Postgraduate Diploma in TB-HIV Management

Purpose

This qualification seeks to bridge the training gaps identified by targeting primary care and community-level clinicians. and other professional HCWs and provide them with the knowledge and capacity to manage TB/HIV co-infected patients as well as implement infection control measures in a primary health care setting. By targeting underserved, rural and hard-to-reach districts and sub-districts as well as working with PHC facilities across South Africa, this qualification will support the decentralization of services and help increase geographic coverage and access to comprehensive prevention, care and treatment services for TB and HIV.

This will be achieved through providing up-to-date information on diagnostics and treatment policies, as well as providing basic research understanding and skills in order for clinicians to report on basic operational research projects, including assessing clinic recorded data, in a primary health care (PHC) setting. The qualification is offered part time over two years.

Rationale

In Southern Africa, tuberculosis (TB) remains a major cause of morbidity and mortality, and is the leading cause of death in HIV/AIDS patients. Given the overwhelming burden of these two diseases, TB and HIV need to be treated predominantly at primary health care (PHC) level and significant task shifting to junior doctors and especially nurses is required. However, these patients can be very ill and clinical skills are often out of balance with responsibilities. Healthcare worker (HCW; Doctors and nurses) competency and adequacy largely determine programme quality and efficiency, particularly in the TB programme and ART clinics. Therefore, this skills gap hampers the effective scale-up and delivery of quality TB and HIV services at the PHC level. The overall result is poor progress toward the goals of the current HIV, STIs and TB National Strategic Plan (NSP). Thus, HCW training is vital to improving quality and performance of TB/HIV services.

In 2012 the International Center for AIDS Care and Treatment Programmes (ICAP) and the Desmond Tutu HIV Centre (DTHC) performed a Training Needs Assessment among various stakeholders in the Provincial Departments of Health and TB Control Programmes and among key informants, including TB/HIV Managers and TB Programme Coordinators, in Free State, Northern Cape, Mpumalanga, Eastern Cape, Western Cape and Limpopo. The institution identified the following learning needs and gaps: a training course that incorporates general and more specialised topics, including advances in diagnosis and management of all forms of TB, (including MDR/XDR-TB and paediatric TB), TB-HIV co-infection management and infection control. By targeting underserved, rural and hard-to-reach districts and sub-districts as well as working with PHC facilities across South Africa, the qualification will support the decentralisation of services and help increase geographic coverage and access to comprehensive prevention, care and treatment services for TB and HIV. The use of a distance-based, online delivery qualification for this qualification will circumvent the difficulties associated with removing HCWs from the workplace, and access to standard, didactic teaching opportunities for staff working in rural or outlying clinics.

In the Training Needs Assessment performed, some areas expressed infrastructure concerns (in particular the Northern Cape, Mpumalanga and Free State provinces reported inconsistent IT access). However, even in these provinces the concept of onsite online training was well received. The main advantage being that staff does not need to leave their work place in order to receive the training.

This qualification seeks to bridge the training gaps identified by targeting primary care and community-level clinicians, and other professional HCWs and provide them with the knowledge and capacity to manage TB/HIV co-infected patients as well as implement infection control measures in a primary health care setting. By targeting underserved, rural and hard-to-reach districts and sub-districts as well as working with PHC facilities across South Africa, this qualification will support the decentralisation of services and help increase geographic coverage and access to comprehensive prevention, care and treatment services for TB and HIV.

This will be achieved through providing up-to-date information on diagnostics and treatment policies, as well as providing basic research understanding and skills in order for clinicians to report on basic operational research projects, including assessing clinic recorded data, in a primary health care (PHC) setting. The qualification is offered part time over two years.

Recognition of Prior Learning (RPL)

Students will be considered as RPL candidates if they submit a case study in support of their application and have 3 years work experience in the primary health clinical setting.

Entry Requirements

The minimum requirements for admission into this Postgraduate Diploma are

• Bachelor of Medicine and Bachelor of Surgery (MBChB).

And

• Proof of registration with the Health Professions Council of South Africa (HPCSA).

Or

• A four-year Bachelor of Nursing.

And

• Proof of registration with the South African Nursing Council.

Or

• A 4 year Bachelor's Degree in the Health Sciences with current experience in HIV-TB management.

And

• Current practise in a primary health clinical setting.

This qualification comprises compulsory modules at Level 8 totalling 120 Credits.

Compulsory Modules Level 8, 120 Credits

• Clinical Management of HIV, 20 Credits.
• Clinical Management of TB, 20 Credits.
• TB-HIV Co-infection and Infection Prevention and Control, 35 Credits.
• Operational Research, 33 Credits.
• Biostatistics, 12 Credits.

• Demonstrate knowledge of and engagement in clinical management of HIV and TB.
• Understand the theories of HIV and TB epidemiology, treatments, and methods of clinical management of HIV and TB.
• Understand how to apply such knowledge in a clinical setting at the national primary health care level.
• Demonstrate the ability to interrogate multiple sources of knowledge in HIV and TB management and to evaluate knowledge and processes of knowledge production.
• Demonstrate an understanding of the complexities and uncertainties of clinical management of HIV and TB, focusing on regiments and treatment of the diseases as mono or co-infections.
• Demonstrate the ability to determine best treatment options for different patients, and does not require the acquisition of new examination skills.
• Develop and demonstrate the ability to identify, analyse and address complex problems of HIV/TB infection and treatments drawing systematically on international and national guidelines.
• Demonstrate the ability to identify and address ethical issues based on critical reflection on the suitability of different ethical value systems to HIV/TB diagnosis, treatment and management.
• Demonstrate the ability to critically review information gathering, synthesis of data, evaluation and management processes in operational research in order to develop creative responses to problems and issues relevant to HIV and TB.
• Present and communicate academic, professional or occupational ideas effectively to peers and experts, offering creative insights, rigorous interpretations and solutions to problems and issues appropriate to HIV and TB clinical context.
• Demonstrate the ability to operate clinically within the current national HIV and TB guidelines.
• Demonstrate the ability to apply, in a self-critical manner, learning strategies which effectively address his or her professional and ongoing learning needs and the professional and ongoing learning needs of others due to the structure of the online course which encourages self-learning and management.
• Demonstrate the ability to take full responsibility for his or her work, decision-making and use of resources, and full accountability for the decisions and actions of others where appropriate.

The following Associated Assessment Criteria will be assessed in an integrated manner across the Exit Level Outcomes.

• Describe the epidemiology of HIV worldwide, in sub-Saharan Africa and in South Africa.
• Demonstrate effective clinical application of algorithms for HIV diagnosis in children and adults.
• Use new diagnostic tools/algorithms to confirm HIV infection in patients with confirmed or suspected TB.
• Recognise and manage common opportunistic infections.
• Recognise and manage the adverse reactions to co-trimoxazole.
• Discuss the lifecycle of HIV and where the different ART drug classes interrupt this cycle.
• Identify and prepare patients (both adults and children) who are eligible for ART.
• Select the optimal first line treatment for different patient scenarios.
• Monitor patient's response to ART.
• Recognise and manage common side effects and drug interactions of ARV drugs.
• Identify and manage drug resistance and treatment failure.
• Explain why patient-initiated treatment interruptions occur and how to re-initiate patients on ART.
• Recognise and treat Immune Reconstitution Inflammatory Syndrome (IRIS).
• Manage patients with HIV-HBV co-infection, hepatic impairment, renal impairment or epilepsy.
• Describe the global and local epidemiology of drug-sensitive and drug-resistant TB (MDR/XDR TB).
• Demonstrate effective clinical application of algorithms for TB diagnosis.
• Differentiate between drug-resistant TB and drug-sensitive forms of TB.
• Demonstrate accurate recording and reporting, using correct tools.
• Describe the role of BCG vaccination and when it should be used.
• Describe the management of contacts of TB patients, including children under-five and babies born to a mother with TB.
• Explain the modes of action of anti-TB drugs.
• Describe the first line regimen for pulmonary TB.
• Recognise and manage the common side effects related to taking anti-TB medications.
• Identify potential adverse drug interactions while on anti-TB medications.
• Describe drug interactions with TB drugs.
• Describe when to start TB treatment in children.
• Identify which children should be referred for assessment.
• Describe hospital admission and discharge criteria for TB patients.
• Monitor response to treatment properly.
• Manage treatment interruption correctly.
• Describe the available second line TB drugs.
• Describe the development and transmission of drug-resistant TB.
• Describe risk factors for and causes of Drug Resistant TB.
• Manage drug-resistant TB and related activities effectively at the provincial and district TB programme level.
• Recognise treatment and management of drug-resistant tuberculosis from the TB programme perspective.
• Describe the challenges with centralised management of DR-TB in specialised units.
• Describe the advantages and disadvantages of decentralised and deinstitutionalised management of DR-TB.
• Describe drug classes available for the treatment of DR-TB.
• Describe the treatment for mono- and polyresistance.
• Describe the standard treatment regimens for MDR and XDR-TB in adults and children.
• Describe new developments in the treatment of DR-TB.
• Describe how to monitor patients on DR-TB treatment.
• Explain TB/HIV service integration in terms of: What is it? Why is it important? How do we implement TB/HIV integrated services?
• Demonstrate correct application of Isoniazid Preventive Therapy (IPT).
• Explain the advantages and risks of starting ARVs early for TB patients.
• Determine the optimal time period in which to commence a patient on ART as well as the optimal ART regimen for that patient.
• Discuss how to manage HIV-positive patients with TB (including drug-resistant TB) in routine and special circumstances.
• Recognize common drug interactions between TB treatment and ARVs.
• Identify and manage the most common overlapping side effects of anti-TB and ARV drugs.
• Manage patients with TB-IRIS.
• Explain the possible reasons for clinical deterioration of HIV positive patients on TB treatment.
• Discuss the barriers patients face in adhering to treatments.
• Assist patients in developing strategies to improve treatment adherence.
• Explain and apply the theories of health behaviour in developing strategies to improve treatment adherence.
• List key populations for increased adherence support.
• Provide integrated adherence support to the TB/HIV co-infected patient.
• Manage TB/HIV co-infected patients with poor adherence and defaulters.
• Explain why infection prevention and control is important in TB care.
• Identify infection control strategies to prevent the transmission of TB in the healthcare setting.
• Adapt a sample TB Infection Control (TBIC) plan to the local situation.
• Identify the importance of contact tracing.
• Identify necessary post-exposure prophylaxis (PEP) for Sexually Transmitted Infections (STIs) and HIV, including occupational PEP.
• Understand the role of research generally, and operational research (research that seeks to improve health care service delivery by asking and answering questions about the operations of existing health care services).
• Provide both a brief overview of operational research and simple tools to enable clinicians to critically assess clinical practices in their settings.
• Understand major study designs.
• Apply different study designs to answer different types of or questions.
• Explain confounding, identify potential confounding influences in different or settings.
• Understand the tools used to deal with confounding effects in or in study design and/or analysis.
• Develop a practical understanding of how to collect data to address a research question.
• Develop a practical understanding of databases for collecting quantitative data for analysis.
• Understand the basic principles of research ethics and how these apply to the design and conduct of operations research.
• Understand the importance and the characteristics of a good research question.
• Explain a study population and study sample.
• Understand different types of study populations in or and how these can be applied in practice.
• Explain the strengths and limitations of different sampling methods.
• Understand the structure and purpose of a research protocol.
• Review literature on a relevant research topic and write a short literature review.
• Understand the processes and stakeholders involved in planning, conducting and reporting on research.
• Understand the structure of a research report or paper.
• Understand the principles of presenting and interpreting research results.
• Write a research abstract based on research results.
• Summarise graphically various types of data and relationships between variables, calculate measures of central tendency and dispersion, and conduct an exploratory data analysis.
• Recognise and interpret common descriptive and inferential statistics used in scientific journals in the health sciences, and link them to the research question and type of data.
• Interpret study outcomes in terms of the magnitude of the descriptive statistics (e.g. clinical importance of mean differences between groups), statistical significance (p-values), and precision (standard error and confidence intervals).
• Apply simple procedures for estimation and hypothesis testing, understanding their underlying assumptions and recognizing when they are not applicable and other more advanced techniques are needed.

Integrated Assessment

Formative Assessment

For each module this will include 2 written assignments that account for 40% of the grade. All students will be asked to sign a plagiarism declaration when submitting assignments. There will be clear timeframe for marking and return of assignments to allow students to benefit from formative feedback prior to submission of further assessment tasks.

Clinical cases and audit portfolio

The qualitative assignment that constitutes the course mark is an assessment of the application of learning material to the learners work clinical work context. In it we assess the application of the theoretical principals and guidelines of HIV and TB care in practise from their performance via:

• A clinical audit in their work environment, in which current practices are assessed, compared to best practice policies/guidelines and progress reviewed against a standard (such as National Strategic Plan or Millennium Development Goals).
• The description of the management of relevant clinical cases. This is done in a reflective, blog format (with patient confidentiality strictly maintained). Feedback is provided to the students at various points, both from instructors and fellow students, which also encourages peer to peer learning.

Final course assessment consists of an externally moderated, computer-based assessment at the end of the course that accounts for 60% of the grade. Students will log onto the examination page with their student ID and password and will electronically sign confirmation of their identity. A certificate of completion will be given to students who obtain a passing grade (50%) for both the formative and final course exam components. However, course credits will only be obtained after successful completion of the on-site integrated assessments.

DP requirement

Students must complete all the e-learning activities outlined in the course, participate in 75% of online forum discussions tracked via Vula site statistics, and the assignments in order to write the final course exam. Students must obtain a certificate of completion (i.e. a pass mark) for each component course in order to sit the respective integrated assessment. E-learning activities include:

Pre and Post Module assessments

These are assessments that the students write before they view the course material (Pre) and after working through course material (Post). They allow the academic staff to gauge the entry level of the participants as well as gauge the effectiveness of the course material provided in meeting the learning objectives (compulsory).

Study session tasks

These are formative assessments that are provided within the material with automatic feedback provided to the learners at key points. They are designed to help the student integrate material provided in the course material with self-study learning material (prescribed reading material). They mainly comprise short answer questions and short clinical case studies.

Self-Assessments

These are formative assessments that the student does on completion of the online learning material for the specific study session. These are set as multiple choice questions and are designed as a tool for the student to assess their understanding of the material covered.

Learning forums

The forums form the weekly discussion groups on various topical issues pertaining to the clinical management of HIV and TB. These may be journal articles or discussions on treatments guidelines.

Integrated Summative Assessments

This qualification will have two components: TB-HIV Management & Infection Control, and TB-HIV Operational Research. Each component will have an integrated summative assessment held on site at UCT and invigilated by academic staff conversant with the course material. These externally moderated assessments will include additional, different questions on the course material, as compared to the individual final course exams.

The TB-HIV management component will be comprised of 3 courses - courses 1 and 2 will be examined in the first integrated assessment and course 3 will be examined in the second integrated assessment. Students will be required to pass all three TB-HIV management courses before they are allowed to sit the integrated assessments which will be held on the same day.

The TB-HIV Operational Research component will comprise of two courses, with a combined integrated summative assessment.

Summative assessments will account for 60% of the final mark for each component (30% each for the TB-HIV management component). The final marks for each of the courses within components, weighted accordingly, will account for the remaining 40% of the final mark.

If students pass the integrated assessments, they will receive the allocated credits for the respective components of this qualification. Students who obtain a grade of <50% in one or more of the integrated assessments will be allowed a second attempt to sit the assessment/s when the integrated assessment/s are held the next year. Students who fail a second attempt will have to repeat the courses.

These courses are focusing on current best clinical practises and guidelines, as well as the evidence base for those guidelines. There are no specific clinical skills being taught or examined. Therefore there are no clinical examinations or OSCEs.

Rather, this qualification aims to provide updated information on diagnostic tools, as well as an understanding of current diagnostic and treatment policies and guidelines as well as discuss the evidence-base of these policies.