A nurse demystifies the initiation of treatment in infants with HIV at the Paediatric AIDS Treatment for Africa Forum

Sister Martha Mashele at the Paediatric AIDS Treatment for Africa Forum in Gaborone, Botswana

“A nurse can initiate antiretroviral therapy (ART) and treat children with HIV, a common, manageable paediatric condition,” said Sister Martha Mashele, who shared how she overcame her fears and empowered herself to initiate ART and thus, save the lives of children with HIV, before a crowd of doctors, nurses, pharmacists and counsellors gathered at the Paediatric AIDS Treatment for Africa Forum held in Gaborone, Botswana in November 2011.

PATA Forum

PATA is a network of paediatric care and treatment units from Africa that has joined together to share their experiences, as individuals and as teams, working to expand access and improve the quality of healthcare provided to children infected with HIV and their families. In addition to yearly regional meetings, PATA holds an annual PAN-African Forum, with both lectures and interactive sessions to help participants share their knowhow, learn from each other, and get ideas for quality improvement projects they plan to implement when they return home to their facilities (see last blog entry).

The Forums have been going on for several years now, and many of these projects have been implemented, some encountering and generating new ideas, and some achieving impressive results. Teams have a chance to describe both successes and setbacks in an 8-minute presentation during a session called The Speaker’s Corner. In the case of Sister Mashele, who works at the Empilweni Support and Research Unit, of Rahima Moosa Mother and Child Hospital in Gauteng, Johannesburg, the Speaker’s Corner offered a rare opportunity to tap into the expertise and wisdom of one of those healthcare workers who rarely make it into the spotlight, but who have learned a lot over years of service.

“The problem is that the infant mortality figures remain high and continues to rise from the statistics that we’ve seen,” said Sister Mashele. In part this is due to poor linkages between ART and prevention of parent-to-child HIV transmission programmes with MCH (maternal and child health) programmes.

But Sister Mashele focused on the barriers presented by fears of nurses that caring for children is a complicated specialty they haven’t been adequately trained to perform.

“There’s a perception that children should only be seen by a paediatrician – even among doctors. Infants are perceived to be delicate and fragile and no nurse or doctor wants [to be responsible] for this,” she said. As a result both nurses and doctors lack confidence in dealing with paediatric patients.

“Even most doctors are also not trained in paediatric HIV management, or they lack experience in dealing with paediatric patients, so this makes providing support for nurse-initiated management (NIMART) very problematic,” she said. “For us as nurses, we never know when it is okay for us to initiate, and there are also concerns about the management of side-effects.”

To remedy this for herself, Sister Mashele gathered key tools together to increase her knowledge and confidence, namely the IMCI chart booklet because the IMCI/NiMART approach to infant diagnosis and ART Management is being used in South Africa, as well as the National Paediatric HIV Management guidelines.

“Then I started seeing paediatric patients, with guidance/mentorship from other health care providers in the clinic and telephonic support,” she said.

Through this process, she and her colleagues realised that it was difficult for nurses to get the required information from the doctors they were working with or anywhere else. So an NGO Sister Mashele worked for, Enhancing Children's HIV Outcomes (ECHO), later in collaboration with South to South, developed tools that can be used by healthcare providers in a clinic situation such as the “Paediatric HIV care and treatment: A toolkit for South African healthcare workers.” (A current version is available on www.teampata.org/phct_kit.asp).

They also discovered that mentors were difficult to find since there were few nurses experienced in treating children with HIV at the time. So she and her colleagues concentrated on mentoring nursing colleges and nurse clinicians.

“The nursing colleges tutors were very happy to be trained in this because now they could include this in their curriculum when teaching the nurses. In addition, my colleagues mentored other MOs, pharmacists, dieticians and counsellors using a multidisciplinary team approach,” she said.

But she also shared her personal experiences caring for children with HIV.

“Nurses can treat children with HIV and their ability to manage HIV in children demystifies HIV,” she said. “When we see improvement in infant’s wellbeing after we initiate them, it builds up our confidence. The more we initiate and manage the infants, the more confidence we get because you must know that practice makes perfect. It becomes easier the more one does it.”

And whenever they are unsure of what to do in a particular case, the nurse can ask a mentor/trainer, refer to manuals/guidelines or refer up to the next level of care.

She added that nurses are generally the first point of contact the child has with the healthcare system, and in most sub-Saharan African settings, they may never see a doctor. She stressed the fact that even though HIV is a common and manageable illness, it is also a deadly one, so it is vital that the nurses make use of the opportunity to get children with HIV on ART.

“Infants with HIV are fast progressors – quick action saves lives. And in addition to decreasing morbidity and mortality, infants initiated early before becoming sick respond much better to ART,” she said.

Thanks to sr Martha. I wish I could read this to most nurses out there who still have a fear of initiating ART. I've just found very shocking stats in SA of nurses who were trained on NIMART vs those who initiate. People need confidence in what they do.

Just goes to show what are difference nurses can make in healthcare when they have the knowledge,skills and a change in attitude plus having confidence. Kudos Sr. Martha

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