics upgraded to date, of which64 clinics upgraded to date, of which

51 prescribing and dispensing51 prescribing and dispensing13 prescribing only13 prescribing only

• 55 clinics to be upgraded by March 55 clinics to be upgraded by March 20082008

• ChallengeChallenge: adequate numbers of : adequate numbers of prescribers and dispensersprescribers and dispensers

Tsamaya ClinicTsamaya Clinic

Pharmacy RenovationPharmacy Renovation

Task ShiftingTask Shifting 2006: after lengthy negotiations with MoH, 2006: after lengthy negotiations with MoH,

Local Government and Nurses Association, Local Government and Nurses Association, agreement for nurse to agreement for nurse to PrescribePrescribe and and DispenseDispense ARVs ARVs

Resulted in 2 nurse training initiativesResulted in 2 nurse training initiatives -nurse prescriber*-nurse prescriber* -nurse dispenser-nurse dispenser Plans ongoing to integrate Plans ongoing to integrate Harvard/PEPFAR Master Trainer Program Harvard/PEPFAR Master Trainer Program

given mandate to train alongside MoHgiven mandate to train alongside MoH Integrated into ongoing site support Integrated into ongoing site support

activities of Harvard/PEPFARactivities of Harvard/PEPFAR*for continuing patients stable on ART (VL<400)

Traditional role of nurses at Traditional role of nurses at clinics and health postsclinics and health posts

Backbone of Botswana Health Care SystemBackbone of Botswana Health Care System

General patient consultationGeneral patient consultation Prescribe (review) and dispense general Prescribe (review) and dispense general

medicines for both acute and chronic care medicines for both acute and chronic care purposes.purposes.

Manage medicines at the clinics and Manage medicines at the clinics and health posts: quantify, order, receive, health posts: quantify, order, receive, distribute & maintain records. distribute & maintain records. (Includes (Includes PMTCT medicines). PMTCT medicines).

Nursing roles in the HIV eraNursing roles in the HIV era

Provide routine HIV Testing (task shifted to Provide routine HIV Testing (task shifted to lay counselors)lay counselors)

Prepare patients for HAART initiation:Prepare patients for HAART initiation:- pre-HAART investigations- pre-HAART investigations- adherence counseling (ongoing task - adherence counseling (ongoing task shifting)shifting)

Patient follow up (defaulters )Patient follow up (defaulters ) Collect ARVs on behalf of patients from the Collect ARVs on behalf of patients from the

hospitals.hospitals.

Nurse prescriber training objectivesNurse prescriber training objectives

To equip Nurses with the knowledge and To equip Nurses with the knowledge and skill:skill:- to correctly prescribe ARVsto correctly prescribe ARVs- to appropriately monitor therapeutic outcomes to appropriately monitor therapeutic outcomes - To identify and manage appropriately adverse To identify and manage appropriately adverse

reactions related to ARVsreactions related to ARVs- To address adherence issues To address adherence issues - To understand when referral is needed (failure To understand when referral is needed (failure

management, severe toxicity)management, severe toxicity)- To provide other aspects of HIV care (lab To provide other aspects of HIV care (lab

monitoring, IPT, CTX)monitoring, IPT, CTX)

Format nurse prescriber trainingFormat nurse prescriber training• Pre and post testPre and post test• 4 weeks training-1 week didactic, 3 weeks 4 weeks training-1 week didactic, 3 weeks

practical attachmentpractical attachment presentationspresentations group work/discussionsgroup work/discussions role plays (including standard operating role plays (including standard operating

procedures)procedures)• Attachment to the hospitals or dispensing Attachment to the hospitals or dispensing

satellite clinics under supervision of Master satellite clinics under supervision of Master TrainersTrainers

• Follow up of the participants at the sites by Follow up of the participants at the sites by BHP-PEPFAR Master Trainers to monitor, BHP-PEPFAR Master Trainers to monitor, support & mentor support & mentor

Goals of Nurse dispenser trainingGoals of Nurse dispenser training

To equip Nurses with the knowledge and To equip Nurses with the knowledge and skill:skill:- to correctly dispense ARVsto correctly dispense ARVs- to appropriately monitor therapeutic outcomes to appropriately monitor therapeutic outcomes - To identify and refer for adverse reactions To identify and refer for adverse reactions

related to ARVsrelated to ARVs- To measure adherence and address/refer To measure adherence and address/refer

adherence issues adherence issues - To review CTX useTo review CTX use- To familiarize them with the tools required for To familiarize them with the tools required for

managing ARV drug inventory and reporting.managing ARV drug inventory and reporting.• Capacity to do basic inventory in absence of Capacity to do basic inventory in absence of

pharmacy staffpharmacy staff

Format nurse dispenser trainingFormat nurse dispenser training• Pre and post testPre and post test• 4 days didactic training4 days didactic training

presentationspresentations group work/discussionsgroup work/discussions role plays (including standard operating role plays (including standard operating

procedures)procedures)• Attachment to the hospitals or dispensing Attachment to the hospitals or dispensing

satellite clinics under the supervision of a satellite clinics under the supervision of a pharmaceutical officerpharmaceutical officer

• Follow up of the participants at the sites by Follow up of the participants at the sites by BHP-PEPFAR Pharmacist Master Trainers to BHP-PEPFAR Pharmacist Master Trainers to support, monitor & mentor them.support, monitor & mentor them.

Success of the trainingSuccess of the training Plan was to train 120 Nurses on ARV Plan was to train 120 Nurses on ARV

drug management & dispensing in drug management & dispensing in 2007:2007:- 86 nurses trained on dispensing- 86 nurses trained on dispensing

- 40 nurses trained on prescribing (20 - 40 nurses trained on prescribing (20 currently in training) currently in training)

Most of trained dispensing nurses are Most of trained dispensing nurses are assisting the pharmaceutical officers at assisting the pharmaceutical officers at 33 satellite clinics with ARV dispensing.33 satellite clinics with ARV dispensing.

Most dispensing nurses are also activeMost dispensing nurses are also active

Patients seen by 2 prescribing Patients seen by 2 prescribing nurses IDCC-nurses IDCC-July-Sept 2007July-Sept 2007

MonthMonth FemaleFemale MaleMale Sub TotalSub Total

JulyJuly 201201

189189146146

123123347347

312312

AugustAugust 118118

92928383

5757201201

149149

SeptembeSeptemberr

121121

41419090

2929211211

7070

TotalTotal 1390(5781390(5780)0)

Very low % needed referral, appropriate regimens used

Mentoring and monitoring of quality Mentoring and monitoring of quality at facilitiesat facilities

Combined activity between sites and Master Combined activity between sites and Master TrainersTrainers

Ensures that nurses get adequate mentoringEnsures that nurses get adequate mentoring Data collected will also be used for Data collected will also be used for

improvement and real-time monitoring and improvement and real-time monitoring and evaluation of program evaluation of program

Tools developed include:Tools developed include:• activity log (Nurse to complete for each activity log (Nurse to complete for each

encounter)encounter)• Performance evaluationPerformance evaluation• Chart reviewChart review

Activity log: DispensingActivity log: Dispensing

DateDate Patient Patient file #file #

Age Age GendeGenderr(M/F)(M/F)

Last VL Last VL (date)(date)

Last CD4 Last CD4 count count (date)(date)

Pregnancy Pregnancy status status Y/N/Y/N/UNKUNKNANA

RegimenRegimenNewNewRefillRefillSwitchSwitch

RegimenRegimen Date Date startedstarted

Date of next Date of next refillrefill

Mentoring and monitoring of Mentoring and monitoring of quality-proposedquality-proposed

Nurse dispensingNurse dispensing:: Performance evaluation checklist (observed)Performance evaluation checklist (observed) Pharmacy logsPharmacy logs Activity log (quality and minimum activity)Activity log (quality and minimum activity) Chart reviewChart reviewNurse prescriberNurse prescriber Performance evaluation checklist (observed)Performance evaluation checklist (observed) Chart reviewChart review Activity log (quality and minimum activity)Activity log (quality and minimum activity) Outcomes (VL suppression)Outcomes (VL suppression)

Challenges/way forwardChallenges/way forward WorkloadWorkload

• Minimum and maximumMinimum and maximum Re-deployment of nurses to other positionsRe-deployment of nurses to other positions Mentoring needs to be strengthenedMentoring needs to be strengthened

• How to ensure this occurs at the district and local levelHow to ensure this occurs at the district and local level Continuous monitoring and evaluation essential Continuous monitoring and evaluation essential

to maintain quality of care, ARV service levels to maintain quality of care, ARV service levels and adherenceand adherence

Focus on outcomes over timeFocus on outcomes over time Integration of the prescribing and dispensing Integration of the prescribing and dispensing

trainingtraining