Primary Healthcare Nurse Practitioner
(PHC-NP) and Medical Officer (MO) Task
Sharing of MDR-TB in Rural Kwa-Zulu
Natal, South Africa
Jason Farley, PhD, MPH, NP, FAAN
Associate Professor, Johns Hopkins University School of Nursing
Adjunct Associate Professor, Uni. of KZN, SA and Uni. of Technology Sydney
Pres-Elect, Association of Nurses in AIDS Care www.aids2014.org

Farley, J.E.
1 ; Walshe, L.
1 ; Budhathoki, C.
1 ;
Mlandu, N.
2 ; Nomusa, N.; Ndjeka, N.
3 ; van der Walt, M.
4
Johns Hopkins University School of Nursing 1 ; Ugu District
Department of Health, KwaZulu Natal, South Africa 2 ;
South African National Department of Health 3 ; South
African Medical Research Council 4 www.aids2014.org

• South Africa has the 2 nd highest rate of new
TB cases in the world
(http://www.cdc.gov/tb/topic/globaltb/Southafrica.htm)
• Highest rate of drug-resistant TB cases in
Africa
(http://www.cdc.gov/tb/topic/globaltb/Southafrica.htm)
• 4 th Highest Prevalence of HIV/AIDS
(http://www.cdc.gov/tb/topic/globaltb/Southafrica.htm)
• Over 70% of all TB cases co-infected with HIV
(SA DOH, 2012) www.aids2014.org

• Following national guidelines, every effort should be made to ensure eligible clients are enrolled as soon as possible.
– all primary care, antenatal,
TB and mobile outreach health facilities must become fully functional nurse-initiated
ART and MDR-TB initiation sites for adults, children and pregnant women.
www.aids2014.org

• Prospective cohort of MDR-TB patients jointly managed by a PHC-NP and a MO.
– Patients who initiated treatment between January 1 and December 31,
2012
– Who either completed IP or experienced a negative outcome (i.e., death, failure, default) were included.
• We evaluate the intensive phase (IP) quality indicators and risk for IP negative outcomes.
• Descriptive statistics by provider type for demographic and time-to-event variables. www.aids2014.org

• Provider comparisons for time-to-event IP indicators were made using a log-rank test, and contribution of other covariates, e.g. gender, HIV status assessed.
• Cumulative risk of remaining event free beyond a time point shown using a Kaplan-Meier plot
• A competing risk analysis with death, failure or default as competing negative outcomes was completed. www.aids2014.org

www.aids2014.org

Diagnosis and Clinical Management of MDR-TB
Short Course Overview
Mentored Training Experiences:
 Audiology training
 Visual assessment training
 Laboratory Monitoring & Evaluation
 ADR evaluation & treatment www.aids2014.org
1 week intensive theory
+
1 Month CNP Clinical
Mentoring
+
Competency Evaluation
+
Ongoing Clinical Mentoring

Developing Systems Level Strategies for Safe
Prescribing www.aids2014.org

• After extensive training of the PHC-NP, patients were assigned a primary provider with task sharing throughout.
CNP
Outpatient
Standardized
MDR-TB
Treatment per guidelines
Standardized HIV
Management
MD
Hospital
Patients requiring any changes to standardized treatment
Baseline liver disease, baseline renal disease, seizure, psychosis, pregnant, low BMI (<45 kg)
<13 years old, Diabetic, past Drug induced hepatitis, Re-treatment MDR-
TB, Requires O2 support; Nonambulatory; Critical values for Baseline
FBC, U&E, LFTs?
www.aids2014.org

www.aids2014.org

• 186 eligible patients, 50% females with 77% unemployment.
• At enrollment, median age was 33 years (Q1-Q3 26-
40), median weight 54 kg (Q1-Q3 47-60).
• HIV co-infection was 73% (median CD4 count 237,
Q1-Q3 121-399); 77% on ART. www.aids2014.org

Characteristic Overall Nurse Physician
Age (yrs),
Median (Q1-Q3), n n=186 n=122 n=64
Sex, n (%)
Male
Female
Unemployed, n(%), n=173
93 (49.7)
94 (50.3)
133 (76.9)
65 (52.8)
58 (47.2)
91 (78.5)
28 (43.8)
36 (56.2)
42 (73.7)
BMI, Median (Q1-Q3), n 19.6 (16.4-
22.6), n=133
19.1 (16.4-
21.9), n=110
Normal ALT, n (%), n=158
Normal creat clearance, n
(%), n=128
HIV positive, n (%), n=185
CD4 count,
Median (Q1-Q3), n
On ART, n (%), n=138 www.aids2014.org
142
(89.9)
116
(90.6)
135 (73.0)
237
(121-399), n=120
106 (76.8)
95
(89.6)
84
(93.3)
92 (75.4)
233
(120-424), n=85
72 (76.6)
22.3
(15.9-26.1), n=23
47
(90.4)
32
(84.2)
43 (68.3)
241
(135-352), n=35
34 (77.3)
P-value*
0.732
0.281
0.565
0.109
0.950
0.180
0.301
0.324
0.950

Characteristic
Outcome, n (%), n=186
MDR-TB diagnosis to Tx start
(days),
Median (Q1-Q3), n
Tx start to culture conversion
(days),
Median (Q1-Q3), n
Overall
71 (51-97),
186
Nurse
71 (51-96),
123
Physician
74.5 (51-98),
64
P-value*
0.810
58 (32-92),
149
57 (32-91),
101
62 (32-111.5),
48
0.594
Tx start to end of intensive phase (days),
Median (Q1-Q3), n
196 (180-
210) 143
196
(186-212)
98
196
(176-205)
45
0.608
*P-value from a Fisher’s exact test for categorical outcome, from a Wilcoxon rank-sum test for diagnosis to Tx start, and from a log-rank test for the time-to-event variables www.aids2014.org

www.aids2014.org

• There was no significant difference between nurse managed patients and physician managed patients for time from treatment initiation to a negative outcome (default, failure or death) (p=0.561, HR=1.17)
Andersen, P.K., et al. 2012. Competing risks in epidemiology: possibilities and pitfalls; International Journal of
Journal of the American Statistical Association, 94(446), 496{509.

Nurse Physician P-value* Characteristic
Outcome, n (%), n=186
Overall
Still on Treatment (Tx) 68 (36.6)
Cure
Failure
Death
Default
Tx start to a negative outcome (default, failure or death) (days),
Median (Q1-Q3), n
51 (27.4)
12 (6.5)
26 (14.0)
29 (15.6)
134
(32-350)
61
*P-value from a log-rank test
47 (38.2)
35 (28.5)
6 (4.9)
18 (14.6)
17 (13.8)
134
(26-370)
39
21 (33.3)
16 (25.4)
6 (9.5)
8 (12.7)
12 (19.1)
167.5
(32-308)
22
0.609
0.561
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• MDR-TB IP quality indicators are similar among patients initiated in a task sharing model.
• No difference in risk for negative outcomes was noted based on provider type suggesting task sharing may be a human resource solution to improve access to care in MDR-TB/HIV co-infection.
www.aids2014.org

• Task sharing = equivalent, although not ideal outcomes
• Increase # of new initiations per week
– 6 in baseline period to 18 in NI-MDR period
• CNP see’s all patients at triage
• Implementation of baseline physical exams and symptom screening on 100% of CNP patients
• Increase in community-based management
– Less than 10% in baseline period to 29% in NIT period www.aids2014.org

Nurses Stepping Up to Increase Access to
Care
Bed capacity
HCW availability excellence?
here?
What if the provider has been clinic or home?
Individual Resources
Taxi availability
Health status to care?

www.aids2014.org

• Medical Research Council
– Martie van der Walt
• Ugu District Department of
Health
– Ntombasekaya Mlandu
– Bheki Shazi
• National Department of
Health DR-TB Directorate
– Norbert Ndjeka
– Pamela Richards
– David Mamjeta
• Murchison & KGV Hospitals
– Simi Lachman & Iqbal Master
– Marge Govender-Singh
– BL Ngesi
• KwaZulu-Natal Department of Health
– Jackie Ngozo
– Bruce Margot
• Johns Hopkins University
– Louise Walshe & Jeane Davis
– Chakra Budhathoki
– Rachel Kidane, Keya Joshi, Katrina
Reisner, Maria Brown www.aids2014.org

• Jason Farley
– jfarley1@jhu.edu
– @jasonfarleyJHU www.aids2014.org

www.aids2014.org