Nurses Face New Challenges in South Africa

July 12th, 2011

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By , BSN, RN

In the country of South Africa, nurses are about to step into the role of primary care providers. A shortage of physicians and an over-abundance of patients is setting this new paradigm into motion, and the plan is the brainchild of nurse-researcher at Johns Hopkins University School of Nursing in Baltimore, Maryland.

In South Africa, there is an increasingly common and hazardous situation where two co-occurring epidemics, called a syndemic, are resulting in the deaths of hundreds of thousands of people each year. South Africa has the highest population of people in the world with HIV/AIDS, 5.6 million in 2009. Tuberculosis, specifically multi-drug resistant tuberculosis (MDR-TB), is the number-one cause of death in South Africa. The number of people suffering from both diseases is staggering.

It is a vicious cycle, as people living with HIV have a much greater risk of developing tuberculosis because of their weakened immune systems, and TB has the ability to accelerate the course of HIV/AIDS. South Africa has one of the highest co-infection rates in the world. Despite accounting for just 0.7% of the global population, the country accounts for 28% of the world's people living with both HIV and TB.

Adding to the problem, like everywhere on the African continent, South Africa has a severe shortage of physicians. This lack of medical care combined with the ever escalating syndemic of TB and HIV/AIDS presents unprecedented challenges for healthcare. "How can we work effectively and efficiently in a system when a physician can't see patients more than once a week, even when they're inpatients?" questions Jason E. Farley, PhD, MPH, CRNP.

"In South Africa, 60 to 70% of people with drug-resistant forms of TB also have HIV co-infection. It presents a large burden. We need to fight these diseases simultaneously," says Farley, a researcher and assistant professor at the Johns Hopkins University School of Nursing, as well as a nurse practitioner in the Division of Infectious Diseases within the Johns Hopkins AIDS Service.

Nurses Take the Lead

Farley's answer? Get nurses involved. In May 2010, Farley received a $274,000 grant from the Medical Research Council of South Africa to fund a community-based research study, titled Co-INFECT Project: Nurse Initiation of MDR-TB; A Clinic Cohort Study.

One of the project's studies will focus on South African nurses, in a primary care setting, being trained to diagnose MDR-TB in HIV patients and then referring them to an MDR-TB specialty center. At the specialty center (Murchison Hospital), patients will be followed by trained primary health care nurses supervised by physicians.

This represents a new role for nursing in South African hospitals. Never before have the nurses taken the lead role in following the care of this patient population. It's a shift Farley believes makes sense.

"Patients don't do well because physicians aren't available. The longer you have to wait, the more advanced the disease becomes, the weaker the patient gets," Farley says. "If nurses can get equivalent treatment outcomes, we can improve access to care."

Study Tests Case Management Model

Another phase of the CO-INFECT project will study the impact of a nurse case management (NCM) model on the MDR-TB treatment outcomes. The study will evaluate the treatment outcomes by comparing the cure/treatment completion rates at a control site versus the same rates at the nursing intervention sites.

The primary care nurses trained as part of this project will perform a specific set of tasks, referred to as the "bundle of interventions." The participating nurses will follow the patients along the path of care, monitor patient related events (adverse drug events, adherence to drug regimens), track patients as they navigate the system, and other tasks. All their work will be measured and monitored by the research team.

Farley points to the proven success of this NCM model in the U.S. "We've seen this [model] be successful for women undergoing breast cancer therapy, in HIV patients…we're going to translate this intervention into South Africa," he says.

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