HIV care in most countries and settings depends on multidisciplinary teams, although it can take time to develop these. Even well-established services often lack some professionals such as trained specialist pharmacists who could be invaluable.
It has been argued that the role of the HIV specialist doctor becomes ever more central as the multidisciplinary team expands, as he/she needs to take overall responsibility for the treatment and care provided, even though the individual patient may only rarely be seen by that specialist. Additional and different resources may be needed, for example, to enable doctors to take on a greater role in training colleagues. However, even this role may need to be shared and delegated.
ROUX: All practical tasks and functions regarding ARV delivery can be delegated, providing there is someone experienced at hand with whom to consult. A system of 'mentorship', where more experienced workers are available initially to demonstrate and later to oversee management works well. Another application of this basic idea is to develop capacity and skills through a 'hen and chicken' approach where those who have been trained can train others - while still being assisted through a dendritic support network.
"We have not quite achieved multidisciplinarity because our pharmacist is not part of the clinic (yet) and our counsellors are still learning about the specific adherence problems we encounter. We have had access to HAART for 18 months now and have just accumulated enough information on the 150-odd children we have on treatment to have some sort of idea of what is going wrong and why - not much by the way, our figures compare well with those recently quoted out of Africa.
"When it comes to acknowledging people's roles, and non-monetary rewards, the reward of seeing well children running around the clinic goes a long way to providing affirmation. I think an opportunity for each health care worker to write down a job description - followed by a joint review by worker and supervisor would help to chart subtle changes.
"In my view the doctor becomes more of a facilitator, consultant and supervisor - but it's a delicate balance because one also wants to be a hands-on part of the system that delivers continuity of care. The 'hen and chicken' idea, if it includes sufficient time to rotate through a 'base clinic' and satellite clinics, would spread training capacity.
GREEN: All of the major hospitals in Indonesia have long had an 'AIDS Working Group', which is usually multidisciplinary. However, few of these groups have had any real impact partly because only recently have the hospitals started to receive a significant number of AIDS cases. Some of these groups have taken responsibility for management of ART in their area.
"I suspect that the possible degree of delegation is greater than the willingness of the profession to delegate. My experience is that doctors are very protective of their positions. There clearly is a need to convince the profession that lay people can play a role&
"In Indonesia, we hear stories of nurses and other professionals who are unwilling to move into counselling, primarily because there is no career structure in this 'profession', but also because it is a tremendously stressful job.
REGENSBERG: We support fully the concept of a multidisciplinary team. In our programme, the bulk of the disease management is in fact done by a group of trained pharmacists and nurses supported by two full-time doctors and several part-time HIV Specialists. In practice the doctors/consultants only deal with the more complex cases or where there is multi-drug resistance. The nurses and pharmacists are kept up to date by encouraging them to attend CME meetings and regular training sessions are held.
ORRELL: In our programme in Guguletu, Cape Town, the doctors do only the clinical piece. All the education is handled by therapeutic counsellors. Each patient is assigned a counsellor at the commencement of therapy three patients per counsellor. The counsellors are HIV positive themselves and have had three weeks of training as treatment support personnel. The nurse takes bloods, dispenses drugs and makes appointments.
RABKIN: The MTCT-Plus Initiative [which operates in several African countries] was designed from the start to utilize multidisciplinary teams, based on the success of this care strategy in resource-rich settings as well as recognition of the human resources constraints in resource-poor settings. Our training programmes include whole teams, and emphasizes the need for regular team meetings, interdisciplinary communication, and the involvement of lay providers, including peer educators.
PRABHU: Delivery of these services needs to be through an HIV dedicated team, since it requires a lot of time, commitment and allocation of resources to ensure that workers in the field are adequately paid for, which is very important. Units of these HIV teams could be set up in different regions with training and overall supervision by experts in the field, to ensure that processes run smoothly and that anyone who accesses these services get the best quality of clinical care available. Even if it takes a longer time to implement, quality must not be sacrificed. Involvement of peer educators, nurses and other health workers is welcome, as long as a central HIV physician who understands the issues is at the helm of affairs and steering the boat along.
BENTWICH: Physicians still need to be assessing progression of disease and drug adverse effects. That said, there is growing reliance on physician assistants (when they are available) and of course on nurses. Generally these two categories can take on much of the work load off physicians. Our setting has not suffered from under staffing and so it is difficult to compare to developing countries. However from experience I gained in Africa, the development of multidisciplinary teams is doable and extremely worthwhile. The doctors have to adjust to their new roles of educators of larger staffs and as leaders of multidisciplinary teams, but the most successful and "ideal" model would be the one that succeeds in maintaining some sort of direct role in the treatment of patients aside from the leadership and educational roles. There is no substitute for a good role model. The more responsibility and commitments there is in the leadership the more the staff and people are ready to take such roles themselves.