1. 1 Using Clinical Mentorship to build the capacity and confidence of Zimbabwean nurses to initiate ART Dr. Tafara Moga Care & Treatment Technical Advisor EGPAF 29 August 2014

2. Outline Background Setup and Implementation Results Recommendations Acknowledgements Opportunities for Private practitioners

3. Background National PMTCT program was started in 1999 and the ART program was launched in 2004 Despite decentralization efforts, only 15% of ANC facilities were ART initiating sites by December 2012 (MOHCC, 2013) ART initiation for pregnant women and children were largely doctor-led This contributed to; – Low ART coverage for HIV+ pregnant women eligible for ART – 40% as of Dec 2012 (MOHCC, 2012) – Low pediatric ART coverage - 43% as of December 2012 (MOHCC, 2014)

4. The “knowledge – practice gap” Didactic in-service training Clinical Practice, Competency & Proficiency Despite in-service trainings, nurses cite lack of confidence as a key barrier to initiating ART Unclear mechanism to close this gap

5. Definition of Clinical Mentorship Clinical mentorship is a system of practical training and consultation that fosters on- going professional development to yield sustainable high-quality clinical care outcomes. (WHO)

6. Key Operational Definitions Mentee: nurse who received training in HIV management and working at the mentee site. Mentor: a practicing clinician with considerable expertise or experience in HIV management (OI/ART) Mentee site: a site with functional MNCH unit which was not offering ART initiation services before CM

7. Objectives Primary Objective – To build a pool of nurses equipped with skills and confidence in initiating HIV positive pregnant women and pediatric patients on ART Secondary Objectives – To improve the motivation of nurses by providing effective technical support. – To increase the number of sites accredited to initiate clients on ART

8. Steps taken in Setting up the Clinical Mentorship Program Sensitization of provincial & district managers Identification of mentee sites & mentees Identification of mentors Identification of Centers for Attachment Training of Mentors Clinical Attachment of Mentees Clinical Mentorship (visits, telephonic)

9. The roles of a mentor To provide ongoing coaching and mentoring to less-experienced HIV clinical providers (nurses) by assisting in case management responding to questions reviewing clinical cases providing feedback

10. Composition and Functions of mentor teams. Doctor – Clinical case management (drug regimens, when to initiate ART, when to stop therapy or refer patients, possible drug side effects etc) OI-nurse – Counseling (adherence preparation and support), ART M&E tools Pharmacy technician – Stock management (pharmacy ART register, drug storage, the CR form and good pharmacy practice).

11. Methodology MDT of mentors visited mentee sites fortnightly for a 3 month period. Two mentee sites per district covered per period. – As mentors have other roles to play at their stations. Mentors were supported with fuel, allowances for meals and airtime.

12. Activities during a Clinical Mentorship visit Mentorship visit is one full day by the whole team per site. In between visits mentorship continued telephonically Observe Case management and reinforce skills Review patient monitoring cards and registers Clinical case review meeting Document work including recommend ations

13. Mentorship Tools Clinical mentorship was guided by 5 tools – Tool 1: Clinical competency assessment (pre- mentorship) – Tool 2: Mentee’s Log book – Tool 3: Mentors’ monthly report – Tool 4: Mentee’s Evaluation of the mentors – Tool 5: Clinical competency assessment (post-mentorship)

14. Expected Outcomes Primary outcome A pool of nurses equipped with skills and confidence to appropriately initiate, manage and follow up patients on ART within MNCH settings. Secondary Outcomes i.Increased ART coverage for eligible PMTCT mothers ii.Increased pediatric ART coverage iii.Reduction in lead time from eligibility to ART initiation iv.Increased number of sites accredited to initiate ART v.A family centered approach to ART services within MNCH vi.Increased retention in care & reduced LTFU

15. Sustainability and Continuity After the 3months of intensive mentoring, we recommend that mentorship be incorporated into routine/ scheduled site support by the DHE.

16. 16 Results

17. Distribution of mentee sites ProvinceNumber of Districts Number of Mentee sites Number of Mentees Mash. East91733 Manicaland71430 Mat. North71423 Midlands81637 Masvingo71444 Mash. West71435 Mat. South71428 Total52103230

18. ART uptake among pregnant women at mentee sites by province: 2012 and 2013 Comparison Source: EGPAF PMTCT Program data

19. Comparison of Trends in uptake of ART Initiation in ANC between Mentee and Non-mentee sites

20. Comparison of mean ART uptake in mentee and non-mentee sites PeriodART Uptake in ANC (%) Non-mentee sites (n = 447) Mentee sites (n = 103) Difference Pre- mentorship21276 Post- mentorship365822 Difference153116* *p- value= 0.048

21. Results 94% of mentees reported having confidence to manage all types of patients on ART 168 Children <2years old were appropriately initiated on ART at the mentee sites during the intervention period Clients initiated on ART by mentees include pregnant and lactating women, general ART clients and children < 2years 92% of the 103 mentee sites had been accredited as stand alone ART initiating sites by December 2013

22. Results Mentees reported a decrease in lead time to ART initiation for all types of patients.

23. Conclusions Clinical mentorship is a feasible way of bridging the gap between didactic training and clinical practice. Clinical mentorship in HIV management is effective in building the confidence of trained nurses to initiate pregnant women and children on ART

24. Recommendations to the MOHCC To consider accelerating the roll out of clinical mentorship to support decentralization and expedite the roll out of 2013 HIV management guidelines. To consider adopting an integrated clinical mentorship approach (across programs) as an effective way to transfer knowledge into practice.

25. Opportunities for Private practitioners May be a source of mentors for HCW in the public sector – Volunteer your time at any local clinic May need mentoring as – Some are less experienced with adherence counselling (seen as less profitable) – Some may not be familiar with the latest national guidelines on HIV management Opportunity to get mentorship from central hospitals and other private places

26. Acknowledgements Ministry of Health and Child Care UK Department for International Development (DFID) Children’s Investment Fund Foundation (CIFF)

27. Towards virtual elimination of Pediatric HIV

28. “Tell me and I forget, teach me and I may remember, involve me and I learn.” – Benjamin Franklin

29. Input Process Output Outcome Impact Logical Framework # visits # mentor/visit # mentee hours Clinical Activities Clinical skills Results at program level # nurses mentored # nurses initiating ART # clinics providing ART Results at level of target population # patients initiated Type &/age of client initiated on ART % Retained In care Long term effects of the program Reduced LTFU Improved quality of life E-MTCT