Document(s) 11 de 31

Introduction

In December 2003, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS launched the ‘3 by 5’ initiative to help low- and middle-income countries provide treatment to three million people living with HIV/AIDS. Although the target date of December 2005 was not met, the global efforts to scale up access to antiretroviral therapy (ART) have brought positive changes worldwide. At the end of 2006, more than two million people living with HIV were being treated with ART in low- and middle-income countries.¹

It has been an enormous challenge to introduce ART in a safe and effective way in resource-limited settings. The lack of human resources and clinical expertise has required approaches such as task shifting and continuum-of-care models where non-HIV specialists, nurses and lay providers all play a role in HIV/AIDS care. The public health approach that was proposed by the WHO in 2003 has provided the tools necessary to deliver decentralized HIV care, including ART with limited resources.²

It is clear that supportive supervision and clinical mentoring is the cornerstone of this public health approach in most of the resource-constrained clinical settings, where the health system is already weak and overwhelmed. Telemedicine (using the telephone, email, Internet or videoconferencing) is one possible way of offering clinical mentoring. We have established a telemedicine service for physicians working in HIV/AIDS services in low-resource settings.

The HIV/AIDS TELEmedicine service

The Institute of Tropical Medicine in Antwerp (ITMA) has run a short course on ART (SCART) every summer since 2003. The course provides three weeks of training on ART and clinical management of HIV infection for more than 40 physicians from resource-poor countries. After completing the course, a hybrid web/email forum is offered to the participants to support their decision-making and assist in the management of difficult HIV/AIDS cases in their daily clinical practice (Figure 9.1).³

The patient’s history, physical examination, laboratory findings and questions to be answered are sent to a network of HIV/AIDS specialists using a discussion forum accessed through the TELEmedicine website (Figure 9.2). All postings submitted to this discussion forum are stored in a database and available for consultation. An internal email account is also available for direct contact between members, facilitating the exchange of recent literature, policy documents and interaction between sites. In addition, a system of email warning messages can be used to give early notice when a new posting is available on the discussion forum.

The TELEmedicine website contains interesting clinical cases and answers to common questions. This information can be consulted through a search function for continuing medical education (CME). Policy documents, guidelines and supporting material on HIV/AIDS care in low-resource settings and links to other important web-sites are also accessible.^4,5 The website conforms with the Health On the Net Foundation Code of Conduct.⁶ This code is designed to improve the reliability of health information on the web. It defines a set of rules for website developers to ensure that readers always know the source and the purpose of the information that they are reading.

Service usage

Between April 2003 and March 2007, the TELEmedicine service received 642 second-opinion requests, from more than 35 resource-constrained countries. Three-quarters of the teleconsultations concerned management of complex medical problems in a specific patient and one-quarter were questions in the field of organization of health services for HIV prevention, treatment and care, vaccination programmes and guidelines.

In the first three years of activity (April 2003–March 2006), there were 491 queries. Of these, 47% (n = 230) were related to the general use of antiretrovirals, side effects, second-line regimens, prevention of mother-to-child transmission (PMTCT), immune reconstitution syndrome, TB/HIV and management of other co-infections during ART; 40% (n = 197) were related to the diagnosis and treatment of specific opportunistic infections and 13% (n = 64) to general topics such as the organization of health services for AIDS care, directly observed TB therapy, vaccination programmes and guidelines (Figure 9.3).

During the first three years of TELEmedicine activity, we noticed a significant increase in the proportion of questions related to organizational issues of HIV programmes: from 8% during the first year to 27% during the third year (P < 0.001). The opposite occurred for questions on general use of antiretrovirals (from 14% to 5%), management of side effects (from 12% to 5%) and management of specific opportunistic infections (from 44% to 30%); these differences were significant (P < 0.05).

There was a clear reduction in the numbers of questions on general use and side effects of antiretrovirals and a significant increase in questions concerning the

Figure 9.1 TELEmedicine website³

Figure 9.2 TELEmedicine website discussion forum

Figure 9.3 Telemedicine referrals (first three years of service). ARVs, antiretrovirals; IRIS, immune reconstitution inflammatory syndrome; OIs, opportunistic infections; TB, tuberculosis; PMTCT. prevention of mother-to-child transmission

organizational issues of ART programmes. This is related to the maturing of the HIV/AIDS programmes. Thus, in the last two years, we have received many questions about ART roll-out: how to increase access to treatment and care, how to implement PMTCT services in ART clinics, and how to extend care to paediatric HIV cases. These questions do not arise in the early stages, when the burden of first-line access to HIV care is the main problem. It is also clear that management of opportunistic infections remains a challenge, and training programmes should not neglect this aspect of HIV care.⁷

User satisfaction

A survey was conducted in 2006 to evaluate clinicians’ perception of the TELEmedicine service. The members were divided into ‘active users’ (i.e. clinicians who participated in the discussion forum) and ‘passive users’ (i.e. clinicians who consulted the TELEmedicine forum but did not post clinical cases and/or questions there).

There was a response rate of 53% among active users (18/34). Among these respondents, the service was judged to have been useful in influencing the management of the patients in 100% of cases, and 67% of the users perceived that the advice was useful in more than 75% of cases. The service was beneficial for the establishment of the diagnosis (78%), for the referring clinician’s education (55%) and for reassurance (39%).⁸

Computer skills

Lack of access to information remains one of the major barriers to the practice of evidence-based medicine in low-resource settings. The problems include limited access to computer facilities, to literature databases and to CME programmes.

At the end of the short courses in 2004 and 2005, we assessed physicians’ access to the web and their abilities to use computers while working in the field. Out of the total of 84 trained physicians, who were mainly African and Asian nationals working for international organizations or for the ministry of health, 75 completed the questionnaires. While 11% of the physicians stated that they did not have access to the web, almost all of them (74/75) said that they had their own email account. Of the respondents, 69% preferred to access the Internet in the evening (17:00–midnight). A connection speed of at least 28.8 kbit/s was available to 40% of them. For 83%, the operating system they used was Windows 2000/XP, 93% had a CD reader and 63% had a sound card on their computers. Two-thirds of the users reported that they were able to download files and to use software such as Acrobat, Excel, PowerPoint, WinZip and Word.

Online course

Although web access and information and communication technology (ICT) ability and use remain limited in low-resource settings, our selected group of physicians who attended the short course showed a good level of basic informatics knowledge, ability to use computers and access to the Internet.⁹ This type of information helped us to plan the delivery of online modules through the website for CME purposes and to start the conversion of the face-to-face course to an online training modality (eSCART).

The eSCART content is structured into 13 different modules and uses a problem-based learning approach with clinical cases, tutorials, additional readings and self-assessments. At a workload of 4–5 study hours per week, the 3-week face-to-face course requires a minimum of 3 months’ online training. To expand the availability of the eSCART course, we intend to work with appropriate international organizations and offer adaptations for HIV/AIDS programmes in low-resource settings.

Other telemedicine approaches

Consultations

Some HIV/AIDS programmes in low-resource settings have developed a consultation system that allows newly trained providers to ask questions of an expert through direct telephone calls, email and call centres. Telephone contact is usually set up so that health care workers and patients can make a toll-free or low-cost phone call to a central location.

Call centre in Uganda

The AIDS Treatment Information Centre at the Infectious Disease Institute (IDI) of Makerere University in Kampala hosts a call centre that responds to providers’ treatment questions. The centre operates during normal office hours.¹⁰ It is staffed by clinical pharmacists, who are supported by the IDI faculty. The call centre automatically records the caller’s telephone number, and the staff return the call at no cost to the caller. The centre automatically develops a database of the most frequently asked questions.¹¹

Satellife (HealthNet)

This is an international not-for-profit organization that uses the Internet for health information purposes in the developing world.¹² The organization aims to improve the communication and exchange of information in the fields of public health, medicine and the environment. There are global discussion groups (e.g. in nutrition, essential drugs, paediatric management and nursing). Using a low-Earth-orbit satellite and telephone lines for telecommunication, the organization provides email access in 140 countries, to a total of about 10 000 health care workers. Special emphasis is placed on areas of the world where access is limited by poor communications, economic conditions or disasters. Where adequate telecommunication links exist, Satellife and other organizations provide higher-capacity email and Internet connections. These allow the transmission of email attachments such as image files. The patient’s findings can be described in an email message, and digital photographs of the patient and their investigations, such as electrocardiograms and X-ray films, can then be attached. This ‘store-and-forward’ telemedicine does not allow real-time interaction, but it permits specialist support in the management of difficult cases (see Chapter 19).

Case conferences

Another way to mentor health care workers is through case conferences, i.e. regular meetings to discuss complex problems in HIV care and to provide updates on practices or guidelines. For example, telephone conferences are used by the Heineken Company for mentoring its health care workers. In the period October 2001 to December 2003, the company had 10 health care workers operating in 5 different African countries. A total of 268 problems were raised during 45 telephone conferences. There were 79 questions (29%) about ART, 53 (20%) about the diagnosis and treatment of opportunistic infection, 43 (16%) about antiretroviral toxicity, 40 (15%) about care organization and policy, 32 (12%) about laboratory or drug supply, and 21 (8%) about biological parameters. The level of satisfaction among local company physicians was 65% for logistics, 89% for scientific relevance, 84% for applicability of advice and 85% overall. The most common complaints concerned the poor quality of the telephone connection and language problems for francophone participants. This showed that database-supported telephone conferencing could be useful for mentoring company health care workers in their routine care of HIV-infected workers and family members.¹³

Twinning

An established relationship between two institutions to share expertise is referred to as twinning. Ideally, these are long-term partnerships (at least three years), with clear, common objectives that serve as a basis for exchanging expertise and experience for the benefit of both institutions. A twinning broker, such as the Twinning Center,¹⁴ develops and supports twinning partnerships. The Twinning Center is also exploring mechanisms to support collaboration between institutions in resource-constrained settings.¹¹

Another example of this approach is the collaboration between the Moi University Faculty of Health Sciences in Kenya and both the Indiana University School of Medicine and the Brown University School of Medicine in the USA.

Twinning increases resources for individual institutions by facilitating a flow of funds and an exchange of information and expertise from one institution to the other. There is, however, a limit to the number of available twinning programmes, and trainers from foreign institutions are not always knowledgeable about local conditions, language or policy.¹⁵

Other web-based collaboration and telemedicine systems

There are a number of other web-based collaboration and telemedicine systems, not restricted to the field of HIV.

AIDSPortal

This is an Internet portal that provides tools to support global collaboration and knowledge sharing among new and existing networks of people responding to the AIDS epidemic.¹⁶ AIDSPortal offers: networking (members can access a directory of people and organizations to locate others interested in similar problems or working in a particular place); policy dialogue (the most up-to-date information on policy initiatives and international processes is easily accessible through AIDSPortal, and people can share information about their engagement); country-led management (supporting constructive dialogue between national responses and experiences and international processes); and access to information (AIDSPortal facilitates access to information given the time and resource constraints facing organizations responding to HIV and AIDS).

Community-based HIV treatment programme in Haiti

Partners In Health and Zanmi Lasante launched a community-based HIV treatment programme in Haiti’s impoverished central plateau. It is a web-based medical record system linking remote areas in rural Haiti. It is used to track clinical outcomes, laboratory tests, drug supplies, communications, data analysis and drug supply management. Decision support is particularly useful for interpreting laboratory results. Technicians at two clinical sites enter patients’ CD4 cell counts. Each night, a program checks for patients with low CD4 counts who are not receiving the appropriate drug regimen. A warning email message is sent to all 20 Zanmi Lasante clinicians and contains a link to the electronic medical records of patients who require additional treatment. Reminders can also be generated for patients who require extra drugs or investigations.¹⁷

Cell-Life

This is a platform for communication, information and logistical support to manage HIV/AIDS patients, enabling close monitoring of ART adherence and providing support to health care workers visiting AIDS patients in remote areas. The system supports communications technology, such as mobile phones and the Internet.^18,19

RAFT (Réseau en Afrique Francophone pour la Télémedecine)

The RAFT project permits remote collaboration, case discussion and data sharing over low-bandwidth networks between the Geneva University Hospitals and 10 French-speaking African countries.^20,21 The core activity of the RAFT is the webcasting of interactive courses. Other activities include videoconferences, teleconsultations based on the iPath system, collaborative knowledge base development, support for medical laboratory quality control, and the evaluation of the use of telemedicine in rural areas (via satellite connections) in the context of multisectorial development. The project uses Linux and other open source software.

iPath

This is Internet-based software for the exchange of medical knowledge, distance consultations, group discussions and distance teaching in medicine and allows image sharing in pathology, radiology and dermatology.^22,23 It is being used in Africa, Asia and the Pacific. It is built with open source software, which is available free at www.sourceforge.net. More than 200 discussion groups use the iPath system.

Conclusions

More than two million people infected with HIV are now receiving ART in middle-and low-income countries. However, this has created extraordinary demands on health care workers in areas where health systems were already weak and overwhelmed. Thus, there are several problems in scaling up treatment programmes. A number of approaches are being tried, including mobilization of national and private partners, decentralization of HIV/AIDS services, and training and mentoring of health care workers.

It is evident that training and supervision are critical factors. Over the past few years, private donors and large organizations, such as the President’s Emergency Plan for AIDS Relief and the Global Fund, have begun to be involved in pre-service training and mentoring of health care workers dealing with HIV/AIDS care in low-resource settings. Some developing countries have established collaborations with external partners to access training curricula or shape existing didactic material into a new model of teaching (training of trainers, onsite refresher courses, CME and distance learning), and some of the programmes have even expanded the range of support, offering attachments or onsite mentoring.

Telemedicine is one of the approaches to mentoring health care workers in low-resource settings, even though exhaustive data about its effectiveness are not yet available. In many settings, connectivity and computer literacy are still major limitations. In our experience, the opportunity for continued dialogue with physicians in the field has been valuable. It has allowed the identification of HIV/AIDS knowledge gaps and provided answers to some critical questions. Decisions on how to best support programmes on HIV/AIDS care in low-resource settings should really be made after taking into account the questions raised in the field.

The Institute of Tropical Medicine in Antwerp offers both face-to-face training courses and online training in ART. The TELEmedicine website also supports the management of difficult HIV/AIDS clinical cases via a discussion forum, where a network of international specialists is available to give second opinion advice. This is just one example of mentoring health care workers and providing direct support in the management of HIV/AIDS clinical cases. We believe that by giving clinicians the opportunity to access support and clinical mentoring, it is possible to lower the threshold for launching ART programmes. In addition, updating staff through CME helps to maintain quality in ART programmes, even in resource-limited settings.

Acknowledgements

This work was supported by the Belgian Directory General of Development Cooperation. We thank Vera Van Boxel and Joris Menten for the data analysis and Carlos Kiyan for offering advice.

Further reading

Latifi R. Establishing Telemedicine in Developing Countries: From Inception to Implementation. Amsterdam: IOS Press, 2004.

Norris AC. Essentials of Telemedicine and Telecare. Chichester: Wiley, 2002.

Sørensen T. Guidelines for a country feasibility study on telemedicine. Norwegian Centre for Telemedicine, 2003. Available at: www.telemed.no/guidelines-for-a-country-feasibility-study-on-telemedicine.64916-7398.html.

Swinfen Charitable Trust Website. Available at: www.swinfencharitabletrust.org.

Wootton R, Craig J, Patterson V. Introduction to Telemedicine, 2nd edn. London: Royal Society of Medicine Press, 2006.

References

¹ World Health Organization. Towards Universal Access: Scaling up Priority HIV/AIDS Interventions in the Health Sector. Geneva: WHO, 2007. Available at: www.who.int/hiv/mediacentre/univeral_access_progress_report_en.pdf.

² World Health Organization. Antiretroviral Therapy for HIV Infection in Adults and Adolescents: Recommendations for a Public Health Approach. Geneva: WHO, 2006. Available at: www.who.int/hiv/pub/guidelines/artadultguidelines.pdf.

³ TELEmedicine website. Available at: telemedicine.itg.be.

⁴ Zolfo M, Lynen L, Dierckx J, Colebunders R. Remote consultations and HIV/AIDS continuing education in low-resource settings. Int J Med Inform 2006; 75: 633–7.

⁵ Zolfo M, Arnould L, Huyst V, Lynen L. Telemedicine for HIV/AIDS care in low resource settings. Stud Health Technol Inform 2005; 114: 18–22.

⁶ Health On the Net Foundation. Quality and Trustworthiness of the Medical and Health Web. Available at: www.hon.ch/visitor.html.

⁷ Zolfo M, Koole O, Renggli V et al. Online consultations for HIV/AIDS care in resource-limited settings. In: Proceedings of the 11th Congress of the International Society for Telemedicine, 26–29 November 2006, Cape Town, South Africa.

⁸ Zolfo M, Renggli V, Koole O et al. Telemedicine survey on users’ satisfaction. In: Proceedings of the 11th Congress of the International Society for Telemedicine, 26–29 November 2006, Cape Town, South Africa.

⁹ Zolfo M, Lynen L, Renggli V et al. Computer skills and digital divide for HIV/AIDS doctors in low resource settings. In: Proceedings of Med-e-Tel, 5–7 April 2006, Luxexpo, Luxembourg.

¹⁰ AIDS Treatment Information Centre Website. Available at: www.idi.ac.ug/index.php?m=menu&i=170.

¹¹ World Health Organization. WHO Recommendations for Clinical Mentoring to Support Scale-up of HIV Care, Antiretroviral Therapy and Prevention in Resource Constrained Settings. Geneva: WHO, 2006. Available at: www.who.int/hiv/pub/guidelines/clinicalmentoring.pdf.

¹² AED-SATELLIFE website. Available at: www.healthnet.org.

¹³ Clevenbergh P, Van der Borght SF, van Cranenburgh K et al. Database-supported teleconferencing: an additional clinical mentoring tool to assist a multinational company HIV/AIDS treatment program in Africa. HIV Clin Trials 2006; 7: 255–62.

¹⁴ HIV/AIDS Twinning Center website. Available at: www.twinningagainstaids.org.

¹⁵ McCarthy EA, O’Brien ME, Rodriguez WR. Training and HIV-treatment scale-up: establishing an implementation research agenda. PLoS Med 2006; 3: e304.

¹⁶ AIDSPortal website. Available at: www.aidsportal.org.

¹⁷ Jazayeri D, Farmer P, Nevil P et al. An Electronic Medical Record system to support HIV treatment in rural Haiti. AMIA Annu Symp Proc 2003: 878.

¹⁸ Cell-Life website. Available at: www.cell-life.org.

¹⁹ Skinner D, Rivette U, Bloomberg C. Evaluation of use of cellphones to aid compliance with drug therapy for HIV patients. AIDS Care 2007; 19: 605–7.

²⁰ AFT website. Available at: raft.hcuge.ch.

²¹ Geissbuhler A, Bagayoko CO, Ly O. The RAFT network: 5 years of distance continuing medical education and tele-consultations over the Internet in French-speaking Africa. Int J Med Inform 2007; 76: 351–6.

²² iPath website. Available at: telemed.ipath.ch/ipath.

²³ Brauchli K, Oberholzer M. The iPath telemedicine platform. J Telemed Telecare 2005; 11(Suppl 2): 3–7.

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