Pre-training knowledge and opinions among HCWs on TB and HIV
Two groups of HCWs (total n = 67) completed the pre-training assessment (Fig ). While most HCWs had adequate knowledge of HIV transmission routes, 7% of participants believed HIV was not transmitted through breast milk and 3% answered that HIV could be transmitted via mosquito bites. Questions on important concepts such as the window period in HIV testing, universal precautions and the natural history of HIV were answered correctly by most HCWs.
Figure 1 Pre- and post-training HIV and TB knowledge among 67 health care workers involved in TB management in Kinshasa, DRC. p-values were obtained by Chi-square testing for difference in proportions. HIV: human Immunodeficiency virus; TB: tuberculosis; CD4: (more ...)
Important gaps were identified and included knowledge of HIV epidemiology, the link between TB and HIV, the meaning of CD4 counts, principles of CPT, OI management and occupational PEP (Fig ). The majority (56%) of participating HCWs substantially underestimated the burden of HIV in Africa, with 36% participants being convinced that only 10% of people living with HIV reside in Africa. In contrast, the HIV prevalence in DRC was overestimated by almost half (45%) of HCWs, with 15% answering that more than 30% of the DRC population was infected with HIV, which is almost 10-fold the Joint United Nations Programme on HIV/AIDS (UNAIDS) HIV prevalence estimate of 3.2% for 2005 [8
]. Only 11 (16%) participants answered correctly that, in the DRC, HIV prevalence is higher among TB patients than in the general population. Less than half (43%) of the HCWs knew that lower CD4 counts are associated with more severe immunosuppression. Fourteen (21%) participants did not know that CPT should be continued when anti-tuberculosis treatment is completed. Only 29 (43%) chose to first clean the lesion in case of a needle-stick injury.
Opinions on patients' rights and confidentiality varied. Most HCWs (48, or 72%) believed that a patient's HIV test result could not be divulged to a colleague when referring the patient for care (OI treatment), because the test result is a medical secret. When asked if the HCW has to test all TB patients for HIV, 44 participants (66%) answered yes, 21 participants (31%) answered no and two participants left the question open. Most believed this was: "to ensure good care and follow-up of our patients even after the treatment of tuberculosis", but two participants answered "because the HIV test is obligatory" and three others answered "to develop statistics on HIV among TB patients". Fifteen (22%) participants did not agree that a HCW can accept a test refusal because: "Refusing an HIV test is equivalent to keeping the patient ignorant and that is discrimination" and "It is for the patient's own good. The patient should know his serology so he can better protect himself and prolong his stay on earth."
Content of the training modules
Table details the content of the training. Topics included HIV epidemiology, transmission modes and natural course of HIV infection, HIV prevention within the health care setting (universal precautions), the link between TB and HIV, the WHO policy on collaborative TB/HIV activities, provider-initiated HIV counseling and testing in the TB clinic, care for HIV co-infected TB patients, and monitoring and evaluation of HIV activities, including the use of a modified TB treatment card. Training on the management of HIV co-infected TB patients focused on CPT, nutritional education and psychosocial support. Training on management of OIs focused on care feasible at primary health care level and indications for referral, rather than extensive training on diagnostics. Modules on ART were not included because of the policy to refer patients for ART and the extremely limited access to and experience with ART for patients with TB in the DRC [1
Content of training modules for TB/HIV collaborative activities at the primary health care level.
Topics were introduced using PowerPoint® presentations, interactive question-and-answer sessions, group discussions and case studies, either with the entire group or in small breakout sessions. HIV counseling was demonstrated by health care workers experienced in these activities, followed by practice during role-play sessions in small groups such that trainees could actively acquire the new skills. Trainers gave immediate feedback on trainees' performance during these sessions.
The training materials in French, consisting of a participant's manual, a trainer's manual, Power Point® slides, a training evaluation questionnaire and the revised treatment card can be obtained from the corresponding author.
Experience with continuing education and participatory problem solving
Continuing education, motivation and problem solving occurred during on-site supervisory visits and monthly meetings with HCWs actively involved in implementing HIV activities for patients with TB. Project staff noticed that, even though the training included role playing to familiarize HCWs with pre- and post test HIV counseling, several HCWs felt uncertain about their skills. This problem was resolved by the presence of trainers on-site during the first "real life" HIV counseling session. HCWs also struggled with the reorganization of their daily work schedule, a necessary step for efficient integration of HIV counseling and testing into routine patient care. This was resolved through on-site discussions with the HCW, and re-evaluated on the next supervisory visit.
Monthly meetings were an opportunity for continuing education, peer discussion and problem solving. Training modules for these meetings focused on specific issues such as family counseling, approach to counseling of minors, causes and effects of stigmatization, role of support groups for HIV co-infected patients, community participation in HIV and TB prevention and palliative care. Discussions among HCWs at the meetings mostly concerned approaches to patients who refuse HIV testing at TB diagnosis, counseling strategies for patients who refuse to accept their HIV status, management of patients who default CPT and strategies to help patients disclose their HIV status to family members.
Evaluation of the training and revision of the training manual
High training participation rates were achieved (91% to 100%) at all four consecutive Saturday training sessions and the training received positive feedback from participants. Sixty-five (97%) participants completed the post-training assessment, including 38 nurses, 16 laboratory technicians, 7 physicians and 4 district supervisors. The mean test score increased from 72% pre-training to 87% post-training (p < 0.001). There was no statistically significant difference in post-training score by type of HCW (p = 0.19), with a mean post-training score of 87% for nurses, 86% for laboratory technicians, 89% for physicians and 92% for district supervisors. The mean post-training scores of clinic's HCWs were significantly correlated with the clinic's HIV testing acceptance rate (Fig. ).
Correlation between mean post-training scores and HIV testing acceptance rate (first 3 months of implementation of HIV activities for TB patients) at 14 primary health care clinics in Kinshasa, DRC.
Post-training, HCWs demonstrated significantly increased and adequate knowledge of HIV transmission routes, HIV counseling and testing principles, natural history of HIV, link between TB and HIV, meaning of CD4 counts, CPT and management of OIs, patients' rights and the importance of confidentiality (Fig ). The only topics for which the proportion of correct answers remained below 80% were related to HIV epidemiology and PEP. One third of participants continued to have difficulties in estimating the burden of HIV and TB/HIV co-infection in the DRC and sub-Saharan Africa. Only 43 (66%) participants answered the PEP questions correctly.
Results of pre- and post-training assessments and observations made during the training guided the revision of the initial training manual. Topics that raised confusion or remained insufficiently understood were revised and more time was allocated to these topics in the revised modules. The revised modules were approved by the DRC National TB Program and used in roll-out of provider initiated HIV counseling and testing for TB patients in the DRC.