Human capacity-building plan for scaling up HIV/AIDS treatment

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Objective: publish core training packages

At the country level, the expansion of antiretroviral treatment to 3 million people by 2005 cannot be achieved by one professional group alone but only if a range of groups work hand in hand.

These include those directly involved in the treatment process at the point of service delivery (such as health care workers, counsellors, nurses and medical officers) and those providing critical adjunct services (including pharmacy, laboratory and referral services). Equally important is the contribution of testing and counselling services, other entry points to antiretroviral therapy (such as treatment services for tuberculosis, sexually transmitted infections or injecting drug users) and the existence of skilled programme planners and managers. Finally, the community itself often takes on critical functions in supporting treatment.

Both the groups involved in antiretroviral therapy and the task distribution among these groups vary between regions and countries, depending on the existing health infrastructure and resources. For example, whereas many countries in Africa report an absolute shortage of health personnel and therefore give priority to expanding the workforce and devolving tasks, countries in eastern Europe are challenged to upgrade the skills of the substantial existing medical workforce and to explore new ways of delivering services to hard-to-reach populations.

Almost all countries planning to radically scale up antiretroviral therapy, however, experience a mismatch between the skilled individuals who are available and those who are needed to contribute to this goal, which necessitates massive expansion of existing training efforts. In this, countries are challenged to explore innovative methods of providing training, encouraging the use of multiple potential training providers and reaching a maximum number of trainees while minimally disrupting the ongoing provision of services. Further, training for antiretroviral therapy cannot occur in isolation but needs to be firmly embedded in a broader approach to HIV/AIDS prevention and care and support for people living with HIV/AIDS.

Some countries have already trained hundreds of professional and lay service providers, and national and international organizations have developed a variety of training materials for a number of groups. Many had to do so without technical support, resulting in delays, difficulty in identifying the most appropriate content and methods and, in some cases, suboptimal training results.

Strategic approach

Simplifying and standardizing treatment regimens has been considered a prerequisite for massively scaling up antiretroviral therapy. Likewise, WHO will work towards making available simple but appropriate training packages that can be easily adapted by in-country training providers. Such training packages will add value to existing efforts and facilitate the establishment of additional training opportunities.

WHO has already developed simplified antiretroviral therapy guidelines and produced compatible HIV/ AIDS care guidelines for nurses, other multipurpose health workers and lay providers working at firstlevel facilitiesiii. WHO is also currently developing simplified and appropriate training packages that correspond to these guidelines.

Training packages will be standardized to WHO’s clinical and operational recommendations and focus on essential core competencies. At the same time, they will be flexible and adaptable to a range of different training contexts and modalities, such as residential short courses and in-service and pre-service training. These packages can be easily adapted by in-country training providers and may alternatively serve as a set of standards to which partners may adapt or develop other training courses.

Training packages will be developed in close collaboration between WHO headquarters and regional offices and partners that have already developed resources, many of which are members of the International HIV Treatment Access Coalition (ITACiv). Given the differences in task distribution between countries, training packages will focus on core competencies that are essential in team approaches to HIV/AIDS care and antiretroviral therapy at levels where the need for skilled personnel is greatest.

Training packages will be placed in the public domain and serve as tools for the ongoing expansion of training at the country level. Adapting training packages to local contexts is critical; they need to be in line with national delivery models and guidelines. WHO regional and country offices and partners active in each region will proactively support this process (see the objective on providing technical support for training). WHO will also support countries in establishing mechanisms that allow for training certification and quality control based on WHO standards (see the objective on establishing in-country certification of HIV/AIDS competence).

Training packages can also be used in the initial emergency expansion of pre-service training by targeting them to students prior to graduation. This phase should be initiated in parallel to revising written curricula, which is likely to be a longer-term process. Students can be assessed using the same WHO standards available for in-service training. This phase will require action plans at the national and institutional level that address the efficient training of teachers and clinical staff and the preparation of material for teaching and assessing students as well as clinical practice sites.

Finally, the use of the training packages will be embedded in the development of comprehensive and sustainable approaches to human resource development (see the objective on developing a national approach to training and human resources).

Activities and results

  • Compilation of existing resources. WHO and other international and national partners have already developed a number of resources that can immediately inform the development of training programmes. Available training material will be collected, reviewed and made available via the Internet and, upon request, through an international Capacity-Building Help Desk (see the objective on providing technical support for training).
    Involvement of partners. The Forum for Collaborative AIDS Researchv, in collaboration with the International HIV Treatment Access Coalitioniv, has initiated the development of a training resource inventory. WHO will support the continuation of this process and invite partners to share their training resources and to contribute to updating the inventory and making material available in the public domain.
    Service for countries. Countries and institutions can easily access a wide range of existing material online and obtain personal support in identifying the material most appropriate to their needs.
  • Development of WHO core training packages for in-service personnel. The development process will focus on training packages for the key competencies involved in chronic HIV/AIDS care and antiretroviral therapy at first- and second-level facilities. These core competencies include the integrated management of HIV/AIDS at first-level points of service delivery, provision of lay and community support for antiretroviral therapy, laboratory and pharmacy services, counselling and testing skills, team approaches to antiretroviral therapy and skills in planning, managing and evaluating programmes. Training packages will take a modular and task-based approach, facilitating their use for a variety of professionals involved in scaling up antiretroviral therapy. Training packages will be developed based on WHO guidelines, will build on existing training material and will discuss antiretroviral therapy in the context of comprehensive prevention, care and support for people living with HIV/AIDS.
    Involvement of partners. The developmental process will be closely coordinated with WHO regional offices, and partners will be invited to play an active role by sharing their expertise and their existing training material by participating in working groups and/or by drafting material on behalf of WHO.
    Service for countries. Training packages will be accessible to countries through the Internet or a WHO office. WHO regional offices and a network of partner institutions active in the region will provide active technical support for their use (see the objective on providing technical support for training). WHO will work with countries and institutions to certify trainees who have successfully participated in training activities based on the WHO training packages (see the objective on establishing incountry certification of HIV/AIDS competence).
  • Rapid development of pre-service training. Training packages can be used to support the immediate introduction of pre-service training for relevant professional groups and thus prepare them for later specialization as stipulated in national regulations. The initial phase should support targeted training for students prior to graduation without waiting to revise written curricula. In parallel, existing curricula should be revised and/or new curricula developed and approved by the appropriate bodies. Training should begin immediately using WHO standard courses and other courses modified to meet WHO standards (after rapid in-country adaptation for in-service and pre-service use), which should be complemented by technical seminars and reference materials. This will require action plans at the national and institutional level that address the efficient training of teachers and clinical staff and the preparation of materials for teaching and assessing students as well as clinical practice sites. WHO and partners should make available national medical and nursing school curricula that have already integrated antiretroviral therapy and HIV/AIDS care. Initially introduced in the later years of the academic programme, this material should be gradually be extended backwards and the new principles and concepts incorporated into earlier years, and written curricula should be fully revised.
  • Continued innovation of training techniques to increase efficiency. Just as operational guidance to the scaling up process itself requires continual review and refinement, so does the accompanying training material. Given that the emergency situation will not allow lengthy field testing, mechanisms for closely monitored early implementation of training packages will be developed and used to validate and improve training material. Innovative methods for increasing training efficiency must also be explored. Such techniques may include the use of video, skill stations, on-site detailing approaches, etc.
    Involvement of partners. Training providers will play a critical role in guiding the early implementation and refinement of training packages, and interested institutions are invited to participate. A collaborative project on video development has already been initiated.
    Service for countries. Countries will be able to work with material from the moment it is published, and frequent updates will be issued to incorporate feedback from the field level.

Indicators and milestones