|Year : 2018 | Volume
| Issue : 4 | Page : 264-269
Capacity building in HIV/AIDS care in antiretroviral therapy center through open and distance learning
Biplab Jamatia, Tapan Kumar Jena
Health Sciences, School of Health Sciences, Indira Gandhi National Open University, New Delhi, India
|Date of Web Publication||14-Nov-2018|
School of Health Sciences, Indira Gandhi National Open University, Maidan Garhi, New Delhi - 110 068
Source of Support: None, Conflict of Interest: None
The number of people living with HIV (PLHIV) in India is 26.26 lakhs (18.00–27.85 lakhs) as per annual report 2016–2017 of the National AIDS Control Organization (NACO). Till September 2016, 361 care and support centers were functional, and a total of 10,70,928 PLHIV received care and support services. There are 528 functional antiretroviral therapy (ART) centers and 1108 linked ART centers across the country including 88 ART plus centers till September 2016. About 2000 trained doctors would be needed to man these facilities. It is planned that MBBS doctors with Postgraduate (PG) Diploma in HIV Medicine (PGDHIVM) shall be considered for the post of senior medical officer at ART centers. The PGDHIVM would help to standardize HIV Medicine training and also help to bridge the gap in trained workforce for ART centers. With the above background, Indira Gandhi National Open University developed a 1-year program on HIV Medicine for MBBS doctors, which is being offered through open and distance learning in collaboration with NACO with the objectives that the learner would be able to imbibe comprehensive knowledge on basic of HIV as related to details of management of HIV/AIDS in tertiary care setup, manage all complications as well as opportunistic infections due to HIV/AIDS at time of need, and recognize and handle emergencies related to HIV/AIDS and its complication and take bedside decision for management whenever is required. This program comprises 36 credits (1 credit = 30 study hours), which is divided into four theory and two practical courses. All learners have been provided a total of 20 blocks having 76 units along with three practical logbooks as learning materials for this program. There are 28 days of hands-on skill training in medical colleges identified as the center of excellence by NACO and another 30-day training in an ART center. The program was launched in 2012, and 122 candidates have successfully completed it so far.
Keywords: Antiretroviral therapy center, HIV/AIDS training, open and distance learning, postgraduate diploma in HIV medicine, school of health sciences
|How to cite this article:|
Jamatia B, Jena TK. Capacity building in HIV/AIDS care in antiretroviral therapy center through open and distance learning. CHRISMED J Health Res 2018;5:264-9
|How to cite this URL:|
Jamatia B, Jena TK. Capacity building in HIV/AIDS care in antiretroviral therapy center through open and distance learning. CHRISMED J Health Res [serial online] 2018 [cited 2018 Dec 10];5:264-9. Available from: http://www.cjhr.org/text.asp?2018/5/4/264/245458
| Introduction|| |
The estimated number of people living with HIV (PLHIV) in India was 21.17 lakhs (17.11–26.46 lakhs) in 2015 which stands at 26.26 lakhs (18.00–27.85 lakhs) as per annual report 2016–2017 of the National AIDS Control Organization (NACO). Children (<15 years) account for 6.54%, while females contributed around two-fifths (40.5%) of total HIV infections. Till September 2016, 361 care and support centers are functional, and a total of 10,70,928 PLHIV received care and support services. There were 528 functional antiretroviral therapy (ART) centers and 1108 linked ART centers across the country including 88 ART plus centers till September 2016. As per the United Nations Program on HIV/AIDS report of 2017, PLHIV who know their HIV status are 16 lakhs in 2016. Care, support, and treatment program provides comprehensive management to PLHIV which includes free ART, psychosocial support, and prevention and treatment of opportunistic infections (OIs) including tuberculosis (TB) and facilitates home-based care. Ten centers of excellence (COEs) and seven pediatric COEs provide tertiary level specialist care and treatment, i.e., second-line and alternative first-line ART, management of complicated OIs, and specialized laboratory services. Community care centers provide psychosocial support, ensuring drug adherence, treatment of OIs, and tracking the “lost to follow-up” cases. Link ART centers and ART plus centers have also been established for the decentralization of first-line and second-line treatment services.
Undergraduate MBBS curriculum as per the Medical Council of India (MCI) regulations on graduate medical education, 1997, did not specially mentioned about the knowledge and skills about the HIV and AIDS. Curriculum of MD in general medicine, a postgraduate (PG) training program of MCI, mentioned only about the pre and post test counseling for HIV and health education about AIDS in the section under communication skills. About 2000 trained doctors would be needed to manage and run the facilities, for example, ART clinic as per estimation done by NACO. The qualification for the senior medical officer (SMO) position in ART centers is MD while that for medical officer is MBBS. However, an inadequate number of MD doctors opt for the SMO post at ART center. Hence, it was envisaged that the MBBS doctors with PG Diploma in HIV Medicine (PGDHIVM) could be considered for the post of SMO at ART centers. The PGDHIVM would help to standardize HIV Medicine training and also help to bridge the gap in trained workforce for ART center. As per the sanctioned positions, there are two doctors in each ART facility, one doctor in each community care center and one doctor as incharge of link ART center (Integrated Counselling and Testing Center) who are directly involved in patient care and would be the potential candidates for the 1-year training program in “HIV Medicine.”
With the above background, the school of health sciences, Indira Gandhi National Open University (IGNOU), developed a 1-year program on HIV Medicine for MBBS doctors, which is being offered through open and distance learning (ODL) in collaboration with the NACO, Ministry of Health and Family Welfare, Government of India. The objectives of the program are to impart comprehensive knowledge and skills on the basics of HIV as related to details of management of HIV/AIDS in tertiary care setup, management of all complications as well as OIs due to HIV/AIDS at the time of need and recognition and ability to handle emergencies related to HIV/AIDS and its complication and take effective bedside decision for overall management as and when required. This program was launched in 2012 in three program study centers (PSCs).
| The Skills Training Model|| |
The practical hands-on training through ODL is imparted through pedagogically designed model having three steps at three levels [Table 1]., The tertiary level infrastructure, i.e., medical college, where academicians could be involved as counselors, provides the second step of learning process. Demonstration and discussion of all skills are carried out here. The involvement of secondary level health infrastructure, i.e., district hospital/ART center, where the subject specialists help the learners in repetitively performing the skills, guide them in practicing those skills which they have been taught at the tertiary level. The students could then manage patients at the primary level health setup or at any other setup where they are normally posted. This could also be a clinic/health setup run by the student himself where he/she tries to practice the skills, learned in higher setups, without any supervision.
|Table 1: Hands-on skills training model for health sciences of Indira Gandhi National Open University|
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In IGNOU parlance, the three levels of institutions are known as PSC, skills development center (SDC), and workplace (WP), respectively. For administrative purpose, the PSCs are linked with regional centers (RCs) which are part of the IGNOU establishments. The PSC becomes the nucleus of the program implementation process. The program incharge (PIC) is stationed at the PSC. He/she is a permanent faculty of the medical colleges with additional responsibilities of being the PIC. He/she primarily monitors the learning process of all students enrolled in his/her institution. The students are required to visit the PSC to attend the contact sessions for hands-on practical training. The end assessment examination is also conducted here. Every student has an option to select his/her nearest SDC. Not more than two students are allowed in any SDC.
If we dissect out the entire skills training process, then we can observe that theory related to the practical training is provided in self-learning materials (SLMs). Learners read the theory components of the practical skills at home. In medical college, hands-on skill training is provided by medical college faculty. For example, palpation of the liver is a skill that needed to be taught. Medical college faculty demonstrates the palpation of the liver to a group of students and then helps one or two students to palpate holding their hand. Then, the faculty asks some students to palpate liver in his presence. If the students succeed to palpate as per standard guidelines, then teacher asks the same student to practice the skill on more number of cases so as to build up confidence. In this skill training model, the supervision step is carried out at the SDC/ART centers. All doctors practice those skills at SDC under supervision of SMO of ART center, which they have been trained in the medical college. At the ART center, they also get exposed to practice skills under resource-constrained situation. Moreover, these are the facilities where they would actually be practicing after completion of training. After adequate practice, the students are again posted to the PSC (medical college). This gives a second opportunity to revisit the skills that they were demonstrated earlier. Hence, slow learners who might have faced difficulties in handling patients in resource-constrained setting are able to make up their learning deficiencies. As the program is aimed at working doctors, all students are able to hone their skill at their WP too.
| Course Details|| |
The 1-year PGDHIVM has been designed taking into consideration the needs of the learners and the model followed by IGNOU. As this program is for MBBS doctors, the skills that need to be imparted in this program have been identified as listed in [Table 2]. All activities, methodology of training, and duration of training for acquiring each of the skills have also been identified. Thus, the total duration for hands-on skill training has been further divided into four contact sessions according to the sequence in which these skills need to be imparted. All theory topics have been identified to support the learning of the identified skills. All the above activities were done in several rounds of meetings involving various experts at national level. In this program, the weightage given for both the theory and practical components is 50% each. The duration of the program is 1 year.
|Table 2: List of the hands-on skills, activities, methodology of training, and duration of contact sessions of PG Diploma in HIV Medicine program|
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All necessary skills have been incorporated in this training program so that the successful candidate can manage the ART center of NACO independently. There are 28-day training in the COE or the PSC for hands-on skill training and 30-day training in the SDC/ART center. The duration of each contact session in the PSC varies between 6 and 10 days depending on the skills allocated to the spell. The first, second, and fourth contact sessions are for 6 days and third contact session is for 10 days. Different activities in each day of different contact sessions were already given in [Table 2]. All learners as well as counselors were informed in advance about the different activities to be carried out in each day of the contact sessions. The duration of contact spells is kept short taking into the realistic picture that the working student can be away from his duty place for a limited period in one go. Students have to fill two logbooks for the two practical courses of the activities performed in the PSC. For 30-day training at SDC/ART center, allotment of center is made according to the residential location of the student so that least time is wasted form travel. Nearly 100% attendance in all contact spells in PSC and training in SDC/ART is mandatory.
The program is of 36 credits (1 credit = 30 study hours), which is divided into four theory and two practical courses. The SLMs for the program includes a total of 20 blocks (modules) having 76 units (chapters) along with three practical logbooks. All these materials are provided to students in the beginning of the session. Live interactive teleconferences are also conducted in identified months which are one-way video and two-way audio interactions. The students interact with the experts through telephone or SMS or fax. The duration of interaction of each session is 45 min.
COE as designated by NACO were identified as training center or PSC for this program. Every training center admits a maximum of 20 students to maintain learner–teacher ratio. Each PSC has minimum nine master trainers as academic counselor as designated by NACO which comprise four from internal medicine and one each from microbiology, dermatology, pediatrics, gynecology, and TB and lung diseases.
After the third contact session in PSC, learners undergo training for 30 working days in the ART center. The ART training centers are designated as SDC. Each SDC is allotted a maximum of two students only for the training purpose. As per plan, every student has to work up at least 30 cases and need to fill up logbook which includes six adult cases (3 cases of pre-ART and 3 cases of ART), six cases of pediatrics (3 cases of Pre-ART and 3 cases of ART), six cases of gynecology/pregnant women (3 cases of pre-ART and 3 cases of ART), three cases of HIV-TB, and three cases of HIV-OIs. The above-mentioned 24 cases are mandatory for every candidate. Attending the post-exposure prophylaxis (PEP) case(s) and 2nd-line ART cases is desirable if the cases become available at ART center. For the remaining six cases, candidates select any case as they like from ART center. All the case workups are to be duly signed by nodal officer and Senior Medical Officer (SMO)of ART center. Students need to report to nodal officer of the ART center and get a completion certificate from him after completion of SDC training. The SDC posting is mandatory only for nonsponsored candidates who do not have experience working in ART center. The SDC posting is not required for candidates who have been sponsored by NACO since they have been working in ART centers before undergoing training and are also being taken care as a part of WP training.
The assessment strategy of the program comprises internal and term-end evaluations. The weightage for internal examination for theory and practical components is 30% and 50%, respectively. Theory assignment is given by the university to all students. There are two assignments for each of the first, second, and third theory courses. However, there are three assignments for fourth theory course. This is according to the credit load of the courses. The internal practical evaluation is conducted by two internal examiners in the respective PSCs. Proficiency certificate in all skills has to earn by each student to make them eligible for term-end practical examination which is issued by the PIC of the PSC. The theory term-end evaluation is conducted by the university. The term-end practical examination is conducted in the PSC with two internal examiners and two external examiners. Maximum of 10 candidates are assessed in term-end practical examination in 1 day. Details of the marking scheme and procedures of examination are standardized and followed in all centers uniformly.
Although the duration of the program is 1 year, learners have option to complete the program within 3 years in maximum. Learners can enroll for readmission by paying proportionate fee to avail one more additional year, if they fail to successfully pass in all assessment components within the maximum period.
| Quality Assurance|| |
Lots of measures have been taken to ensure the quality of training of the PGDHIVM program. In the development phase, the curriculum has been standardized involving experts at national level. One-day orientation workshops/training has been conducted for all course writers and course editors to write and edit self-learning materials. In the training/workshop, course writers and editors have been informed about concept of ODL, how to write course materials for students of ODL and how it is different from the conventional textbook. During the training, all participants were divided into few groups and each group was encouraged to write structure of a unit, learning objectives, and few portions of the same unit which was presented to the other groups for feedback and modification. A copy of the book named “Manual for course writers” which was produced by IGNOU was also given to all course writers and editors. All SLMs have been written by experts of respective field. All training centers, i.e., PSC have been activated as per laid down norms for minimum numbers of academic counselors and adequate infrastructure. NACO-designated COE has been recommended by NACO for the establishment of PSC for the program. IGNOU RC inspects the PSC and provides detailed report justifying establishment of the PSC for a particular program. Orientation training of all academic counselors was organized before conduction of the training. All students are briefed in induction meeting before starting the program. A program guide has been developed to provide all necessary information including curriculum, implementation process, assessment design, and other administrative support such as examination form for the program. The same has been provided to all learners as well as the academic counselors. Constant feedback is provided by the PIC of each PSC for each contact session to coordinators at IGNOU. NACO is also monitoring the activities of the training of this program, especially the SDC training in the ART centers. PIC meeting feedback is received time to time. Joint Coordination Committee (JCC) which have members from NACO and IGNOU also review the quality and implementation of this program in time to time.
| Limitation|| |
The training package was developed with the experts and NACO. It was a great challenge to prepare SLMs for the program. Although the experts from the NACO are the best person to write the training materials, they were not able to spare sufficient time for this task. Hands-on skill training has been imparted in these PSCs as per prescribed curriculum. A total of 120 learners were enrolled in 6 PSCs in 2012 when 70 students out of 120 students were sponsored by NACO. However, three PSCs could not be activated due to administrative issues. The students of nonactivated PSCs were then transferred to the three activated PSCs and training was imparted. Admission was not offered in 2013 and 2017 due to administrative reasons. Till date, 288 learners had been enrolled in this program and 122 students had successfully completed their program.
Perception of student's satisfaction in this training program was also obtained. Five to ten students in every batch of the students did not received study materials in time due to the postal delayed. All students appreciate the course materials and the quality of hands-on skills training in PSC and SDC. Few students complained about the delayed deceleration of result which is mainly due to the administrative issue of the transfer of marks from the RC to the headquarter. A PIC review meeting was organized annually to review this program so that the feedback can be integrated for the revision of the program. This program is undergoing revision. Till now, there is no feedback from students, academic counselors, as well as PICs to increase the duration of current contact sessions or number of activities in the PSC (28 days) and SDC (30 working days) to meet the objectives of the training program. This issue was never an agenda of the annual PIC meeting as well as in the meeting of JCC constituted by members from NACO and IGNOU.
| Conclusion|| |
A training program to impart skills to manage HIV/AIDS patients in the ART center through ODL is feasible. Quality training outcome through ODL has been demonstrated through this experiment. National challenges for workforce training can be met through ODL if proper design, implantation strategy, and monitoring are taken care at all levels.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jena TK, Dutta PK. Skill Training in Health Through Distance Education. 10th
AAOU Conference, Tehran, I. R. Iran; 14-16 November, 1996.
[Table 1], [Table 2]