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Stepping Up: Nurses Role in MDR-TB/HIV Co-Infection in South Africa
Primary Healthcare-Nurse Practitioner (PHC-NP) and Medical Officer (MO) Task
Sharing of MDR-TB in Rural Kwa-Zulu Natal, South Africa
Jason Farley, PhD, MPH, NP, FAAN
Associate Professor, Johns Hopkins University School of Nursing
Adjunct Associate Professor, Uni. of KZN, SA and Uni. of Technology Sydney
Pres-Elect, Association of Nurses in AIDS Care
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Co-Investigators
Farley, J.E. 1; Walshe, L. 1; Budhathoki, C. 1; Mlandu, N. 2; Nomusa, N.; Ndjeka, N. 3; van der Walt, M.4
Johns Hopkins University School of Nursing1; Ugu District Department of Health, KwaZulu Natal, South Africa2; South African National Department of Health3; South
African Medical Research Council4
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TB in South Africa
• South Africa has the 2nd highest rate of new TB cases in the world (http://www.cdc.gov/tb/topic/globaltb/Southafrica.htm)
• Highest rate of drug-resistant TB cases in Africa (http://www.cdc.gov/tb/topic/globaltb/Southafrica.htm)
• 4th Highest Prevalence of HIV/AIDS (http://www.cdc.gov/tb/topic/globaltb/Southafrica.htm)
• Over 70% of all TB cases co-infected with HIV (SA DOH, 2012)
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Background
• Following national guidelines, every effort should be made to ensure eligible clients are enrolled as soon as possible.
– all primary care, antenatal, TB and mobile outreach health facilities must become fully functional nurse-initiated ART and MDR-TB initiation sites for adults, children and pregnant women.
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Methods
• Prospective cohort of MDR-TB patients jointly managed by a PHC-NP and a MO. – Patients who initiated treatment between January 1 and December 31,
2012– Who either completed IP or experienced a negative outcome (i.e., death,
failure, default) were included.
• We evaluate the intensive phase (IP) quality indicators and risk for IP negative outcomes.
• Descriptive statistics by provider type for demographic and time-to-event variables.
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Methods Cont’d
• Provider comparisons for time-to-event IP indicators were made using a log-rank test, and contribution of other covariates, e.g. gender, HIV status assessed.
• Cumulative risk of remaining event free beyond a time point shown using a Kaplan-Meier plot
• A competing risk analysis with death, failure or default as competing negative outcomes was completed.
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PREPARATIONS OF CLINICAL NURSE PRACTITIONER
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1 week intensive theory
+
1 Month CNP Clinical Mentoring
+
Competency Evaluation
+
Ongoing Clinical Mentoring
Diagnosis and Clinical Management of MDR-TBShort Course Overview
Mentored Training Experiences: Audiology training Visual assessment training Laboratory Monitoring & Evaluation ADR evaluation & treatment
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Developing Systems Level Strategies for Safe Prescribing
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Original Assignment to Provider
• After extensive training of the PHC-NP, patients were assigned a primary provider with task sharing throughout.
CNPOutpatient
Standardized MDR-TB Treatment per
guidelines
Standardized HIV Management
MDHospital
Patients requiring any changes to standardized
treatment
Baseline liver disease, baseline renal disease,
seizure, psychosis, pregnant, low BMI (<45 kg)
<13 years old, Diabetic, past Drug induced hepatitis, Re-treatment MDR-
TB, Requires O2 support; Non-ambulatory; Critical values for Baseline
FBC, U&E, LFTs?
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RESULTS
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Baseline Patient Data on Enrollment
• 186 eligible patients, 50% females with 77% unemployment.
• At enrollment, median age was 33 years (Q1-Q3 26-40), median weight 54 kg (Q1-Q3 47-60).
• HIV co-infection was 73% (median CD4 count 237, Q1-Q3 121-399); 77% on ART.
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Baseline Cohort Data Characteristic Overall Nurse Physician P-value*
Age (yrs), Median (Q1-Q3), n
33 (26-40), n=186
34 (26-40), n=122
32 (26-40.5), n=64
0.732
Sex, n (%) Male Female
93 (49.7)94 (50.3)
65 (52.8)58 (47.2)
28 (43.8)36 (56.2)
0.281
Unemployed, n(%), n=173 133 (76.9) 91 (78.5) 42 (73.7) 0.565
BMI, Median (Q1-Q3), n 19.6 (16.4-22.6), n=133
19.1 (16.4-21.9), n=110
22.3 (15.9-26.1),
n=23
0.109
Normal ALT, n (%), n=158
142(89.9)
95(89.6)
47(90.4)
0.950
Normal creat clearance, n (%), n=128
116 (90.6)
84 (93.3)
32 (84.2)
0.180
HIV positive, n (%), n=185 135 (73.0) 92 (75.4) 43 (68.3) 0.301
CD4 count, Median (Q1-Q3), n
237 (121-399),
n=120
233 (120-424),
n=85
241 (135-352),
n=35
0.324
On ART, n (%), n=138 106 (76.8) 72 (76.6) 34 (77.3) 0.950
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Are Initial Intensive Phase Outcomes Worsened by Task Sharing?
Characteristic Overall Nurse Physician P-value*
Outcome, n (%), n=186
MDR-TB diagnosis to Tx start (days), Median (Q1-Q3), n
71 (51-97), 186
71 (51-96), 123
74.5 (51-98), 64
0.810
Tx start to culture conversion (days),Median (Q1-Q3), n
58 (32-92), 149
57 (32-91), 101
62 (32-111.5), 48
0.594
Tx start to end of intensive phase (days),Median (Q1-Q3), n
196 (180-210) 143
196 (186-212)
98
196 (176-205)
45
0.608
*P-value from a Fisher’s exact test for categorical outcome, from a Wilcoxon rank-sum test for diagnosis to Tx start, and from a log-rank test for the time-to-event variables
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Are Intensive Phase Outcomes Worsened by Task Sharing?
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Are Negative Outcomes Increased?
• There was no significant difference between nurse managed patients and physician managed patients for time from treatment initiation to a negative outcome (default, failure or death) (p=0.561, HR=1.17)
Andersen, P.K., et al. 2012. Competing risks in epidemiology: possibilities and pitfalls; International Journal of Epidemiology; Fine, J. P., & Gray, R.J. 1999. A proportional hazards model for the subdistribution of a competing risk. Journal of the American Statistical Association, 94(446), 496{509.
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Are Final Treatment Outcomes Worsened?
Characteristic Overall Nurse Physician P-value*
Outcome, n (%), n=186
Still on Treatment (Tx) 68 (36.6) 47 (38.2) 21 (33.3)
CureFailureDeath
Default
51 (27.4)12 (6.5)
26 (14.0)29 (15.6)
35 (28.5)6 (4.9)
18 (14.6)17 (13.8)
16 (25.4)6 (9.5)
8 (12.7)12 (19.1)
0.609
Tx start to a negative outcome (default, failure or death) (days),Median (Q1-Q3), n
134 (32-350)
61
134 (26-370)
39
167.5 (32-308)
22
0.561
*P-value from a log-rank test
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CONCLUSIONS & LESSONS LEARNED
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Conclusions from Data
• MDR-TB IP quality indicators are similar among patients initiated in a task sharing model.
• No difference in risk for negative outcomes was noted based on provider type suggesting task sharing may be a human resource solution to improve access to care in MDR-TB/HIV co-infection.
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Implementation Science Lessons Learned
• Task sharing = equivalent, although not ideal outcomes
• Increase # of new initiations per week– 6 in baseline period to 18 in NI-MDR period
• CNP see’s all patients at triage
• Implementation of baseline physical exams and symptom screening on 100% of CNP patients
• Increase in community-based management– Less than 10% in baseline period to 29% in NIT period
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Nurses Stepping Up to Increase Access
to Care
Individual ResourcesTaxi availability Health status
Clinician competenceDiagnostic Capability
Bed capacityHCW availability
What if the CNP could start care here?
What if a MDR-TB center transforms to a center of
excellence?
What if a patient can have direct timely
diagnosis and linkage to care?
What if the provider has been trained to care at the hospital,
clinic or home?
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Acknowledgements
• Medical Research Council– Martie van der Walt
• National Department of Health DR-TB Directorate
– Norbert Ndjeka– Pamela Richards – David Mamjeta
• KwaZulu-Natal Department of Health
– Jackie Ngozo– Bruce Margot
• Ugu District Department of Health
– Ntombasekaya Mlandu – Bheki Shazi
• Murchison & KGV Hospitals– Simi Lachman & Iqbal Master– Marge Govender-Singh– BL Ngesi
• Johns Hopkins University– Louise Walshe & Jeane Davis – Chakra Budhathoki– Rachel Kidane, Keya Joshi, Katrina
Reisner, Maria Brown
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