McGill nursing student reports on HIV Care and Treatment at TANWAT Hospital

Update for Highlands Hope

I thought it might be interesting for me to share about my work in the Care and Treatment Centre (CTC) at TANWAT. The CTC is the clinic for following patients who have tested positive for HIV through voluntary counseling and testing (VCT). The Tanzanian government trains CTC staff and provides the antiretroviral (ARV) medications that are dispensed free of charge to patients that are eligible.

The eligibility criteria in most parts of Africa is a CD4 count of less than 200, which is very low comparative to high income countries where many more people have access to ARVs. Once a patient starts antiretroviral therapy, they need to take this medicine every day for the rest of their life. If they stop the medication for a bit, the chance is high that the HIV virus will become resistant to one of the drugs, and this has huge public health implications particularly where HIV prevalence rates are high.

There is a lot of work involved in following patients who are taking medication for life. Lab tests must be run regularly to ensure that the medication isn't harming the patient's liver and also to ensure that the medication is being effective (ie. improving the patients immunological status). Many patients have side effects from medications or get other opportunistic infections. These are all aspects of the monthly follow-up sessions that the nurses do with patients.

A typical day at the CTC usually has 2-3 nurses staffing it and seeing 30-50 patients. Each patient will have a check-in meeting with a nurse, who will determine if the patient's therapy is progressing as normal or if they are experiencing any other health issues and would need to see the doctor. In their CTC training, nurses are educated on common side effects and which medications should be prescribed to manage these. This makes the clinic fairly nurse independent, with most patients only being seen by the nurses. After this interview, they meet the dispensing nurse who provides the medications they are to take and also the teaching and adherence reinforcement.

One issue that I have seen is the amount of paperwork that the nurses have to fill out at the CTC. The antiretroviral medications are provided by the government and strictly regulated. When they are dispensed to a patient, the patient must sign in a register that they are receiving them and the nurse must countersign that they are dispensing. Each patient also goes into a register of patients (no matter whether they receive ARV drugs). At the end of the day, each patient's visit is again tracked in registers that record the history of every patient. All of this paperwork thus far is by hand, and it is the nurses who complete it.

A new addition to the CTC is that the government now wants to track the patients using a computer database. So all of the patient charts are being entered into the computer. This is in addition to the paperwork that the nurses are already doing (which usually takes at least a couple of hours at the end of the clinic day). Some of the nurses have received computer training, however most have not. Even the nurses who have had basic computer training are not used to regularly using a computer and so the speed of entering patient visits into the computer is not very fast.

For an outside observer, it seems like an unfortunate use of the highly skilled nurses time when a few hours of every day is spent doing paperwork. In Canada, these activities would be completed by a data clerk. But is also a demonstration to me of the fact that even the best of ideas for how to help with the HIV epidemic are not necessarily easy to implement. There is a lot of capacity building that needs to go along with it. The addition of a computer tracking system is adding several hours of data entry to each CTC day, and with no additional training for the nurses who have to do this process. The benefit of the computer eventually is obvious, they will be able to see which patients are attending the clinic as they should be, which have not come for several months (thus lost to follow-up), as well as more detailed tracking such as which side effects are most common, etc. But when the nurses are already over-worked and spending many overtime hours at the CTC, it seems to me that the transition to using the computer is not going to be as hoped.

Another interesting CTC-related activity that I was fortunate enough to join Betty at this week is a meeting for 3 of the local CTCs (ie. three different hospitals in the area). At the meeting, the coordinators of respective CTCs shared information on how many clients they have registered and how many of these are "Lost to Follow-up", meaning that they have not come to appointments for some months.

The meeting was a brainstorming session to figure out what can be done to fix the situation and prevent future problems with attendance. A fantastic part of the meeting is that it was not only clinicians & volunteer groups that follow patients in home-based care as well as some of the local groups of people living with HIV had also been invited to share their perspective on what some of the issues are. This provided an excellent forum for all of the real issues to surface.

Some examples that arose are of people choosing traditional medicines instead, as well as a problem with a particular church who has been telling patients that they can heal them through prayer and thus they should stop their medicine. The plan is that this group of clinicians and community representatives will now meet regularly every few months to try to improve the care that they are providing and ensure that adherence to ARVs is as high as possible.

On a more personal note, I am finding it difficult to believe that we have already been here for almost 2 months! We are feeling very comfortable working with the health care team at TANWAT and have been made to feel incredibly welcome here. We only have 6 weeks left to go with our school work here and I'm already starting to feel sad at the prospect of leaving our new friends. That's yet another lesson for us with Global Health work.

Fortunately, we are encouraged to know that the link for TANWAT with McGill is a strong one and that more students will be coming to learn from the nurses here.