Nursing Workforce Optimization Study: A Multi-method Evaluation and Process Improvement Intervention for HIV Service Delivery in Tanzania and Zambia.

ABSTRACT: Nurses are often suboptimally used in HIV care, due to misalignment of training and practice, workflow inefficiencies, and management challenges. We sought to understand nursing workforce capacity and support implementation of process improvement strategies to improve efficiency of HIV service delivery in Tanzania and Zambia. We conducted time and motion observations and task analyses at 16 facilities followed by process improvement workshops. On average, each nurse cared for 45 clients per day in Tanzania and 29 in Zambia. Administrative tasks and documentation occupied large proportions of nurse time. Self-reported competency was low at baseline and higher at follow-up for identifying and managing treatment failure and prescribing antiretroviral therapy. After workshops, facilities changed care processes, provided additional training and mentorship, and changed staffing and supervision. Efficiency outcomes were stable despite staffing increases. Collaborative approaches to use workforce data to engage providers in improvement strategies can support roll-out of nurse-managed HIV treatment.

Evaluation of a New Field Epidemiology Training Program Intermediate Course to Strengthen Public Health Workforce Capacity in Tanzania.

OBJECTIVES: Sub-Saharan Africa faces a shortage of skilled epidemiologists to prevent, detect, and respond to health threats. Tanzania has implemented one of the first Centers for Disease Control and Prevention Field Epidemiology Training Program (FETP) Intermediate courses in Africa. This course aims to strengthen health workforce capacity in surveillance system assessment, outbreak investigation, and evaluation, prioritizing HIV control. We conducted an outcome evaluation of this new course. METHODS: We used a pre/post evaluation design using data from 4 cohorts of trainees who took the FETP Intermediate course from 2017 to 2020. We conducted knowledge assessments before and after each cohort and combined those results. Outcomes included knowledge and self-rated competency and trends in integrated disease surveillance and response (IDSR) data. We collected data through tests, field assignments, exit interviews, and data audits. We compared the mean change in pre-/posttest scores using linear regression and 95% CIs. We used content analysis to summarize exit interviews. RESULTS: Fifty-three FETP trainees from 10 regions enrolled in the FETP Intermediate course, and 52 (99.0%) completed the course. We found substantial increases in mean knowledge (44.0 to 68.0 points) and self-rated competency (4.14 to 4.43) scores before and after the course. Trainees evaluated 52 surveillance systems and 52 district HIV care programs, and 39 (75.0%) trainees participated in outbreak investigations. From before to after cohort 1, timeliness and completeness of IDSR reports increased from 4.2% to 52.1% and from 27.4% to 76.5%, respectively. Course strengths were quality of instruction, individualized mentoring, and practical skills gained. Challenges were mentor availability, limited time for data analysis practice, and balancing work and field assignments. CONCLUSIONS: The Tanzania FETP Intermediate course substantially improved trainee knowledge and helped to improve local data quality and reporting. This course is a promising model to strengthen subnational capacity to prevent, detect, and respond to public health threats in Africa.

The prevalence and pattern of skin diseases in relation to CD4 counts among HIV-infected police officers in Dar es Salaam.

Among HIV-infected individuals, skin diseases cause significant morbidity and are frequently the initial indication of immunosuppression. From an on-going cohort study to determine prevalence and incidence of HIV infection among police officers (POs) and their suitability for HIV vaccine trials, a sub-study was carried out to determine the prevalence and pattern of skin diseases among HIV-infected POs and relate this to their immunodeficiency status. Consenting HIV-infected POs and their age and sex-matched HIV-negative officers were assessed for presence and type of skin diseases at their workplaces. A questionnaire was used for data collection. Immunodeficiency was measured by plasma CD4+ lymphocytes using flow cytometry. Between November 1998 and 31 December 2000, 716 POs were assessed. Overall HIV-1 prevalence was 17.7% (127/716). One hundred and ninety-one POs (26.7%) had at least one skin diagnosis. HIV-infected POs had significantly higher (41.7%) prevalence of skin diseases than HIV-uninfected POs (26.4%), P = 0.002. Fungal infections were common in both HIV-infected and uninfected POs. Among the HIV infected, other common diseases were: herpes zoster (11.8%); pruritic papular eruption (PPE) (7.1%); seborrheic dermatitis (5.5%); and Kaposi's sarcoma (KS) (1.6%). KS and PPE were associated with severe immunodeficiency, with mean absolute (percentage) CD4+ counts of 75.5 cells/microL (4.0%) and 71.7 cells/microL (4.8%), respectively. The values for herpes zoster and seborrheic dermatitis were 271.1 cells/micronL (12.4%) and 206.3 cells/microL (11.3%), respectively. Skin diseases were common among HIV-infected POs. PPE and KS are markers of severe immunodeficiency due to HIV. PPE, herpes zoster and KS strongly suggest underlying HIV-related immunodeficiency and patients with these conditions should be counselled and tested for HIV.