**5. Barriers and enablers to effective NIMART training and implementation**

A study conducted by Mboweni and Makhado [15] in South Africa revealed structural or health care system, environmental, patient, human resource, training, and mentoring factors as challenges influencing NIMART training and implementation and supported by various studies in Africa and globally. Such barriers should be dealt with decisively to enhance the effectiveness of NIMART training and implementation, improving the quality of care and HIV services.

#### **5.1 Health care factors**

Health care system or structural factors plays a significant role in the effectiveness and efficiency of delivering HIV services and health care services in general, including achieving universal health coverage (UHC). According to Mboweni and Makhado (2019), several challenges are influencing NIMART training and implementation in South Africa and other African countries, which includes:


#### *5.1.1 Poor leadership role model*

The success of the HIV programme and ending the HIV and TB epidemic lies in the commitment of the district, provincial and national leadership with clear political will and leadership strategy. Therefore, poor leadership affects the implementation of the NIMART programme. All internal and external stakeholders should have clear roles and responsibilities to avoid duplication and overlapping of functions and facilitate the integration of HIV and non-communicable disease as they are both chronic diseases.

Supportive supervision by district and local management is key to dealing with gaps in training and implementation at facility levels, such as shortage of medication, equipment, and supplies as soon as possible. There is no district clinical mentorship programme; if available, it is mostly partner driven. Partners are HIV and TB communities or non-profit organizations mostly funded by donors. The United States President's Emergency Plan for AIDS Relief (PEPFAR) supports the government in preventing, controlling, and managing HIV and TB. Their existence is based on funding, meaning HIV management can collapse when they are unavailable and create dependency as most nurses working for government no longer render HIV services and rely on NIMART nurses from NGOs. Patient care is delayed as some patients are referred to another facility or have to wait for a partner NIMART-trained nurse.

#### *5.1.2 Inadequate integration of service*

The high shortage of skilled human resources for health requires better planning through integrating HIV, communicable and non-communicable services. Vertical integration might allow underutilized resources to remain and contribute to inefficient operations, excess capacity and duplication must be removed from the system. Health service integration is defined as the "managerial or operational changes to health systems to bring together inputs, delivery, management, and organization of particular service functions." Integration improves access, facilitates services, and addresses what has brought together inputs, delivery, management and organization of particular service functions." Integration improves access, encourages the use of services, and addresses what has been referred to as the four 'D's' – duplication, distortion, disruption, and distraction. A health facility should be a one-way stop where the patient can receive all services without moving from one consultation room to another. However, adequate staff allocation is key to ensuring quality, reducing long waiting hours, and improving patient satisfaction. Such staff needs to be provided with appropriate training to provide quality care and be integrated during NIMART training, where adult care 101 can be integrated and continued within the facility level during clinical mentorship support visits.

Integrating health services improves multiple healthcare outcomes among HIVinfected people who inject drugs. This can be relevant to managing other key population groups eye marked to reduce new HIV infections. A mind shift set from vertical programmes to context-specific equitable access to integrated services is crucial to achieving the 95–95-95 and 10–10-10 plus 90% targets by 2030 by dealing with issues related to:


*Perspective Chapter: Enhancing the Nurse-Initiated Management of Antiretroviral Therapy… DOI: http://dx.doi.org/10.5772/intechopen.107982*


All stakeholders should speak in one voice and put PLWH and communities at risk at the centre, with a non-judgmental attitude and embracing diversity [7]. Key populations in the HIV programme refer to a group of people who are vulnerable and disproportionately affected by HIV owing to risk behavior and marginalization and frequently lack access to health care services and include: lesbians, gays, bisexuals, transgender, sex workers, men who have sex with men, people who inject drugs, prisoners or inmates, and people in intergenerational relationships with older men or women groups and adolescents.

#### *5.1.3 Inadequate information systems and processes*

The healthcare process refers to interrelated or interacting healthcare activities transforming inputs into outputs. The processes and systems are essential in improving the quality and performance of the healthcare environment and can help providers with reliable, cost-effective, and sustained healthcare processes and enable them to achieve their goal of improving care delivery and enhancing patient outcomes. Therefore, inadequate information systems and the process can affect quality and decision-making.

#### *5.1.3.1 Inadequate patient information systems and processes*

There are inadequate information systems and processes for follow-ups and tracing of patients. It became difficult to provide continuous quality care to patients, especially those working in farming, mining, and industrial areas, as they are highly mobile and migrant workers. Facilities ended up with a high loss to follow-up and missed appointments, and systems and processes should be developed to address such. There should be one system nationally to track patients' movements as they visit other facilities using ID as a unique identifier.

#### *5.1.3.2 Inadequate viral load management systems and processes*

Viral load management is critical in managing and monitoring the effectiveness of treatment or treatment outcomes in HIV management. It is currently lacking or not implemented effectively in most health facilities. If no systems and processes are in

place, it will affect patient outcomes. Most patients' blood for viral load is not collected per cohort. Either they are missed, or patients did not visit the facility, and there are no effective systems to identify such on time for tracing or tracking the patients. Viral load management is also crucial in monitoring the 95–95-95 UNAIDS target by 2030 to ensure that ART patients adhere to treatment and are virally suppressed. Quality improvement is key to identifying gaps and developing processes and systems that can be followed to improve VL monitoring in all health facilities. Patients, key populations, and the community should be educated on the slogan of undetectable equals untransmissible (U=U), to reduce new HIV infection through early ART initiation and adherence to lower the HIV viral load in the blood and by reaching that level where the transmission will be low and should be emphasized that this only applies to the transmission through sexual intercourse and not through other methods transmission; therefore they need to continue to implement relevant preventatives measures [16].

#### *5.1.3.3 Poor data management systems and processes*

Data management is collecting, keeping, and using data securely, efficiently, and cost-effectively. Managing digital data in an organization involves various tasks, policies, procedures, and practices. Data are critical to HIV programme management as it identifies gaps and monitors progress. Management should be data-driven to direct planning and allocation of resources. Therefore, the whole programme will lack direction if data are not managed well. The study revealed poor adherence to data management SOPs, incomplete clinical records, inconsistent clinical records quality audits, and lack of data verification. The facility manager's responsibility is to ensure that data are well managed in the facility. However, it is not happening in some facilities or is inadequate. Health care providers, including NIMART nurses, mostly do not accurately complete clinical records or registers. Such gaps make it difficult for the data team to capture quality data in the DHIS and TIER.NET. They also do not comply with the SOPs and HIV guidelines, compromising quality. Clinical records quality audits are not conducted consistently. Hence, gaps in clinical records are not attended to until data capturing. This is the responsibility of the clinical nurse mentor, HIV programme manager, and NIMART-trained nurse with the support of and under the leadership and guidance of the facility manager. The data team should ensure that the facility or institutional data is always verified, cleaned, timely, and ready to use. Access to timely and accurate facility data is vital for decision-making and planning. There should be a data collection system, processes, and equipment with a well-trained data or information team. A proper and highly effective ICT infrastructure is also necessary to collect realtime data from the facility or community level. The programme also needs well-trained staff to conduct data cleaning and verification process to ensure quality.

#### *5.1.3.4 Stigma and discrimination*

HIV was labeled as a gay disease from its beginning around the 1980s, which had the foundation of stigma and discrimination and has remained to the present. The failure of the HIV programme is owing to stigma and discrimination. Most PLWH are not accessing health services owing to stigma from community and health care workers. Stigma and discrimination become barriers that delay PLWH's early access to ART leading to complications and death. Suppose the world has to end the HIV epidemic. In that case, the focus will be on ending stigma and discrimination, especially among key populations such as adolescents, young women, LGBTQI–а common abbreviation

*Perspective Chapter: Enhancing the Nurse-Initiated Management of Antiretroviral Therapy… DOI: http://dx.doi.org/10.5772/intechopen.107982*

for the lesbian, gay, bisexual, transgender, queer, and intersex community. Countries should end criminalization and punitive laws against LGBTQI and people who inject drugs and develop strategies to enhance access to health services. This will help deal with behavior that exposes them to HIV, reducing new HIV infections. Inequalities should be confronted to end the HIV epidemic [17].

#### **5.2 Environmental factors**

NIMART-trained nurses continuously reported poor infrastructure, that the health facilities are poorly maintained, small, and cannot accommodate the growing number of patients needing health services. They work in an overcrowded and congested environment, worsening infection during the COVID-19 pandemic. The consultation rooms are small and not well ventilated despite implementing ideal clinic initiative standards for quality care. Some patients have to wait outside for a long time and are exposed to heat or cold to implement infection control measures. Such small facilities do not have enough space for supplies, equipment, and medicines. Therefore, proper planning and budgeting is need to refurbish or extend the health facility.

#### **5.3 Health care providers' factors**

Health care providers can play a major role in ensuring that HIV services are accessible, efficient and effective. However, various factors must be considered to ensure quality, such as staff attitude, shortage, and scheduling.

#### *5.3.1 Staff attitude*

Some health care workers have negative staff attitudes toward patients and are a barrier to accessing health services, which has to change. Nurses must comply with their pledge and work according to SANC regulations and Batho Pele or customer care principles in line with the South African Constitution Act 108 of 1996 regarding human rights and patients' rights charter. Training should be provided to sensitize nurses on these legislations, including stigma and discrimination and key populations.

#### *5.3.2 Shortage of skilled healthcare workers*

Low- and middle-income countries like South Africa still experience a high shortage of skilled human resources for health, making those available staff overworked or overburdened and suffer from exhaustion and stress. This requires better planning, budgeting, and allocation of work schedules by the healthcare leadership. Some staff members resigned or transferred to work in other areas as they no longer cope with the workload, especially in rural provinces. Those left continue to be overworked, dissatisfied, and experience burnout, affecting the quality of HIV management and other programmes. Some form of intrinsic and extrinsic incentives is necessary to motivate nurses trained on NIMART. Despite task shifting, there is still high staff turnover, and more needs to be done. Nurses still perform non-clinical roles, and there is a need for task shifting in other roles like ordering and dispensing medication by assistant pharmacists rather than pharmacists, administrative work to administrators, and collecting specimens for phlebotomists or laboratory technicians as it delays actual management of patients. Nurses cannot become all-rounders as it compromises their clinical skills.

#### *5.3.3 Confidence in HIV management*

NIMART training should be aimed at providing knowledge and skills and building confidence and a positive attitude to manage PLWH. The districts should prioritize the establishment of the Department of Health district clinical mentorship teams and avoid reliance on partners to build the confidence of NIMART nurses at a facility level where patient care and management are taking place than at a classroom level where theory and simulation take place. On-job support to conduct the physical assessment, staging, interpretation of guidelines and results, selecting the correct regimen, drug interactions, and management of complications and opportunistic infections is key to improving the clinical competence of NIMART-trained nurses to the acceptable level of providing quality HIV management.

#### *5.3.4 Clinical supervision and support by management*

Management support is key to achieving the organizational goals and objectives, and once it is lacking, the HIV programme is not going to perform as expected. Management should manage by identifying gaps and be more proactive than reactive. Most challenges experienced by NIMART nurses and other health care providers might be minimized through the support of national, provincial, district, and local management. They will plan better and prioritize resources effectively where it is needed most.

#### **5.4 Patient factors**

Patients' social, psychological, physical, and financial factors need to be consider in HIV management. Failure to consider these factors might lead to poor clinical and virologic outcomes. Poor clinical outcome refers to a situation where the patient's condition is not improving despite taking antiretroviral treatment, while virologic outcomes refer to a situation where the viral load remains high or does not improve despite the patient starting on treatment.

#### *5.4.1 Social factors*

Patients need to modify their lifestyle, stop or reduce smoking, and alcohol consumption, eat a healthy diet, and exercise. Patients need treatment and scheduled appointments and avoid over-the-counter medication or traditional herbs that may interfere with treatment. Continuous patient self-care management education is key in every visit, including the importance of adherence to medication through health education and counseling. There is a need to modify a lifestyle that interferes with appointments and adherence to treatment because missing appointments interfere with the regular taking of medication, resulting in poor clinical and virologic outcomes. Some clients experience intimate partner violence (IPV) or gender-based violence (GBV), especially women when they have to disclose their HIV status and end up hiding and not taking medication as prescribed or missing their appointments.

#### *5.4.2 Psychological factors*

Stigma and discrimination also play a significant role in lack of disclosure, stress, anxiety, and depression, and loss of follow-up and should be dealt with decisively

*Perspective Chapter: Enhancing the Nurse-Initiated Management of Antiretroviral Therapy… DOI: http://dx.doi.org/10.5772/intechopen.107982*

by NIMART nurses and the healthcare system. Factors leading to stigma and discrimination should be identified and addressed appropriately, including prevention. Sensitization of health care providers and the community about stigma and discrimination can be integrated into training and education and during community education and awareness campaigns. All stakeholders should be involved and sensitization, including PLWH, traditional and religious leaders, CBOs and NGOs. Mental health services should be provided to PLWH to reduce stress, anxiety, and depression. Enhanced adherence counseling (EAC) should be provided to all patients who missed appointments and did not adhere to treatment. Lack of support also results in poor adherence to treatment and lack of disclosure; patients need to identify a friend and family support and be referred to psychosocial counseling to help cope, accept the diseases, and move on with life. Community support groups can also be used to refer patients so that they have an opportunity to share their experiences with other people. Some do not have money to access health facilities monthly and can be registered for home or community medication distribution if they qualify or are assisted by community health workers. Some are physically disabled or very ill and need support with daily self-care management.

#### *5.4.3 Financial or economic factor*

Patients with financial difficulties or lack of support might miss appointments due to a lack of transport money to visit a health facility or pay for treatment in a private health facility or pharmacy. Some patients are unemployed without any government grant to support themselves, especially immigrants and those living with a disability or mental illness who need support. ART is available free of charge in South Africa's public health services. Stable patients on ART and the communities should be made aware of the minimum package of interventions to support linkage, adherence, and retention in care and differentiated models of care for stable chronic patients on treatment, which include repeat prescriptions (RPCs) collection strategies after six months on treatment through facility pick point (FAC-PUP), adherence clubs (AC) within the facility or community, external pick up points (EX-PUP) from the local shops, pharmacies or NGOs (National Department of Health AGL, 2021).

#### **5.5 Inadequacy in NIMART training**

South Africa has the largest and most high-profile ART programme globally, with 7.7 million initiated on treatment. However, quality is still a challenge and should be addressed through proper training, including standardization of the curriculum, use of strategies that can stimulate critical thinking, competency-based education, training and assessment, and application of the conceptual framework to enhance NIMART training and implementation.

#### *5.5.1 Standardization of NIMART curriculum*

The literature review and the study findings revealed that the NIMART curriculum was not standard and partner-driven, and recommendations were made to standardize the curriculum. The National Department of Health in South Africa did not have a standard curriculum to guide the country and train providers. The content covered and even the period offered differed. Some offer it in five days while others in ten days. The curriculum is a standards-based sequence of planned experiences where students practice and achieve proficiency in content and applied learning skills. The curriculum is the central guide for all educators as to what is essential for teaching and learning so that every student can access rigorous academic experiences. The disruption of onsite training by the COVID-19 pandemic has propelled the department to develop a standard training programme. It is now being attended to and offered online through the national knowledge and training hub and is accessible to all professional nurses either from m private or public sector and allocated CPD points. However, it is unclear which curriculum was followed in developing the training materials.

### *5.5.2 The use of strategies that stimulate critical thinking*

Facilitators or educators should use interactive teaching strategies to stimulate critical thinking, including problem-based, reflective, case studies, and seminars. Health workers play a major role in learning and teaching by active participation based on their experience and knowledge of managing PLWH. Facilitators and educators should be adequately trained to facilitate NIMART and should be carefully selected during the recruitment process. Moreover, they should possess skills like nursing education or health sciences education with computer and good presentation skills, not just pick anyone to facilitate learning and teaching. In addition, experience in HIV and AIDS management is also necessary. They should do away or eliminate traditional strategies or didactics of the presentation without active participation or involvement of participants.

#### *5.5.3 Use of competency-based education, training, and assessment model*

Integrating theory with practice is key to improving health workers' competency levels and performance. Clinical mentoring and competency tools were developed to assess the competency of nurses after training and can be certified as competent than being presented with a certificate of attendance. All health workers trained should undergo a clinical mentoring process by allocating an experienced mentor for 6 to 12 months to support the trained health workers onsite or virtually through SMS, WhatsApp, and telephonically. Final assessments are conducted through OSCE or simulated case studies and onsite job assessments while managing the patients in the health facility to determine the competency of the trained health workers. NIMARTtrained nurses should complete the logbook or portfolio of evidence with stipulated cases needed to manage children, men, women, ANC pregnant women, HIV/TB Co-infected cases, and adults. They need to show the integration of adult primary care in managing chronic diseases and integrated management of childhood illness when implementing NIMART or managing PLWH. Other education and training strategies that can improve NIMART implementation include pre-service, continuous in-service training, and CPD.

#### *5.5.3.1 Pre-service training*

Introduction or strengthening of NIMART as pre-service training to nursing students can help facilitate capacity building of new nurses before they can enter or join the health care system and prepare them to work effectively and efficiently in providing quality services to the community and PLWH. According to WHO (2014), **pre-service education** or **pre-service training is used interchangeably** and refers to

#### *Perspective Chapter: Enhancing the Nurse-Initiated Management of Antiretroviral Therapy… DOI: http://dx.doi.org/10.5772/intechopen.107982*

any structured activity aiming to develop or reinforce knowledge and skills before a health care professional enters public health service or private practice. "Pre-service" refers to activities before a person takes up a job requiring specific training, i.e. before a person 'enters service. This also includes courses for graduates and undergraduates, which are 'pre-service courses' if they provide the competence needed to perform new services. *Pre-service training* is the *training* nurses receive before they begin managing patients in a health facility after completing formal training. This stage is vitally important as it lays the foundations for motivation and ensures that new nurses are competent before entering the consultation room.

Pre-service coordination is meant to increase efficiency for patients and office staff. Patients know upfront what their service will cost before they arrive, and they have the opportunity to pay for that service in full, in part, or to make payment arrangements. Nurses should be exposed to HIV and non-communicable and communicable disease guidelines, policies, and protocols before they start working as part of induction and orientation to their new roles in health facilities to provide integrated, comprehensive quality care to their clients or patients. This will also reduce time spent orientating the new nurses and be used effectively for patient clinical management. Again, training will reduce stress and anxiety as the new nurses will be familiar with such guidelines and confidently manage the patient. Unnecessary referral to other professionals or facilities will be reduced, facilitating access to services in the first or primary level of care. This can be designed through stakeholder coordination by the national, regional, or district training centres together with higher education institutions offering training and education to nurses and partners supporting the Department of Health, and can be offered through staggering the content every academic year or allocating weeks specifically for NIMART and Adult Primary care (APC) 101 like how Integrated Management of Childhood Illness (IMCI) is being integrated into HEIs learning and teaching programmes. Adult Primary Care (APC) is the new name for Primary Care 101 (PC 101). APC is a symptom-based integrated clinical management tool using a series of algorithms and checklists to guide the management of common symptoms and chronic conditions.

In adults, a clinical tool is a comprehensive approach to the adult's primary care for 18 years or older. APC has been developed using approved clinical policies and guidelines issued by the national Department of Health and is intended for use by all healthcare practitioners working at the primary care level in South Africa as a clinical decision-making tool. This tool accompanies a training package consisting of short onsite sessions using simulated case scenarios. APC is being implemented as part of the Integrated Clinical Services Management (ICSM), a key focus within the Ideal Clinic Realization and Maintenance (ICRM) initiative to improve the quality of care delivered and is complemented by the health for all health promotion tool to promote healthy lifestyles and health education. Therefore, APC 101 is a step-by-step training provided to health workers for the integrated management of communicable, and non-communicable diseases in the primary level of care with limited resources and facilitates the provision of integrated management of NCDs and communicable diseases, including HIV.

#### *5.5.3.2 Continuous in-service training*

Providing continuous or ongoing in-service training is key to keeping health workers updated on the current development and changes in national HIV policies, guidelines, and protocols to provide appropriate services to the community and PLWH. According to WHO, in-service training refers to training persons already employed, e.g. health providers working in the public or private sector.

In-service training refers to practical work experience during studies and usually, after one or two years of the theory are completed. In-service nurse training enhances the performance of a nurse. A nurse feels enriched with additions of ideas, concepts, and activities. In-service training improves the overall personality of a nurse. Sometimes it is called in-service education and training (INSET), and it improves various aspects of the overall performance of a nurse. This has to be planned periodically and facilitated within the facility to access all staff members and encourage discussion of real cases within the facility. Online nursing is a dynamic profession subject to rapid changes, like the HIV programme hence the need for in-service training for nurses. In-service training can be described as training that has been systematically planned, is carried out by a trainer within an institution, and takes place during normal working hours. Nurses are essential in transforming healthcare and health systems. Being educated to degree-level ensures nurses are well equipped to provide high-quality care. It also prepares them to take the lead, inform and design health services delivery, decision making, and policy development.

#### *5.5.3.3 Continuous professional development*

CPD is the term used to describe the learning activities professionals engage in to develop and enhance their skills. Health workers are expected to keep themselves abreast of the current trends and development in research to provide quality services. NIMART should be registered and accredited as one of the CPD programmes with SANC or HWSETA that must attend annually to accumulate points. CPD enables learning to become conscious and proactive rather than passive and reactive. Furthermore, CPD is professionals' holistic commitment to enhancing personal skills and proficiency throughout their careers. CPD combines different methodologies for learning, such as training workshops, conferences and events, e-learning programmes, best practice techniques, and ideas sharing, all focused on helping an individual to improve and have effective professional development. This can be managed by professional bodies such as SANC and HWSETA.

#### *5.5.4 NIMART training and implementation regulation*

NIMART training is not yet registered and accredited as a formal pre-service or CPD programme. It is not recognized as an expert in government even though it is recognized by non-governmental organizations (NGOs) supporting the government with HIV management. There are no incentives for providing an additional expert role as a NIMART nurse or clinical mentor, which demoralizes NIMART nurses. This delays the implementation of WHO recommendations for task shifting of creating an enabling regulatory environment for implementation, sustainability, and quality care. This requires all stakeholders, guideline developers, decision, and policymakers to fast-track engagements to register and apply for accreditation of the NIMART training with all relevant education and training quality assurance bodies such as SANC, HWSETA, and Department of Higher Education and Training as vocational training and consider as expert skills with additional remuneration for scarce skills or other forms of incentives can be implemented to motivate nurses.

*Perspective Chapter: Enhancing the Nurse-Initiated Management of Antiretroviral Therapy… DOI: http://dx.doi.org/10.5772/intechopen.107982*
