Addressing human resources for health needs to support HIV epidemic control: prioritizing site-level interventions in Democratic Republic of the Congo, 2018-2020

Introduction: The United States President's Emergency Plan for AIDS Relief (PEPFAR) in Democratic Republic of the Congo (DRC) continues to fund programs aimed at achieving epidemic control in three provinces where 30 percent of people living with HIV/AIDS in the country reside. Challenges around human resources for health impede the delivery of quality HIV/AIDS services in DRC. Methods: In partnership with the United States Health Resources and Services Administration (HRSA), PEPFAR, and DRC Ministry of Health (MoH), Columbia University's International Center for AIDS Prevention (ICAP at Columbia University) worked with 16 PEPFAR-identified high-priority health facilities and developed specific interventions to address challenges in achieving PEPFAR 95-95-95 targets. Once interventions were selected and prioritized using a collaborative, criteria-driven approach, implementation of these human resources for health improvements began alongside care and treatment efforts already underway. This study began in October 2018, and high-priority interventions were launched in July 2019. Monthly reporting of key PEPFAR metrics continues for evaluation purposes. Results: All 16 high-priority health facilities participated fully. Of several hypothesized interventions, 12 were selected as highest priority, and budgets and task plans were developed for each. The interventions were launched for implementation and evaluation within six months of Ministry of Health approval. Conclusion: This assessment delineated necessary interventions to address site-specific human resources for health challenges/deficiencies. Downstream reporting of key PEPFAR 95-95-95 metrics, including Monitoring, Evaluation, and Reporting indicators, will allow intervention teams to conduct program evaluations and their impacts on targets

Increasing nursing student interest in rural healthcare: lessons from a rural rotation program in Democratic Republic of the Congo

Background Many challenges exist in providing equitable access to rural healthcare in the Democratic Republic of the Congo (DRC). WHO recommends student exposure to rural clinical rotations to promote interest in rural healthcare. Challenges to rural engagement include lack of adequate infrastructure and staff to lead rural education. This case report highlights key steps in developing a rural rotation program for DRC nursing students. Case presentation To implement a rural rotation (RR) program, ICAP at Columbia University (ICAP) consulted with students, the Ministries of Health (MoH) and Education (MoE), and nursing schools to pilot and expand a rural rotation program. Nursing schools agreed to place students in rural clinics and communities. Key stakeholders collaborated to assess and select rural sites based on availability of nursing mentors, educational resources, security, accessibility, and patient volume. To support this, 85 preceptors from 55 target schools and 30 rural health facilities were trained of which 30 were selected to be “master trainers”. These master trainers led the remaining 55 preceptors implementing the rural rotation program. We worked with rural facilities to engage community leaders and secure accommodation for students. A total of 583 students from five Lubumbashi schools and two rural schools outside Kinshasa participated across 16 rural sites (298 students in 2018–2019 school year and 285 in 2019–2020). Feedback from 274 students and 25 preceptors and nursing school leaders was positive with many students actively seeking rural assignments upon graduation. For example, 97% agreed or strongly agreed that their RR programs had strengthened their educational experience. Key challenges, however, were long-term financial support (35%) for rural rotations, adequate student housing (30%) and advocacy for expanding the rural workforce. Conclusions With nearly 600 participants, this project showed that a RR program is feasible and acceptable in resource-limited settings yet availability of ample student accommodation and increasing availability of rural jobs remain health system challenges. Using a multipronged approach to rural health investment as outlined by WHO over two decades ago remains essential. Attracting future nurses to rural health is necessary but not sufficient to achieve equitable health workforce distribution

Sex differences in delayed antiretroviral therapy initiation among adolescents and young adults living with HIV in DR Congo

Background: In DR Congo, adolescent girls are disproportionately vulnerable to HIV. Nonetheless, females are often more engaged in the health-care system, including during antenatal care, when women enrolled on Option B+ for prevention of mother-to-child transmission of HIV initiate antiretroviral therapy (ART). We aimed to understand the extent of delayed ART initiation among adolescents and young adults newly enrolled in HIV care, and to assess whether there were any sex differences. Methods: Aggregate data from 365 ICAP-supported sites in Kinshasa and Haut-Katanga provinces in DR Congo from April 2016 to May 2017 were reviewed to describe delayed ART uptake among adolescents and young adults aged 15–24 years. Delayed uptake was defined as not beginning treatment within 1 month of enrolling in care among those eligible for ART. Pregnant and non-pregnant women were combined since available data did not disaggregate by pregnancy status. DR Congo began implementing “test and start” during the study period. All analyses used group-level data and were conducted using multivariable logistic regression, adjusting for setting and age group. Findings: Between April 2016 and May 2017, 861 adolescents and young adults (128 male and 733 female) enrolled in HIV care and treatment services. 21 (16%) males and 58 (8%) females had not begun treatment within 1 month of enrolling in care, despite eligibility for ART (odds ratio [OR] 2·28, 95% CI 1·33–3·92). The male predominance remained after controlling for setting (urban vs rural) and age group (15–19 years vs 20–24 years) (adjusted OR 2·03, 95% CI 1·17–3·53). Aggregate data did not allow for analysis of individual explanations, but reasons for delayed ART may include the need to stabilise patients before starting treatment and patients’ preferences. Interpretation: Despite being more vulnerable to HIV, female adolescents and young adults have faster ART initiation than males after enrolling in HIV treatment. It is likely that Option B+ expedites ART initiation for females. Going forwards, ICAP will strengthen its adolescent package of support with community-based adolescent-friendly interventions targeting males, with the goal to enrol all adolescents and young adults on ART in accordance with DRC's test and start guidelines. Funding: CDC/PEPFAR

Increasing Nursing Student Interest in Rural Healthcare: Lessons From a Rural Rotation Program in Democratic Republic of the Congo

Abstract BackgroundMany challenges exist in providing equitable access to healthcare in the Democratic Republic of the Congo (DRC) including resource disparities between rural and urban areas coupled with a majority rural population. One of the most promising ways to close the gap between rural and urban healthcare access and quality is through the support of human resources for health (HRH), especially nurses, in rural health settings. Current barriers including lack of nursing students from rural communities, insufficient infrastructure, and absence of programs for rural practice exposure, have allowed disparities between rural and urban healthcare to persist. MethodsTo implement a rural rotation (RR) program for nursing students in DRC, whereby students are immersed in a rural clinical and community placement for an extended period of time, ICAP at Columbia University (ICAP), with funding and support from the United States Health Resources Service Administration (HRSA), consulted with stakeholders in DRC including students, the Ministry of Health (MoH), the Ministry of Education (MoE), and nursing schools and associations to improve health workforce education including understanding the disparities and realities of rural health care. Following this, schools of nursing in the Lubumbashi area agreed to add nursing students into rural workforce settings, including time in clinical as well as community health on a rotational basis. ICAP then worked with the MoH and MoE to select rural sites that could adequately support rotating nursing students and develop expectations for the RR program. Assessments of the selected rural sites were conducted, and the availability of nursing mentors, teaching materials, security, and accessibility, as well as patient volumes, were identified. Building on prior work to strengthen preceptors, a training of trainers approach was used. Out of a cohort of 85 trained preceptors from across 55 target schools and 30 rural health facilities, 30 were selected to be “master trainers” based on their experience in training others, their performance in initial preceptor training, and willingness to contribute more to overall success of the RR program. These master trainers educated the remaining 55 preceptors in rural practice. Concurrent with the training, ICAP, along with the MoH and MoE, worked with communities around the rural health facilities to secure accommodations for nursing students and to engage them with community leaders for purposes of future health promotion and clinic collaboration.ResultsAll five target schools from the Lubumbashi area that were selected for the project chose to participate. Kinshasa was not targeted for the project but did have two schools in rural areas outside the urban center interested and willing to accept students on rotations. Over the life of the project, 583 students successfully participated in the program and completed rural rotations as planned. Sixteen rural sites and 298 students participated in the rotational program during the 2018-2019 school year. For the 2019-2020 school year (through March), 285 students participated.Post-rotation feedback RECEIVED FROM 274 students, as well as from over 25 preceptors, and nursing school leaders, has been very positive and has resulted in more nursing students seeking rural assignments upon completion of their studies. Ninety-three percent of students surveyed, for example, indicated that they agreed or strongly agreed that they would recommend participation in RR programs to their classmates. Ninety-seven percent agreed or strongly agreed that their RR program had strengthened their education experience and increased their willingness to serve in rural areas in the future. The most significant challenges, however, were financial support (35%) and housing (30%).ConclusionsWith nearly 600 successful participants, this project showed that a RR program is both feasible and acceptable for nursing students, faculty, and rural clinic staff in resource-limited settings. Student exposure to rural practice is critical to increasing interest (and therefore downstream HRH staffing) in rural area healthcare. ICAP, HRSA, and DRC ministry leadership believe these early successes are indicative of both the opportunity available and value-added of such a RR program. Going forward, HRSA, ICAP and key stakeholders will continue to collaborate to sustain this project and advocate for employment and placement of student nurses who expressed interest, into rural employment following graduation. In addition, expanding such programs to other majority rural areas of sub-Saharan Africa seems both feasible and affordable with the right up-front collaborations and program design with key stakeholders.</jats:p

Addressing Human Resources for Health Needs to Support HIV Epidemic Control: Prioritizing Site-Level Interventions in Democratic Republic of the Congo, 2018-2020

Introduction: The United States President's Emergency Plan for AIDS Relief (PEPFAR) in Democratic Republic of the Congo (DRC) continues to fund programs aimed at achieving epidemic control in three provinces where 30 percent of people living with HIV/AIDS in the country reside. Challenges around human resources for health impede the delivery of quality HIV/AIDS services in DRC. Methods: In partnership with the United States Health Resources and Services Administration (HRSA), PEPFAR, and DRC Ministry of Health (MoH), Columbia University's International Center for AIDS Prevention (ICAP at Columbia University) worked with 16 PEPFAR-identified high-priority health facilities and developed specific interventions to address challenges in achieving PEPFAR 95-95-95 targets. Once interventions were selected and prioritized using a collaborative, criteria-driven approach, implementation of these human resources for health improvements began alongside care and treatment efforts already underway. This study began in October 2018, and high-priority interventions were launched in July 2019. Monthly reporting of key PEPFAR metrics continues for evaluation purposes. Results: All 16 high-priority health facilities participated fully. Of several hypothesized interventions, 12 were selected as highest priority, and budgets and task plans were developed for each. The interventions were launched for implementation and evaluation within six months of Ministry of Health approval. Conclusion: This assessment delineated necessary interventions to address site-specific human resources for health challenges/deficiencies. Downstream reporting of key PEPFAR 95-95-95 metrics, including Monitoring, Evaluation, and Reporting indicators, will allow intervention teams to conduct program evaluations and their impacts on targets

Increasing nursing student interest in rural healthcare: lessons from a rural rotation program in Democratic Republic of the Congo

Abstract Background Many challenges exist in providing equitable access to rural healthcare in the Democratic Republic of the Congo (DRC). WHO recommends student exposure to rural clinical rotations to promote interest in rural healthcare. Challenges to rural engagement include lack of adequate infrastructure and staff to lead rural education. This case report highlights key steps in developing a rural rotation program for DRC nursing students. Case presentation To implement a rural rotation (RR) program, ICAP at Columbia University (ICAP) consulted with students, the Ministries of Health (MoH) and Education (MoE), and nursing schools to pilot and expand a rural rotation program. Nursing schools agreed to place students in rural clinics and communities. Key stakeholders collaborated to assess and select rural sites based on availability of nursing mentors, educational resources, security, accessibility, and patient volume. To support this, 85 preceptors from 55 target schools and 30 rural health facilities were trained of which 30 were selected to be “master trainers”. These master trainers led the remaining 55 preceptors implementing the rural rotation program. We worked with rural facilities to engage community leaders and secure accommodation for students. A total of 583 students from five Lubumbashi schools and two rural schools outside Kinshasa participated across 16 rural sites (298 students in 2018–2019 school year and 285 in 2019–2020). Feedback from 274 students and 25 preceptors and nursing school leaders was positive with many students actively seeking rural assignments upon graduation. For example, 97% agreed or strongly agreed that their RR programs had strengthened their educational experience. Key challenges, however, were long-term financial support (35%) for rural rotations, adequate student housing (30%) and advocacy for expanding the rural workforce. Conclusions With nearly 600 participants, this project showed that a RR program is feasible and acceptable in resource-limited settings yet availability of ample student accommodation and increasing availability of rural jobs remain health system challenges. Using a multipronged approach to rural health investment as outlined by WHO over two decades ago remains essential. Attracting future nurses to rural health is necessary but not sufficient to achieve equitable health workforce distribution. </jats:sec

Strengthening Human Resources for Health to Achieve Epidemic Control: A Case Study of Democratic Republic of the Congo

Abstract Background The United States President’s Emergency Plan for AIDS Relief (PEPFAR) in Democratic Republic of the Congo (DRC) continues to fund a robust portfolio of programs aimed at achieving epidemic control in three provinces where 30 percent of people living with HIV/AIDS in the country reside. Challenges around human resources for health (HRH), including inadequate staffing and limited capacity, impede the delivery of quality HIV/AIDS services in DRC.Methods In partnership with the United States Health Resources and Services Administration (HRSA), PEPFAR, and DRC Ministry of Health (MoH), ICAP at Columbia University worked with 16 PEPFAR-identified high-priority health facilities (HFs) in DRC and developed HRH-specific interventions to address challenges in achieving 95-95-95 targets. These potential interventions were then prioritized for implementation using a collaborative, criteria-driven approach considering factors such as feasibility, viability, and time-to-impact. Through interviews at all 16 HFs, the joint teams developed an intervention framework, determined short-term priorities, and prepared to implement short-term HRH improvements to reach 95-95-95 targets across all HFs. Interviews used an adapted version of the PEPFAR HRH Rapid Assessment tool to capture key HRH information including staffing levels by type of clinical or administrative position, key barriers to achieving 95-95-95 targets, and perceptions of needed HRH-specific improvements. Results Site-level interviews occurred in April 2019, and the in-country team created a list of possible interventions across six domains: staffing, training, workplace environment, medical supplies and equipment, and monitoring and evaluation. Thirty-five interventions were hypothesized and prioritized into short, medium, and long-term priorities using a framework focused on desirability, feasibility, viability, and time-to-impact. Some interventions were applicable to all HFs while others applied only to selected HFs, the national MoH, or to implementation partners. Twelve interventions were selected as highest priority, and budget allocations and task planning were developed for each of the high-priority interventions. These high-priority interventions were then launched for implementation and evaluation within six months.Conclusions The supply and quality of HRH are critical to achieving epidemic control. This assessment delineated necessary interventions to address site-specific HRH barriers, HRH interventions focused on ensuring adequate staffing, optimal utilization of health workers, and strengthening health workers’ capacity to provide quality HIV/AIDS services to achieve epidemic control. Downstream tracking and reporting of key PEPFAR metrics, including key Monitoring, Evaluation, and Reporting (MER) indicators, will allow intervention teams to conduct program evaluations of key interventions and their impacts on PEPFAR targets.</jats:p