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Measuring the Outcomes of a Comprehensive HIV Care Course: Pilot Test at the Infectious Diseases Institute, Kampala, Uganda
Global Health Sciences Literature Digest
Published December 6, 2006
Journal Article

Weaver MR, Nakitto C, Schneider G, Kamya MR, Kambugu A, Lukwago R, Ronald A, McAdam K, Sande MA. Measuring the Outcomes of a Comprehensive HIV Care Course: Pilot Test at the Infectious Diseases Institute, Kampala, Uganda. J Acquir Immune Defic Syndr. 2006 Nov 1;43(3):293-303.

Objective

To evaluate the effect of a four-week course for African doctors on comprehensive management of HIV, including use of ART.

Study Design

This is a pre/post-study design to evaluate the effectiveness of HIV/AIDS clinical training on medical doctors' practice; evaluation occurred by clinical examination at the beginning and end of the course, and again three to four months later. A telephone survey was administered at one-month follow-up.

Setting

The training was provided by the Infectious Disease Institute (IDI) at Makerere University in Kampala, Uganda during 2004-2005.

Participants

All training participants were African medical doctors; the majority were Ugandan. There were a total of 71 physicians in four cohorts who attended the trainings; on average, they each treated 48 HIV patients/week; 26% worked in referral hospitals, and 35% worked in district hospitals.

Intervention

A four-week course on comprehensive management of HIV, including the use of antiretroviral therapy (ART) was taught by the Faculty of Medicine at the Infectious Disease Institute, Kampala, and by two physicians from the Infectious Disease Society of America. The course consisted of case discussions and classroom sessions covering the epidemiology, basic science, and clinical manifestations of HIV; laboratory diagnosis and management of opportunistic infections; malaria; mental health; pediatric care; ART; HIV prevention; and HIV/AIDS research.

Primary Outcomes

The following main outcomes were measured: 1) clinical skills (clinical care, patient management, professionalism, and interpersonal skills) assessed by observing the examination of patients pre- and post-course, and during a follow-up session three months later; 2) clinical and training activities, monitoring of HIV and criteria for ART initiation, assessed by telephone survey.

Results

The evaluation was limited to those doctors who lived in Uganda. For the clinical exam, 35 of 54 trainees (65%) from the last three cohorts agreed to participate. For the telephone survey, 47 of 71 trainees (66%) from all four cohorts agreed to participate. Clinical examination was performed on 14 of 16 (88%) alumni who participated in the follow-up session. For the pre/post-test evaluation, statistically significant improvement was evident on 11 of 17 measures, and scores were the highest on "establishing rapport," "professionalism," and "appropriate procedures." When comparing post-test scores to follow-up scores, there was significant improvement in three areas: "patient advice," "development of a follow-up plan," and "listening to patients." Trainees participating in the telephone survey were asked about the last HIV-positive patient they saw. Fifty-three percent did not know whether their patient’s weight had changed since the last visit, and 28% did not know if the patient was using contraceptives. Only 42% of telephone respondents answered the first pediatric HIV case correctly and only 13% answered the second case correctly. A greater percentage of 2005 alumni initiated and were monitoring ART compared to 2004 alumni. All alumni had conducted at least one training session for other health care providers.

Conclusions

The authors conclude that the course clearly improved clinical skills in caring for patients with HIV, and that most alumni had also trained others. However, knowledge of pediatric HIV care needs improvement.

Quality Rating

There are no recognized criteria by which to evaluate studies using a pre/post-test design. The authors note the following limitations: the study had a small sample size, and there was significant loss to follow-up. The authors state this made it difficult to detect significant differences in care practices. Also, performance on examination of clinical skills may not be representative of actual practice patterns.

In Context

This study evaluated a training course for HIV/AIDS management that used primarily interactive, clinic-based methods. Other evaluations of training programs have been done, including the United Nations Family Planning Association's HIV/AIDS intervention.(1) A review of RCTs of training interventions in Western countries has shown that didactic methods are usually not effective in changing physician practice,(2) although interactive methods including consultation appear to be much more effective.(3)

Programmatic Implications

With mounting evidence that interactive, rather than didactic, training is more effective in changing clinical practice, HIV training courses should try to incorporate a hands-on approach. Standardized evaluation procedures should also be established to determine if trainings are effective. Encouraging trainees to train others in the field can expand the impact of these courses; however, the value of such "train the trainer" methods should also be evaluated.

References

  1. United Nations Population Fund, Office of Oversight and Evaluation.
  2. UNFPA Support to HIV/AIDS-Related Interventions. Evaluation Report, 1999;16:25–30. [Word, 440K]
  3. Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999 Sep 1;282(9):867-74.
  4. U. S. Department of Health and Human Services, Health Resources and Services Administration. HIV/AIDS Bureau. Programs: The AIDS Education and Training Centers (AETC). Available at: http://hab.hrsa.gov/programs/factsheets/aetc.htm. Accessed April 30, 2006.