Interventionalists' perceptions on a culture of radiation protection.

BACKGROUND: Occupational exposure to ionising radiation poses potential health risks to radiation workers unless adequate protection is in place. The catheterisation laboratory is a highly contextualised workplace with a distinctive organisational and workplace culture. OBJECTIVE: This study was conducted to understand the culture of radiation protection (CRP). METHODS: This study was a qualitative study and data were collected through 30 in-depth and 6 group interviews with 54 purposively selected South African interventionalists (interventional radiologists and cardiologists). The participants included a diversity of interventionalists who varied in sex, geographic location and years of experience with fluoroscopy. The transcribed data were analysed thematically using a deductive and inductive approach. RESULTS: 'Culture of radiation protection' emerged as a complex theme that intersected with other themes: 'knowledge and awareness of radiation', 'radiation safety practice', 'personal protective equipment (PPE) utilisation' and 'education and training'. CONCLUSION: Establishing and sustaining a CRP provides an opportunity to mitigate the potentially detrimental health effects of occupational radiation exposure. Education and training are pivotal to establishing a CRP. The time to establish a culture of radiation in the catheterisation laboratory is now.

Workplace interventions to reduce HIV and TB stigma among health care workers - Where do we go from here?

Fear of stigma and discrimination among health care workers (HCWs) in South African hospitals is thought to be a major factor in the high rates of HIV and tuberculosis infection experienced in the health care workforce. The aim of the current study is to inform the development of a stigma reduction intervention in the context of a large multicomponent trial. We analysed relevant results of four feasibility studies conducted in the lead up to the trial. Our findings suggest that a stigma reduction campaign must address community and structural level drivers of stigma, in addition to individual level concerns, through a participatory and iterative approach. Importantly, stigma reduction must not only be embedded in the institutional management of HCWs but also be attentive to the localised needs of HCWs themselves.

Integrating HIV care into primary care services: quantifying progress of an intervention in South Africa.

BACKGROUND: Integration of human immunodeficiency virus (HIV) care into primary care services is one strategy proposed to achieve universal access to antiretroviral treatment (ART) for HIV-positive patients in high burden countries. There is a need for controlled studies of programmes to integrate HIV care with details of the services being integrated. METHODS: A semi-quantitative questionnaire was developed in consultation with clinic staff, tested for internal consistency using Cronbach's alpha coefficients and checked for inter-observer reliability. It was used to conduct four assessments of the integration of HIV care into referring primary care clinics (mainstreaming HIV) and into the work of all nurses within ART clinics (internal integration) and the integration of pre-ART and ART care during the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) trial in South Africa. Mean total integration and four component integration scores at intervention and control clinics were compared using one way analysis of variance (ANOVA). Repeated measures ANOVA was used to analyse changes in scores during the trial. RESULTS: Cronbach's alpha coefficients for total integration, pre-ART and ART integration and mainstreaming HIV and internal integration scores showed good internal consistency. Mean total integration, mainstreaming HIV and ART integration scores increased significantly at intervention clinics by the third assessment. Mean pre-ART integration scores were almost maximal at the first assessment and showed no further change. There was no change in mean internal integration score. CONCLUSION: The questionnaire developed in this study is a valid tool with potential for monitoring integration of HIV care in other settings. The STRETCH trial interventions resulted in increased integration of HIV care, particularly ART care, by providing HIV care at referring primary care clinics, but had no effect on integrating HIV care into the work of all nurses with the ART clinic.

Integration of HIV care into primary care in South Africa: effect on survival of patients needing antiretroviral treatment.

BACKGROUND: Integration of HIV care into primary care is a potential strategy to improve access to antiretroviral therapy (ART) in high-burden countries. This study was conducted to determine the effect of integration of HIV care on the survival of patients needing ART. METHODS: A questionnaire was used to measure the integration of HIV care into primary care during a randomized controlled trial of task shifting and decentralization of HIV care in South Africa. Cox proportional hazard ratios (HRs) were estimated for the effect of 5 different integration scores (total, pre-ART, ART, mainstreaming HIV, and internal integration) on the survival of patients with CD4 count ≤350 cells per microliter and not yet on ART. RESULTS: A total of 9252 patients were followed up for 12-18 months. Cox proportional HRs adjusted for patient and clinic characteristics showed decreased risk of mortality in clinics with high scores for total integration [HR, 0.97; 95% confidence interval (CI), 0.95 to 0.98; P < 0.001], ART integration (HR, 0.94; 95% CI, 0.90 to 0.99; P = 0.013), and internal integration (HR, 0.97; 95% CI, 0.95 to 1.00; P = 0.041). Analysis of the effect of component scores adjusted for patient characteristics only showed decreased risk of mortality in clinics with high scores for total integration (HR, 0.97; 95% CI, 0.94 to 1.00; P = 0.032), pre-ART integration (HR, 0.92; 95% CI, 0.85 to 0.99; P = 0.027), ART integration (HR, 0.95; 95% CI, 0.93 to 0.98; P = 0.001), and mainstreaming HIV (HR, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). CONCLUSION: In a context of task shifting and decentralization of care, integration of HIV care into primary care is associated with improved survival of HIV-positive patients needing ART.

Task shifting and integration of HIV care into primary care in South Africa: the development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention.

BACKGROUND: Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial. METHODS: DEVELOPING THE INTERVENTION: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services. RESULTS: COMPONENTS OF THE INTERVENTION: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process. DISCUSSION: Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout.The STRETCH trial is registered with Current Control Trials ISRCTN46836853.

Towards universal ARV access: achievements and challenges in Free State Province, South Africa.

OBJECTIVE: To study the progress and challenges with regard to universal antiretroviral (ARV) access in Free State Province, South Africa. METHODS: Data from the first 4 years of the public sector ARV roll-out and selected health system indicators were used. Data were collected from the public sector ARV database in Free State Province for new patients on ARVs, average waiting times and median CD4 counts at the start of treatment. Information on staff training, vacancy rates and funding allocations for the ARV roll-out was obtained from official government reports. Projections were made of expected new ARV enrolments for 2008 and 2009 and compared with goals set by the National Strategic Plan (NSP) to achieve universal access to ARVs by 2011. RESULTS: New ARV enrolments increased annually to 25% of the estimated need by the end of 2007. Average waiting times to enrolment decreased from 5.82 months to 3.24 months. Median CD4 counts at enrolment increased from 89 to 124 cells/mm3. There is a staff vacancy rate of 38% in the ARV programme and an inadequate increase in budget allocations. CONCLUSION: The current vertical model of ARV therapy delivery is unlikely to raise the number of new enrolments sufficiently to achieve the goals of universal access by 2011 as envisaged by the NSP. The Free State is implementing a project (STRETCH trial) to broaden the ARV roll-out in an attempt to increase access to ARVs.

Caring for the caregivers: models of HIV/AIDS care and treatment provision for health care workers in Southern Africa.

Rollout of antiretroviral therapy (ART) has been successfully initiated in many countries, but concerns have been raised about the ability to meet treatment needs in areas where there is a high prevalence of human immunodeficiency virus (HIV) infection/acquired immunodeficiency syndrome (AIDS) and where there are severe deficits in human-resource capacity. Many health care workers in resource-poor areas are experiencing burnout, struggling with external and internal stigma, failing to access HIV testing and treatment early, and subsequently becoming sick and dying of AIDS. Although the human-resource deficit is a well-recognized problem, little has been written about the programs that have been established to provide treatment for HIV-infected health care workers. In the present article, we describe staff care programs at McCord Hospital in Durban, South Africa; Mseleni Hospital in northern KwaZulu-Natal, South Africa; and the Tshedisa Institute in Gaborone, Botswana. These programs provide convenient, confidential, and holistic care for HIV-infected health care workers and health care workers affected by caring for HIV-infected patients. All 3 programs have noted that, among health care workers, there is increasing acceptance of counseling, testing, and treatment. We propose that there is an urgent need for the development of HIV/AIDS care and treatment programs for health care workers that remove barriers to access, provide confidentiality in testing, are conveniently located, and are integrated with tuberculosis programs and other treatment services.