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\fs20\insrsid8530842\charrsid8530842 Lancet. 2008 Jul 26; 372(9635):341-3.
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HIV education for health-care professionals in high prevalence countries: time to integrate a pre-service approach into training }{\fs36\cf1\insrsid6819624 
\par }\pard \s17\ql \li0\ri0\nowidctlpar\faauto\rin0\lin0\itap0\pararsid6819624 {\i\f38\fs17\cf17\insrsid6819624 
\par 
\par V Renggli, I De Ryck, S Jacob, H Yeneneh, S Sirgu, L Mpanga Sebuyira, A P\u-1279\'3ftzer, J Downing, C Portillo, J Murray, S Gove, R Colebunders }{\f38\fs17\cf17\insrsid6819624 
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\fs20\insrsid8723340\charrsid7616024 The HIV pandemic has placed an immense burden on the delivery of health-care services over the past two decades, especially in countries with high HIV prevalence. Ample }{\fs20\insrsid2562439 finances}{
\fs20\insrsid8723340\charrsid7616024 , continuous logistical input, and adequately trained human resources are required to set up high quality HIV treatment programmes. The avail\-
ability of skilled human resources remains one of the most serious obstacles to the roll-out of antiretroviral treatment programmes,}{\cs29\fs20\super\insrsid14250026 \chftn {\footnote\ftnalt \pard\plain 
\s28\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid14250026 \chftn }{\insrsid14250026  }{\insrsid14250026\charrsid14250026 
WHO. The world health report 2006 \endash  working together for health. http://www.who.int/whr/2006/overview/en/index.html (accessed July 24, 2007).}}}{\cs29\fs20\super\insrsid14250026\charrsid14250026 ,}{\cs29\fs20\super\insrsid14250026 \chftn 
{\footnote\ftnalt \pard\plain \s28\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid14250026 \chftn }{\insrsid14250026  }{
\insrsid14250026\charrsid14250026 Ntambwe M. Human health resources are key to HIV treatment in Africa. BMJ 2006; 333: 98.}}}{\fs20\insrsid8723340\charrsid7616024  and to the realisation of universal access to HIV prevention, treatment, and care by 2010.}
{\cs29\fs20\super\insrsid14250026 \chftn {\footnote\ftnalt \pard\plain \s28\ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid14250026 \chftn }{
\insrsid14250026  }{\insrsid14250026\charrsid14250026 WHO. Universal access by 2010. http://www.who.int/hiv/ universalaccess2010/en/index.html (accessed April 9, 2008).}}}{\fs20\insrsid8723340\charrsid7616024 
 Inadequate training of health-care professionals about HIV leads to compromised patient care and perpetuates the spread of myths and other erroneous information that can negatively }{\fs20\insrsid2562439 affect}{\fs20\insrsid8723340\charrsid7616024 
 providers\rquote  attitudes toward people living with HIV/AIDS, to the extent that sta}{\f39\fs20\insrsid8723340\charrsid7616024 \u-1280\'3f}{\fs20\insrsid8723340\charrsid7616024  refuse to care for them.}{\cs29\fs20\super\insrsid14250026 \chftn 
{\footnote\ftnalt \pard\plain \s28\ql \fi-90\li90\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid14250026 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid14250026 \chftn }{\insrsid14250026  }{
\insrsid14250026\charrsid14250026 Quach L, Mayer K, McGarvey ST, Lurie MN, Do P. Knowledge, attitudes, and practices }{\insrsid14250026 among physicians on HIV/AIDS in }{\insrsid14250026\charrsid14250026 
Quang Ninh, Vietnam. AIDS Patient Care STDS 2005; 19: 335\endash 46.}}}{\cs29\fs20\super\insrsid14250026\charrsid14250026 ,}{\cs29\fs20\super\insrsid14250026 \chftn {\footnote\ftnalt \pard\plain 
\s28\ql \fi-90\li90\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid14250026 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid14250026 \chftn }{\insrsid14250026  }{\insrsid14250026\charrsid14250026 
Reis C, Heisler M, Amowitz LL, et al. Discriminatory attitudes and practices by health workers towards patients with HIV/AIDS in Nigeria. PLoS Med 2005; 2: e260.}}}{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 The rapid scale-up of antiretroviral treatment pro\-grammes in resource-limited settings has required an emergency response for capacity building. Standardised }{\fs20\insrsid2562439 simplified}{
\fs20\insrsid8723340\charrsid7616024  treatment protocols and decentralised service delivery have been keystones in the chosen public-health approach.}{\cs29\fs20\super\insrsid11535015\charrsid10698580 \chftn {\footnote\ftnalt \pard\plain 
\s28\ql \fi-90\li90\ri0\widctlpar\tx90\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid11535015 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid11535015 \chftn }{\insrsid11535015  }{
\insrsid11535015\charrsid11535015 Gilks CF, Crowley S, Ekpini R, et al. The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings. Lancet 2006; 368: 505\endash 10.}}}{
\cs29\fs20\super\insrsid10698580\charrsid10698580 ,}{\cs29\fs20\super\insrsid11535015\charrsid10698580 \chftn {\footnote\ftnalt \pard\plain \s28\ql \fi-90\li90\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid11535015 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid11535015 \chftn }{\insrsid11535015  }{\insrsid11535015\charrsid11535015 WHO. Global AIDS treatment emergency requires urgent response: no mor
e business as usual. http://www.who.int/ mediacentre/releases/2003/pr67/en (accessed Nov 26, 2007).}}}{\cs29\fs20\super\insrsid10698580\charrsid10698580 ,}{\cs29\fs20\super\insrsid10698580 \chftn {\footnote\ftnalt \pard\plain 
\s28\ql \fi-90\li90\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid10698580 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid10698580 \chftn }{\insrsid10698580  }{\insrsid10698580\charrsid10698580 
WHO. IMAI/IMCI chronic HIV care with ARV therapy and prevention. http://www.who.int/hiv/pub/imai/Chronic_HIV_ Care7.05.07.pdf (accessed April 30, 2008).}}}{\fs20\insrsid11535015  }{\fs20\insrsid8723340\charrsid7616024 
 To bridge the HIV skills and knowledge gap among practising health-care providers, in-service HIV training courses were launched across the globe. Training was }{\fs20\insrsid2562439 offered}{\fs20\insrsid8723340\charrsid7616024 
 through ministries of health, often in collaboration with international partners, non-govern\-mental organisations, and academic institutions in both public and private sectors. }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 
In-service training has allowed the rapid preparation of clinical teams in many new sites able to provide chronic HIV care, antiretroviral therapy, and prevention. There has also been an increasing emphasis on on-site training of clinical teams followed b
y
 regular supportive super vision and clinical mentoring after training. However, in-service training is expensive and often depends on donor support. Problems with training strategies and poor management can mean that access to in-service training is unev
e
n; those who require training most urgently are often not given priority to attend such training. Moreover, after being trained, health-care professionals are often transferred to other positions. Skilled personnel able to replace the trainees may be lack
i
ng, particularly in remote areas where health-care providers desperately need training, since access to expert support and referrals are more limited than in urban settings. The absence of participants from work exacerbates the human resource crisis by in
creasing the workload for clinic providers who are left to attend to patients. }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 When other members of antiretroviral clinical teams lack training, the application of skills gained by recent trainees can be compromised. An assessment of the Nigerian nationa
l antiretroviral training programme showed that about 50% of trainees were unable to practise gained skills because of lack of support, poor institutional capacity, and lack of motivation from institutions and colleagues.}{
\cs29\fs20\super\insrsid10698580 \chftn {\footnote\ftnalt \pard\plain \s28\ql \fi-90\li90\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid10698580 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\cs29\super\insrsid10698580 \chftn }{\insrsid10698580  }{\insrsid10698580\charrsid10698580 Idigbe EO, Odutolu O, Okonkwo P, et al. Evaluation of the Nigerian national antiretroviral (ARV) treatment training program. SAHARA J 2006; 3: 488\endash 502.}}}{
\fs20\insrsid8723340\charrsid7616024  Emphasis on training whole clinical teams rather than individuals and on-site clinical mentoring has helped to address this problem. }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 
While in-service training provides an immediate response to an acute need for rapid HIV prevention, care, and treatment scale-up, training needs have evolved over time. The increased requirements for more robust training place additional pressures on in-s
e
rvice training delivery and require an adaptation of training initiatives. HIV medicine is a rapidly evolving science with a short half-life of current knowledge. More mechanisms need to be built into training programmes in resource-limited settings to pr
ovide sta}{\f39\fs20\insrsid8723340\charrsid7616024 \u-1280\'3f}{\fs20\insrsid8723340\charrsid7616024 
 with regular updates on HIV knowledge. A practical solution to this dilemma is strengthening pre-service education and continuing medical education programmes.}{\cs29\fs20\super\insrsid10698580 \chftn {\footnote\ftnalt \pard\plain 
\s28\ql \fi-90\li90\ri0\widctlpar\tx90\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid10698580 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid10698580 \chftn }{\insrsid10698580  }{
\insrsid10698580\charrsid10698580 McCarthy EA, O\rquote Brien ME, Rodriguez WR. Training and HIV treatment scale-up: establishing an implementation research agenda. PLoS Med 2006; 3: 989\endash 93.}}}{\fs20\insrsid8723340\charrsid7616024  }{
\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 Pre-service education could boost the numbers of trained health-care professionals in resource-limited settings. At a WHO meeting in June, 2007, several international training partners co
nvened to discuss the inclusion of the Integrated Management of Adolescent and Adult Illness (IMAI) training package into pre-service curricula. A strong emphasis was placed on pre-service education being critical to the successful scale-up of HIV prevent
ion, care, and treatment services. Partners proposed to identify key HIV content to strengthen pre-service curricula and to collaborate in the development of materials to support improved HIV pre-service curricula. }{\fs20\insrsid13258470\charrsid7616024 

\par 
\par }{\fs20\insrsid8723340\charrsid7616024 Several training organisations }{\fs20\insrsid2562439 offer}{\fs20\insrsid8723340\charrsid7616024  pre-service tech\-
nical assistance such as redesigning curricula to include HIV content and faculty development training to build capacity for faculty HIV expertise. For example, the WHO Department of Child and Adolescent Health and Development, together with 
Jhpiego, an international health organisation }{\fs20\insrsid2562439 affiliated}{\fs20\insrsid8723340\charrsid7616024  with Johns Hopkins University (Baltimore, MD, USA), have developed a learning package on the skills needed to }{\fs20\insrsid7690456 
effectively }{\fs20\insrsid8723340\charrsid7616024 teach in a pre-service context.}{\cs29\fs20\super\insrsid15412512 \chftn {\footnote\ftnalt \pard\plain \s28\ql \fi-90\li90\ri0\widctlpar
\tx90\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid15412512 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid15412512 \chftn }{\insrsid15412512  }{\insrsid15412512\charrsid15412512 WHO, Jhpiego. E}{
\f39\insrsid15412512\charrsid15412512 \uc1\u-1280\'3f}{\insrsid15412512\charrsid15412512 ective teaching: a guide for educating healthcare providers. http://www.jhpiego.net/resources/pubs/e}{\f39\insrsid15412512\charrsid15412512 \uc1\u-1280\'3f}{
\insrsid15412512\charrsid15412512  teach/ E}{\f39\insrsid15412512\charrsid15412512 \uc1\u-1280\'3f}{\insrsid15412512\charrsid15412512 Teach_man.pdf (accessed April 30, 2008).}}}{\fs20\insrsid8723340\charrsid7616024 
 IMAI in-service materials have been used in Ethiopia, Swaziland, and Fiji to }{\fs20\insrsid7690456 offer}{\fs20\insrsid8723340\charrsid7616024  pre-service educatio
n to graduating batches of health-care professionals. Ethiopia is planning to fully integrate the content of IMAI training material into pre-service training curricula. Workshops on HIV content integration have been held with key faculty from nursing, mid
w
ifery, and selected medical school departments of universities in Addis Ababa, Gondar, and Jimma to update course syllabi and integrate HIV core competencies. Further examples of pre-service education initiatives in resource-limited settings are given in 
the panel. }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 
Pre-service education provides an organised and systematic approach to ensure that all professionals within a given setting are inculcated with fundamental HIV knowledge before entering the workforce. Pre-service education in the long term is l
ess costly than in-service training and avoids workplace absences. Proper education in HIV prevention, care, and treatment also helps to positively shape the attitudes of health-care professionals towards people living with HIV/AIDS, reduce mis\-
conceptions, and increase access to care.}{\cs29\fs20\super\insrsid2174604 \chftn {\footnote\ftnalt \pard\plain \s28\ql \fi-90\li90\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid2174604 
\fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid2174604 \chftn }{\insrsid2174604  }{\insrsid2174604\charrsid2174604 
Downing J. A meta-evaluation of a palliative care education strategy in rural Uganda. PhD thesis. Manchester, UK: Manchester Metropolitan University, 2006.}}}{\fs20\insrsid8723340\charrsid7616024  }{\fs20\insrsid7690456 Professionals}{
\fs20\insrsid8723340\charrsid7616024  who are enlightened early on during their training can serve as strong patient advocates to educate others about the importance of supporting people living with HIV/AIDS. }{\fs20\insrsid13258470\charrsid7616024 

\par 
\par }{\fs20\insrsid8723340\charrsid7616024 However, academic institutions are under constant pressure to increase student enrolment to expand the health workforce. Increasing stu
dent intakes is often done without attending to investments in infrastructure, equipment, and personnel. Many institutions are in advanced states of decrepitude, especially those that train mid-level or lower level health-care workers\emdash 
ie, those more likely to stay and work in the system\emdash or those located in remote areas away from capital cities. }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 Another key challenge is that pre-service curricula are often already too densely packed, causing reluctance to add further content. Thus, a full review of the pre
-service curricula is needed. However, many faculties do not have expertise in HIV care and treatment nor in curriculum development, and lack resources to undertake such a review. Although pre-service HIV education is required immediately, the process of 
designing new curricula and getting them approved by pertinent stakeholders could take several years. }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 More funding should be dedicated to pre-service education in HIV prevention, care, and treatment. Pre-service curricula need to be reviewed and updated w
ith quality HIV content. A way forward would be the development of a generic HIV curriculum for each cadre of health-care professionals that could be adapted for individual countries and settings. HIV care as a topic has to be thoroughly integrated with o
ther health-care topics, such as tuberculosis, malaria, cancer, and palliative care, and presented in the context of a public-health approach to quality primary health care, community involvement, and participatory planning of services. }{
\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 
Indeed, more than just incorporation of new content into existing curricula is required. Beside investments in infrastructure and equipment, faculties will require ongoing technical assistance and capacity building in curriculum development. Moreover, cli
n
ical support to feel empowered to teach HIV content to students and to remain updated with changing HIV interventions is needed. The presence of faculty mentors working on-site at academic institutions could greatly enhance the quality of teaching in both
 didactic and clinical settings. Clear competencies and learning objectives need to be established to guide students in their clinical rotations. }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 Constructive thinking about teaching methodology, student-faculty ratios, the time ratio between classroom le
arning (and its quality) and clinical practice, and about the actual availability of teachers and clinical instructors is also needed. A network between WHO, partners in pre-service education, and ministries of health and education has to be established t
o strengthen collaboration for }{\fs20\insrsid2562439 defining}{\fs20\insrsid8723340\charrsid7616024 
 quality HIV content for pre-service education and supporting curricula improvement and ongoing updates. This should be done within an integrated approach to primary care. }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 As an extension of pre-service education, we should also strengthen continuing medical education pro\-grammes to keep the HIV knowledge of health-care }{\fs20\insrsid2562439 staff}{
\fs20\insrsid8723340\charrsid7616024  in the }{\fs20\insrsid2562439 field}{\fs20\insrsid8723340\charrsid7616024  up to date, preferably in a manner that does not disrupt patient care. Possible methods include distance learning programmes, furth
er theoretical and practical training sessions at the workplace, and clinical mentoring.}{\cs29\fs20\super\insrsid8486467 \chftn {\footnote\ftnalt \pard\plain \s28\ql \fi-90\li90\ri0\widctlpar
\tx180\aspalpha\aspnum\faauto\adjustright\rin0\lin90\itap0\pararsid8486467 \fs20\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {\cs29\super\insrsid8486467 \chftn }{\insrsid8486467  }{\insrsid8486467\charrsid8486467 
WHO. WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings. http://www.who.int/hiv/pub/ meetingreports/clinicalmentoring/en/index.html (accessed April 30, 2008).}
}}{\fs20\insrsid8723340\charrsid7616024  }{\fs20\insrsid13258470\charrsid7616024 
\par 
\par }{\fs20\insrsid8723340\charrsid7616024 Although in-service training courses are acceptable as an emergency response to disseminate new knowledge in HIV prevention, care, and treatment, training initiati
ves have to evolve further to meet increasing demands and requirements. If we aim for universal access to HIV prevention, care, and treatment, we must ensure that all health-care professionals are properly educated. Therefore, the timely integration of ad
e
quate and regularly updated comprehensive HIV training into pre-service curricula of all cadres of health-care professionals is of paramount importance. Not only redesigning training curricula but also upgrading faculties and providing support for empower
ment in teaching HIV content to students is needed. Continuing collaboration between WHO, partners, and ministries to rapidly produce and continuously update strong HIV content for pre-service education and continuing medical education is needed. 
\par }{\insrsid7616024 \sect }\sectd \sbknone\linex0\sectdefaultcl\sectrsid7616024\sftnbj\saftnnar \pard\plain \ql \li0\ri0\widctlpar\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid13258470 \fs24\lang1033\langfe1033\cgrid\langnp1033\langfenp1033 {
\insrsid8723340\charrsid13258470 
\par }}