The scale up of NIMART at one primary health
clinic was fraught with challenges and opportunities, according to Dr Sundesh
Maharaj, who presented the experience at the Nkwenkwezi Primary Health Clinic in the Eastern Cape, which was
assisted by Africare, another US-based NGO supporting
capacity and other development needs in Africa.17
Africare’s Injongo Yethu
project uses roving clinical support teams to support comprehensive HIV/AIDS
programmes in the Eastern Cape,
including 24 sites in Makana District, 24 sites in Nkonkobe District and 31
sites in Lukhanji District. It employs a clinical systems mentorship model
approach targeted at the provider, team and site level.
The Nkwenkwezi Clinic is a primary health clinic with a catchment area of
4600 in Nkwenkwezi township near Port Alfred. The ANC prevalence in the Eastern Cape is around
23%. Onsite HIV counselling and testing conducted at the Nkwenkwezi Clinic, from October 2010 to March 2011 found a HIV prevalence
of 9.3%amongst all tested clients, and a 20% prevalence amongst
Clinic staff includes a clinic manager, five full-time professional
nurses (three of whom have been trained on NIMART, one sessional doctor who
visits the clinic once a month (3 hour sessions per visit), one pharmacy
assistant, one auxiliary pharmacist, one data capturer, and one cleaner.
Clearly, there was limited doctor support for NIMART at the clinic, limited
infrastructure and space constraints.
Nevertheless, the clinic was approved as a
NIMART site as of 1 April 2010, with two feeder sites: PAL2 and Station Hill
Clinics; while the Port Alfred Hospital serves as the referral centre and
facilitates the supply of ARVs. Lab services are provided by the NHLS Service via
a courier who comes twice daily to collect specimens and deliver results.
Support for people living with HIV includes a support group that meets onsite
weekly, a dietitian available at the referral hospital who also visits the
clinic weekly, and a social worker, available via hospital referral.
Consultations and planning meetings were held
with the site management staff, including the district HIV Programme Manager,
Site Clinic Manager/Supervisor, the Site Multidisciplinary Team and key staff
from the referral hospital to discuss how to support NIMART.
The plan was to hold fortnightly onsite
multidisciplinary team meetings on the initiation of new clients on ART. A
client initiation checklist was provided to ensure comprehensive preparation
for ART initiation — including clinical and social parameters (such as
adherence support). There would be a doctor review of patients conducted at
months 6 and 12, with complicated cases reviewed as they arose, including
participation of staff from the two feeder clinics.
There would also be monthly HIV stakeholder
meetings including the PHC’s and key referral hospital staff and support
services (the social worker, dietitian, and pharmacy staff) to discuss
referrals, drug supply, support services, revisions to guidelines, and case
As a result, there was an increase in
provider-initiated counselling and testing from 50% of patients in October to
90% in March, an increase in cases discussed, roughly 77% of whom have since
been initiated on ART. So far, a total of 96 patients have been started on ART
including twelve who were pregnant, six children and nine TB-coinfected
patients. Four individuals started on ART have since passed away.
Dr Maharaj highlighted the CD4 cell counts at
which patients are now being initiated on ART. At the start of the programme,
there was a sudden drop in the CD4 cell count at initiation, as the most ill
patients who were waiting were initiated on treatment, but since September last
year the CD4 cell count at initiation has been a median of 134.6, which is
substantially higher than the norm in South Africa (~100).
Treatment in Lower-Income Countries (ART-LINC) collaborative has shown that the
most important predictor of a patient’s CD4 response on ART is the baseline CD4
count at the time treatment is initiated,” he said.
so, the infrastructure and shortage of human
resources continue to challenge the clinic, which now has added stress due to
the high influx of patients from the hospitals to the ‘new’ more convenient
NIMART sites, according to Dr Maharaj.
the nurses need to be trained in NIMART with certification,” he said. In
addition, there continues to be limited doctor support, and the number of
patients who must be reviewed every six months is simply getting unwieldy for
just one doctor to manage. Another issue is there are poor community links to
support and follow-up on patients — who are very mobile between clinics.
More mentorship and supervision will be needed to make NIMART sustainable
at this and similar clinics, Dr Maharaj believes, He said that clinic
supervisors will need capacity development to act as mentors, with more nurse
mentor support from the Department of Health. Finally, they will need to
arrange more outreach support visits with hospital doctors.