REVERSING THE BRAIN DRAIN: BUILDING CAPACITY IN HIV/AIDS TREATMENT
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 Rwanda Training, Nov.2004 While such training as described in the box is valuable, there are other approaches which can improve health workers' capacity while ensuring that they remain in their own countries and that the skills taught match the available resources and infrastructure. These include telemedicine, distance learning and hospital linkage programs, especially clinical preceptorship. What is clinical preceptorship? Through clinical preceptorship, the training is conducted in the trainee's workplace. The preceptor accompanies trainees as they treat their patients, and essentially trains them 'on the job'. This approach strengthens the professional and human qualities required of a skilled practitioner and ensures that the skills taught fit in with the trainees' daily realities. The program includes theory, practice and observation. It provides HIV/AIDS healthcare professionals with the most up-to-date information on new treatments and technologies, while incorporating the information into their local clinical practice. The challenge for preceptors is to take into account the specific needs of individual trainees based on their levels of experience and the situations in which they practice. How does a clinical AIDS preceptor work? Professor Michael L. Alkan, Senior Physician of the Infectious Diseases Institute at the Soroka Medical Center and Ben Gurion University Center for Health Sciences, Israel. For years, he has shared his experience and skills with the global medical community, in locations as varied as Ecuador, India, Kyrgyzistan, Nepal, Papua New Guinea, and the US. In this article he shares his experiences of working as a clinical AIDS preceptor in Botswana (for ACHAP, the African Comprehensive HIV/AIDS Partnerships) and in China. Knowledge, innovation and training to overcome AIDS in Botswana Following a request from the ACHAP program conveyed through the MSD HIV initiative, Professor Alkan has been approached by MSD Israel HIV team that has been invited to present the Botswana program at the annual congress of the AIDS centers in Israel. Following this announcement by MSD Israel at the tribune of the congress, several Israeli HIV specialists' and HIV centers nurses enthusiastically proposed their support and declared their willingness to travel. Prof. Alkan has been to date the first that could travel but he paved the way for future participations. He spent two terms in the Maun region, in one of the first four sites to benefit from the launch of the National ARV (antiretroviral) Therapy Program. There he provided theoretical and practical training following a curriculum developed by the government's KITSO AIDS program and based on the Botswana National Guidelines for Antiretroviral Therapy. KITSO AIDS stands for "Knowledge, Innovation and Training Shall Overcome AIDS". A regular day would start with a 30-minute lecture on a general topic such as viral hepatitis, tuberculosis, diagnostics or anorexia. All lectures end up covering HIV/AIDS, the major problem in Botswana. Then it's time for morning rounds, seeing all the patients, both children and adults, with pathologies ranging from a man attacked by a lion ('Where else could I see that?!' he asks) to a baby with AIDS, little more than skin and bones and totally dehydrated from diarrhea. Afternoons are spent at the hospital, coaching the local staff and doing some administrative work. Has he had an impact? The number of patients on anti-AIDS treatment rose from 15 to 50 by the time he left Botswana, which is a huge achievement, considering the short period of time he spent in this country and the current medical environment. 'But when you know that one in three pregnant women is HIV-infected, and that the number of people in need of AIDS treatment is overwhelming, you feel incompetent and useless', was the Professor's humble comment. How will the government be able to finance the growing number of treatments needed, when will we see a reduction in the number of patients being treated? What about the high turnover of healthcare providers in hospitals; how can you ensure continuity in the care and treatment given to the patients? He sees these as the major challenges at the moment. As he puts it: 'There are two extremes to fighting this epidemic: one is the Mother Theresa attitude: save souls, wash old beggar's feet, help the dying into heaven. The other extreme is the way the WHO eradicated smallpox: go all the way to the last village, take care of everybody, so that nobody has a viral load which is high enough to infect partners or offspring. The truth unfortunately is in between these two extremes, and doing a bit of this and some of that might be the only realistic option for poor Africa'. But clinical preceptorships are playing a valuable role and their success is obvious. Combating HIV/AIDS in China In May 2005, Merck & Co., Inc. signed a public-private partnership agreement with the Chinese Ministry of Health to create a comprehensive HIV/AIDS program focused on prevention, care, treatment and support. Merck & Co., Inc and The Merck Company Foundation committed US$30 million over five years to support the China-MSD HIV/AIDS Partnership (C-MAP). The program started in Liangshan Prefecture (Southern Sichuan Province) and aims to establish a model that can be replicated elsewhere in China. This province was chosen in part because the at risk population - largely intravenous drug users and commercial sex workers - are a national priority and drivers of the country's HIV/AIDS epidemic. 
Pr. M.L. Alkan, Infectious Diseases Institute Soroka Medical Center & Ben Gurion University, Beer Sheva, Israel Professor Alkan's role in this partnership was to teach local doctors how to treat HIV/AIDS patients. He visited them once a week at their workplace and gathered them at an office in Xichang City for lectures and to discuss cases. His work was the first step in C-MAP healthcare worker training programs and established the foundation for future preceptors in Liangshan Prefecture. But although the program is well-oiled, Professor Alkan soon discovered that the approach he took in Botswana could not be 'copied and pasted' to different countries. The KITSO Training Program needed to be adapted to China because the country has so little in common with Botswana: the latest UNAIDS statistics are 650,000 HIV infected people in China and 75,000 new infections per year, nationwide. Botswana has 1.6 million and Liangshan Prefecture has 4.2 million people. The usual barriers to preceptorship-language, behavior codes, habits, beliefs, climate and government-are all writ large in China, making it impossible to treat the two countries in the same way. For example, the language barrier meant that the success of his preceptorship depended entirely on his interpreter, Ms Luo Qianlai, who was extremely proficient at translating all his training materials and presentations. Another challenge was posed by China's decentralized administrative system which divides the country into counties, prefectures and provinces, each with a different level of power. The extreme climate affected attendance, with some days being too cold for students to venture out. Behavior codes, habits and beliefs were also very different from his previous experience. 
Nevertheless, the training proved popular. 'Sometimes you get more people taking the final test than your original number of trainees', he says. This is what happened in China. 'I had 14 trainees but 18 people took the test' he laughs. In this case he found out that his students had passed copies of this lecture handouts and CDs to other students who were eager to check their knowledge on HIV/AIDS and take advantage of this unique opportunity in a location as remote as Sichuan Province. Such was the high interest of the medical community for this kind of training.
There is little doubt about the value of clinical preceptorships, but many challenges remain in a country's struggle to upgrade medical knowledge, introduce international standards in the management of patients, and provide quality care and antiretroviral treatment for all in need of therapy. Preceptors face these challenges everyday, but Professor Alkan is undaunted: 'It is the difficulties we encounter in our daily work with the trainees that make our efforts to improve their competencies and skills worthwhile. After all, the ultimate beneficiaries are the patients, and they deserve our time and effort!' By providing in-house training, Professor Alkan and his colleagues are doing much to help the developing world. Not only are they stemming the loss of human resources by the developed world, but they are also helping build local capacity. The shortage of healthcare providers in developing countries is clearly linked to high death rates; if clinical preceptorship can help healthcare personnel stay put, at least one battle will be won in the on-going war against HIV/AIDS! (1) The "triple therapy" is the combination of three different, highly powerful antiretroviral drugs to treat HIV. Before its discovery, people were dying in large numbers. Triple therapy really made a difference because it was the first treatment that allowed people to live longer and better. Interview and article by S. d'Aurelle de Paladines, Editor : Fiona Hall |
A critical problem facing many developing countries is the steady loss of professionals to the developed world, tempted by the higher salaries, better working conditions and professional development opportunities.
Since 1990, the continent has been losing 20,000 Africans a year to other destinations. This hemorrhaging of skills means that Africa has to spend about US$ 4 billion every year on employing non-African expatriates instead. What can be done to stem the flow of professionals from this vast and needy continent?
