National HIV Integrated Training Manual for Healthcare Workers

PACE has been working with NASCOP and implementing partners to develop and pilot the National HIV Integrated Training Manual for Healthcare Workers. This training manual is an innovative way of training, incorporating distance and adult learning principles including self-learning and mentored face-to-face sessions. The face-to-face sessions have an accompanying log book which comprises activities, cases, and required clinical encounters to reinforce learning and to ensure the achievement of core competencies based on the specific roles as defined in the curriculum.

The pilot of the curriculum has successfully taken place at five Regional Training Centers (RTCs) whose educational and HIV training activities PACE has been supporting. The five RTCs are Jaramogi Oginga Odinga Teaching and Referral Hospital (formerly New Nyanza Provincial General Hospital), Rift Valley Provincial General Hospital in Nakuru, Thika Level 5 Hospital, Mathari Hospital and Malindi District Hospital. In addition, over ten other health facilities, along with their supporting implementing partners, have participated in the pilot. The pilot has shown that this training model is acceptable, scalable and has significant cost savings; on average ten-fold savings compared to the previous model. It also reduces time away from work by nearly 13 weeks per year. This training course has been launched by the Ministry of Health and PACE is working with NASCOP to finalize plans for national scale up of this training model.

Thematic Unit of Clinical Infectious Disease

Establishing the Thematic Unit of Clinical Infectious Disease is a strategy to ensure sustainability of PACE activities beyond the grant. The unit will be housed at the University of Nairobi, Department of Clinical Medicine and Therapeutics, and is envisioned as providing high-level technical support to the Ministry of Health, infectious disease services at Kenyatta National Hospital and Mbagathi District Hospital, as well as training activities in infectious diseases.

Additional roles of the unit are developing Kenya’s first post-graduate fellowship program in Infectious Diseases, providing advanced training in short courses, and undertaking research in line with national priorities. Eight UoN faculty have undergone a clinical preceptorship at University of Maryland-Baltimore, and faculty from UMB will rotate at UoN to assist with teaching and the ID service.

National Advanced HIV Clinical Course

With the support of PACE the first National Advanced HIV Clinical Course was hosted at University of Nairobi in October 2013. This was a course borne in response to the local need for advanced HIV training. This was a course co-hosted by NASCOP, University of Nairobi and University of Maryland with 25 participants. Trainers were drawn from these 3 institutions as well as the National Leprosy and TB Program (NLTP), University of Maryland, Baltimore and Mayo. Adult learning principles were used in designing the curriculum that was based on frequently asked questions to NASCOP and a national clinicians’ consultation service. At the end of the course all participants reported an improvement in their confidence rating in their perceived ability to manage specific HIV conditions. The training also demonstrated potential for cost-recovery as organizations were willing to sponsor their employees to attend the training.

Linking Pre-service to In-service

PACE has managed to strengthen the link between in-service and pre-service institutions at various levels of programming. Activities led by pre-service institutions such as the HIV Symposium, the National Advanced HIV Clinical Course have incorporated NASCOP and NLTP into the planning committees. In-service activities such as development of the National HIV Integrated Training Course drew on pre-service institutions and professional associations as technical resources persons in design, development of the training material and in the pilot. Pre-service institutions are increasingly providing technical expertise to NASCOP and we anticipate that this will continue as a role of the Unit of Clinical Infectious Disease.

Provision of Educational Resources

PACE has provided HIV educational resources to six universities and five regional hospitals known as Regional Training Centers (RTC) that we provide training support to. These resources include books in HIV and related areas as well as pocket guides in different fields. We have provided infrastructural support to develop resource libraries including computers, LCD projectors and printers. Recognizing that technology is an important tool for training we have obtained licenses for ‘Uptodate®a web-based, peer-reviewed resource that provides evidence-based clinical decision support. At two universities and one RTC we have installed Therasim® which is a simulator for cases used for clinical teaching. The cases on Therasim® are customized to the Kenyan context and have three levels namely basic, intermediate and advanced through which the learner can progress.

Other Activities

Pre-service HIV Training

· Over 200 University faculty members across six public universities (University of Nairobi, Kenyatta University, Egerton University, Moi University, Maseno University, and Jomo Kenyatta University of Agriculture and Technology) have been trained in Innovative Teaching Methodologies and Clinical Mentorship in order to respond to the need for faculty to adopt more student centered approaches to teaching-learning methods. Twenty eight faculty members from these institutions have participated in the training cascade.

· Over 1000 final year health science students across four universities have participated in an HIV consolidation workshop aimed at providing them with the necessary skills for taking care of HIV infected patients during their internship and medical career

· Four departments or schools have integrated HIV training into their regular teaching curricula at University of Nairobi. This has led to a marked increase in attendance of the workshops from 60% in 2012 to 90% in 2013. During a pre-service stakeholders meeting held in September 2013 each of the six universities that PACE supports developed a work plan to integrate HIV training into the regular teaching schedule for undergraduates

· An electronic discussion forum is hosted on the University of Nairobi website. Over 60 HIV related cases have been posted, with over 16,000 views received on to the site to date

· PACE held a HIV Symposium held in June 2012 with Robert Gallo, the co-discoverer of HIV as a keynote speaker. Over 400 people participated including over 80 faculty from local universities

· Three regulatory bodies have been supported to review their curricula to include HIV as one of the core competencies

· Medical Education Units: Deans and faculty from the six universities that PACE supports were provided with technical support by a medical education consultant to develop university-specific action plans to develop/strengthen medical education units at their institutions. This iswith a view to having medical education units to institutionalize activities such as faculty development, monitoring of teaching-learning activities and continuous quality improvement


· Four regulatory bodies have been supported to develop or revise internship log books and to include HIV as a competency

· Two regulatory bodies have been supported to develop internship center guidelines

· The Kenya Medical Practitioners and Dentists Board was supported to develop and print an internship log book and internship center guidelines

· Over 50 internship Supervisors at the Regional Training Centers are trained in Innovative Teaching Methodology

· A class of over 25 interns is piloting the National HIV Integrated Training Course at Rift Valley Provincial General Hospital. This is with a view to utilizing internship as a training opportunity

In-service HIV training

· PACE supported NASCOP to develop and pilot a competency-based, integrated, modular, role-specific, distance-learning HIV curriculum for health workers. Most of the theory is learnt through self-reading, with facility based face-to-face sessions for skills building and consolidating learning. Through a comprehensive stakeholder engagement process, PACE has generated broad support for this new model of training to replace the previous hotel-based model of HIV training, creating a complete paradigm shift in how healthcare workers are trained in Kenya

· PACE has supported the pilot of this in-service HIV curriculum called the National HIV Integrated Training Manual for Health Workers at five sites and has demonstrated 10 fold cost savings and a reduction in time away from work

· PACE supported NASCOP’s mentorship cascade through training of National and Regional Mentors and continues to provide mentorship to health care workers at the five regional training centers

· The project worked with NASCOP to create a new model for disseminating the revised national ART guidelines, using a facility based, small-group, case-based learning model. PACE also supported dissemination sessions at five health facilities

· The project supported the establishment of five MoH hospitals as Regional Training Centers through provision of learning resources, supporting the facility to set up schedules for regular Continuous Medical Education sessions (CMEs), providing high level faculty for regional CPD sessions, mentoring regional and site mentors and helping sites improve their health systems in order to be ideal for training

· Monthly Continuous Professional Development (CPD) sessions are hosted on behalf of the National AIDS and STI Control Program (NASCOP). The objective is to increase knowledge on HIV as well as provide a platform to influence policy. Over 25 sessions have been held, with approximately 50 participants per session. For sustainability, we are working to transition this activity to NASCOP

· PACE supported NASCOP in tracking trainees through setting up a web-based training tracking database known as TrainSMART hosted at NASCOP. TrainSMART has been successfully customized and installed on the NASCOP server. Training information for participants who participated in the pilot of the National HIV Integrated Training Course is available on TrainSMART as well as auto-generated certificates

· PACE facilitated the conversion of the Emergency Triage and Treatment + (ETAT+) training into a self-learning format. This training aims to reduce infant and child mortality by providing health workers with skills to recognize the sick child and intervene appropriately in the first 48 hours of admission. Kenya Pediatrics Association led the stakeholder engagement with the Division of Child and Adolescent Health and the University of Nairobi and KEMRI-Wellcome Trust and converted the 12 modules of ETAT+ into self-learning. The pilot was successfully completed at two hospitals with 59 participants of different cadres, promoting team teaching


· PACE has supported the development of the material for the laboratory track of the National HIV Integrated Training Course and has supported the training of over 40 laboratory mentors from the RTCs in the laboratory component of this course

· PACE has supported laboratory HIV consolidation workshops at the three universities that graduate Medical Laboratory Science students. To date over 120 have been trained so far

· PACE has supported the review of the Biosafety and Biosecurity training curriculum and developed a competence-based curriculum framework

· PACE has supported the training of 11 faculty from the Kenya Medical Training Colleges (KMTC) in Advanced Malaria Microscopy with a view to preparing KMTC to provide cost recovery malaria trainings to laboratory practitioners

· PACE has provided technical support to the Kenya Medical Technologists’ and Technicians’ Board (KMLTTB) to develop a policy for Continuous Professional Development (CPD)


Progress towards transition of the grant to local partners

Transition of activities

Over the past four years of the grantUniversity of Nairobi has gradually taken responsibility for:

· All pre-service activities

· All in-service laboratory activities

In the past two years Kenya Paediatric Association has taken responsibility for the following in-service activities:

· Provision of CMEs at regional training centres

· Development of a training package for National and Regional mentors

· Facilitation of in-service ITM and clinical mentorship trainings at PACE regional training centres

· Development of the paediatric component of the harmonized HIV curriculum

· Establishment of CPD award allocations for the harmonised HIV curriculum

· Development and roll out of a revised ETAT curriculum

The following activities remain under the responsibility of UMB:

· Finalisation, launch and implementation of the National HIV Integrated Training Course (NHITC) for Health Workers

· Customization and maintenance of the national training database TrainSMART, housed at the National AIDS and STI Control Program (NASCOP)

· Support of training activities at five Regional Training Centers (RTCs)

· Support of the Medical Practitioners and Dentists’ Board towards streamlining internship training

· Monitoring and evaluation activities of the overall grant

Financial transition

The figure below provides an overview of the funding allocated to PACE over the past 5 years, and the distribution of this funding across partners.

Figure 1: PACE funding across partners (year 1 to 5)

The past 5 years have seen a gradual increase in the proportion of funds allocated to University of Nairobi as compared to UMB (Baltimore) and MGIC (Kenya) (see figure below). NB: The dip in funding in Year 5 reflects a decrease in funding from the donor affecting all partners in the grant.

Figure 2: Funding trends for UoN, UMB, MGIC (year 1 to 5)

Sustainability of PACE activities at University of Nairobi

PACE project has made significant contributions towards improving clinical education at pre-service and in-service levels. To sustain and build upon these achievements, we propose to develop a Unit of Clinical Infectious Diseases within the Department of Clinical Medicine and Therapeutics, University of Nairobi.

The Unit will, among other things be the transition strategy for the high-level technical support that University of Maryland, Baltimore provides in Kenya, which includes providing technical support at the national level for guideline and policy development, in-service training systems, advanced clinical training, and technical direction for HIV programs. The Unit will become the focal point for technical expertise in HIV and other infectious diseases, and a key resource for the Ministry of Health.