South Africa

PrEP is a prevention intervention for individuals at very high risk of contracting HIV that includes daily doses of medications that can stop HIV from taking hold and spreading throughout the body if used consistently and as prescribed. According to the U.S. Centers for Disease Control and Prevention (CDC), daily PrEP reduces the risk of sexual transmission of HIV by more than 90 percent – a success rate that increases further when combined with the use of condoms and other prevention methods. Among people who inject drugs, PrEP reduces the risk by more than 70 percent.

South Africa was the first country after the United States to approve PrEP as part of an overall combination HIV prevention strategy, but it has only been introduced in a limited number of sites, including pilot sites that provide services for key populations, such as female sex workers (FSWs) and men who have sex with men (MSM).

With a strong focus on developing a locally-driven and sustainable approach to the roll-out of PrEP – including increasing public awareness of the availability and benefits of PrEP – AIHA empowered Clinical Associates to train additional health workers on how to more effectively implement PrEP across many facility and community-based settings throughout South Africa.

The development of customized study material adjusted to the scope and needs of Clinical Associates in South Africa was crucial to the success of the pilot workshop and ultimately the launch of the online course.

To read the final report on this project, click here.

The 2006 South Africa National Human Resources for Health Planning Framework identified the need for mid-level workers in all professional disciplines to meet the country’s ever increasing need for healthcare services. Pharmacy services are no exception. According to the South African Pharmacy Council (SAPC), the optimal number of pharmacy support personnel the country needs to produce annually is 2,500, yet currently only about 1,000 are completing their studies.

To address this shortage, AIHA managed a twinning partnership between Nelson Mandela University (NMU) and St. Louis College of Pharmacy (STLCOP) from 2013 to 2017. Together, partners worked to support NMU’s Pharmacy Technician (PT) training program, which was established in 2013.

The overall goal of this twinning partnership was to strengthen the capacity of NMU to train skilled mid-level pharmacy workers capable of addressing existing gaps in service. Faculty development was a primary objective of the partnership, implemented through the development of teaching materials and workshops in innovative teaching and assessment methodologies.

To enhance the experience of students before they enter the workforce, partners helped NMU develop and manage a clinical experiential rotation program in various pharmacy work settings. NMU implements a clinical experiential program (externships) for PT students utilizing an electronic management system to better manage the hands-on training with STLCOP technical assistance and support.

AIHA also improved access to learning and teaching resources by introducing tablet devices for NMU modeled on our successful implementation of this method of support to South Africa’s Clinical Associate programs.

At the outset, partners conducted a practice analysis for mid-level pharmacy workers in South Africa to determine and verify PT responsibilities and scope of practice. This exercise also served to create an inventory of knowledge, skills, and competencies PTs need to become productive, effective members of the country’s health workforce. It also helped the team differentiate competencies of previously trained mid-level pharmacy assistants to better inform educational requirements for “up-skilling” to the PT level.

In July 2016, partners released The Southern African Pharmacy Technician Training Manual, the first textbook designed specifically for pharmacy technicians in the southern African region. This jointly developed text can be used as a learning tool for pharmacy technicians in English-speaking countries throughout southern Africa as part of a university- level course or as part of an on-the-job training program for mid-level pharmacy workers.

In 2018, AIHA will support NMU in the development of an in-service short course program for graduated pharmacy technicians, pharmacy assistants, and other healthcare workers. This course will supplement continuous professional development opportunities for health workers focusing on updated HIV guidelines, including UTT and same-day initiation, medication supply management, dispensing ARVs in the context of Centralized Chronic Medicine Dispensing and Distribution (CCMDD), ARV side effects and monitoring, TB co-infection, and health literacy communication.

To read the final closeout report of AIHA’s Twinning Center Program, click here.

In 2008, the National Department of Health in South Africa launched a new Clinical Associates Program to increase the number of mid-level medical professionals in the workforce.

This 3-year degree program produces qualified professionals — similar to Physician Assistants in the United States — who have the ability to assess patients, make diagnoses, determine appropriate treatments, and undertake minor surgical procedures under the supervision of medical officers. The introduction of this new cadre of mid-level worker is serving to strengthen primary healthcare services in the country by bolstering the number of trained healthcare providers working in district hospitals.

With the overarching goal of increasing the number of mid-level medical professionals in South Africa, AIHA established through our HIV/AIDS Twinning Center Program the following three university-based partnerships, which are designed to strengthen the Clinical Associates programs being offered by each South African institution:

• Walter Sisulu University (WSU) in the Eastern Cape and the University of Colorado – Denver (UCD) established in February 2010;
• The University of the Witwatersrand (Wits) in Johannesburg and Emory University in Atlanta
  established in May 2010; and
• The University of Pretoria (UP) and Arcadia University near Philadelphia established in February 2011.

In addition to the twinning partnerships, AIHA provides support for the South African universities and other stakeholders to collaborate on cross-cutting issues that affect the establishment and sustainability of the profession through the Clinical Associates Forum.

The Forum addresses needs related to professional association building, advocacy, career-pathing, student assessment, mentoring by volunteer preceptors, data collection, and coordinated research. The Forum provides the three universities and other stakeholders with the opportunity to meet and discuss best practices and lessons learned and to coordinate strategies for the future of the programs and the profession. These and other related activities are funded by PEPFAR through CDC / South Africa.

While each university program and partnership is unique, all three partnerships focus on similar objectives, such as strategic faculty and staff development and mentoring.

Key accomplishments to date include conducting faculty development workshops for teaching staff and the placement of clinical preceptors at district hospitals. South African faculty have developed skills in teaching skills, student assessment and other key topics at visits to their U.S. partners and participation in U.S. and international conferences. Faculty development workshops initially led by the U.S. partners at WSU have now been integrated into the program and focus on their needs, especially in problem-based learning.

Through our Volunteer Healthcare Corps, AIHA also supports faculty development with long-term volunteer placements of American Physician Assistants to help strengthen the didactic and clinical training for these programs by leveraging best practices and experiences from the United States.

All partners are also working together to strengthen each university’s capacity to more effectively market, advocate, and make policy recommendations that promote the Clinical Associates profession in South Africa.

Additionally, AIHA helped establish and continues to support the Professional Association of Clinical Associates in South Africa (PACASA) as the formal representative body for all Clinical Associates working in South Africa. AIHA support focuses on strengthening PACASA’s organizational development, increasing their membership and representation, and developing a strategic business and sustainability plan. AIHA also supports PACASA’s participation in international and regional bodies, such as the African Network of Associates Clinicians, which represents the mid-level medical profession in more than 10 African countries.

To enable students to pursue more in-depth study in select disciplines, Wits and UP are working on Clinical Associates Honor’s programs in emergency medicine and community health, respectively.

AIHA continues to support the implementation and development of a standardized national exam for graduating third-year students, particularly because there is currently no mechanism for certification by an external body. The fourth annual National Exam Workshop in March 2015 provided ongoing training to faculty and tutors from the three universities in test-question writing and implementation of practical skills-based assessments (OSCEs).

AIHA is continuing our efforts to improve access to evidence-based resources for Clinical Associates students and faculty through our Knowledge Management Program.

In 2014, we helped Wits launch and implement the Digital Integration of Clinical Associates Studies (DICAS) initiative. With the aid of tablet devices, their students now have access to evidence-based resources and curricular resources while training in district hospitals.

Additionally, Wits teamed up with a local technology company, Dimagi, to create an electronic logbook for students to track their clinical experiences; Wits coordinators and faculty can now electronically monitor student performance.

At UP, AIHA is improving access to learning resource materials at rural rotation sites and helped establish a Clinical Learning Center at Tembisa Hospital, a main teaching site. The center features simulation equipment and computer tablets pre-loaded with medical databases.

Additionally, AIHA is training clinical tutors at WSU on integrating evidence-based medical resources into their training and piloting the use of tablets at district hospitals where Clinical Associates train.

To read the final closeout report of AIHA’s Twinning Center Program, click here.

South Africa’s National Department of Health (NDOH) introduced Clinical Associates as a new health occupation designed to fill critical human resource gaps at rural district hospitals and enable task sharing in 2008. The first cohort of Clinical Associates graduated from Walter Sisulu University in December 2010.

This 3-year Bachelor of Clinical Medical Practice (BCMP) program produces qualified professionals, similar to Physician Assistants in the United States, who have the ability to assess and diagnose patients, determine appropriate treatments, and undertake minor surgical procedures under the supervision of medical officers.

The introduction of this new cadre of mid-level medical worker is serving to strengthen primary care services across South Africa by bolstering the number of trained healthcare providers working in district hospitals. In addition to general medical services, Clinical Associates are also trained to provide a broad range of HIV prevention, care, and treatment services, including voluntary male medical circumcision (VMMC), which has been identified by the NDOH as a key HIV prevention strategy for South Africa.

AIHA, through our HRSA-supported HIV/AIDS Twinning Center Program, established three university-based partnerships that worked to strengthen the Clinical Associates programs being offered by each South African institution:

• Walter Sisulu University (WSU) in the Eastern Cape and the University of Colorado, Denver (UCD) 
  2010-2017
• University of the Witwatersrand (Wits) in Johannesburg and Emory University in Atlanta
  2010-2017
• University of Pretoria (UP) and Arcadia University near Philadelphia
  2011-2017

In addition to the twinning partnerships, AIHA provided support for the South African universities and other stakeholders to collaborate on cross-cutting issues that affect the establishment and sustainability of the profession through the Clinical Associates Forum. The Forum addressed needs related to professional association building, advocacy, career pathing, student assessment, mentoring by volunteer preceptors, data collection, and coordinated research. It also provided the three South African universities and other stakeholders with opportunities to meet and discuss best practices and lessons learned, as well as to coordinate strategies for the future of the programs and the profession. These and other related activities were funded by PEPFAR through CDC/South Africa.

In addition, all partners worked together to strengthen each university’s capacity to more effectively market, advocate, and make policy recommendations that promote the Clinical Associates profession in South Africa.

To enable students to pursue more in-depth study in select disciplines, partners at Wits established the Clinical Associates Honors Program in Emergency Medicine in 2017.

While each university program is unique, the partnerships focused on similar objectives, such as faculty and staff development and mentoring. Activities implemented included conducting faculty development workshops for teaching staff and the placement of clinical preceptors at district hospitals.

South African faculty developed skills in effective teaching, student assessment, and other topics during visits to US partner institutions and through participation in international conferences. Faculty development workshops initially led by the US partners have now been integrated into programs and focus on their needs, especially in problem-based learning.

Between 2008 and 2017, AIHA supported faculty development with long-term placement of 32 American Physician Assistants, who volunteered their time and expertise to help strengthen learning and clinical training for these programs by leveraging best practices and experiences from the United States through our Volunteer Healthcare Corps.

AIHA also helped establish and support the Professional Association of Clinical Associates in South Africa (PACASA) as the formal representative body for Clinical Associates working in South Africa. AIHA’s support focused on strengthening PACASA’s organizational development, increasing their membership and representation, and developing strategic business and sustainability plans. AIHA supported PACASA’s participation in international and regional bodies, such as the African Network for Associate Clinicians, which represents the mid-level medical profession in more than 10 African countries.

AIHA supported the implementation and development of a standardized national exam for graduating third-year students, which is important since there is no mechanism for certification by an external body. Annual National Exam Workshops provided ongoing training to faculty and tutors from the three universities in test-question writing and implementation of practical skills-based assessments (OSCEs). AIHA also provided the universities with access to QuestionMark software and training to better manage the national exam, create a test bank of questions, analyze the quality of questions, and provide the option for tests to be taken via computer instead of on paper.

AIHA worked to improve access to evidence-based clinical resources for Clinical Associates students and faculty through our Knowledge Management Program. In 2014, AIHA helped Wits launch the Digital Integration of Clinical Associates Program (DICAP). With the aid of tablet devices, students now have access to evidence-based and curricular resources while training in district hospitals and other remote locations. Additionally, Wits teamed up with the technology company Dimagi to create an electronic logbook for students to track their clinical experiences. With this information on the clinical experiences of students, Wits coordinators and faculty electronically monitor performance and adjust clinical rotations and practical training as needed to ensure students receive optimal hands-on experience.

At UP, AIHA improved access to learning resource materials at rural rotation sites by establishing a Clinical Learning Center at Tembisa Hospital, a main teaching site. The center features simulation equipment and computer tablets pre-loaded with medical databases. Additionally, AIHA trained clinical tutors at WSU on integrating evidence-based medical resources into their training and piloting the use of tablets at district hospitals where Clinical Associates train.

AIHA is collaborating with Wits to utilize the DICAP CommCare application to document the impact of graduates working in public facilities throughout South Africa. DICAP captures data on the daily activities and practice of Clinical Associates where they work, generating reports in real time and tracking the medical and HIV-related services they provide.

AIHA will analyze this data to identify performance gaps and inform future in-service training and continuous professional development needs, then collaborate with our partners to update existing training modules, create new short courses and distance learning opportunities, and ensure the latest HIV guidelines and content (e.g., UTT and same-day initiation) are integrated.

A team of HIV experts from partner universities and affiliated hospital training sites is slated to deliver in-service courses to Clinical Associates who provide HIV/AIDS-related services in PEPFAR’s 27 focus districts.

AIHA, our university partners, and PACASA are members of the NDOH Clinical Associates Task Team working to address issues related to the scope of practice, conditions of service, supervision, deployment, and career path for the profession. AIHA is supporting the NDOH to develop and implement regulations, policies, and guidelines for how to effectively utilize, supervise, and support Clinical Associates to provide effective HIV treatment and VMMC services in underserved parts of the country where they are needed most.

To read the final closeout report of AIHA’s Twinning Center Program, click here.

In 2008, the National Department of Health in South Africa launched a new Clinical Associates Program to increase the number of mid-level medical professionals in the workforce.

This 3-year degree program produces qualified professionals — similar to Physician Assistants in the United States — who have the ability to assess patients, make diagnoses, determine appropriate treatments, and undertake minor surgical procedures under the supervision of medical officers. The introduction of this new cadre of mid-level worker is serving to strengthen primary healthcare services in the country by bolstering the number of trained healthcare providers working in district hospitals.

With the overarching goal of increasing the number of mid-level medical professionals in South Africa, AIHA established through our HIV/AIDS Twinning Center Program the following three university-based partnerships, which are designed to strengthen the Clinical Associates programs being offered by each South African institution:

• Walter Sisulu University (WSU) in the Eastern Cape and the University of Colorado – Denver (UCD) established in February 2010;
• The University of the Witwatersrand (Wits) in Johannesburg and Emory University in Atlanta
  established in May 2010; and
• The University of Pretoria (UP) and Arcadia University near Philadelphia established in February 2011.

In addition to the twinning partnerships, AIHA provides support for the South African universities and other stakeholders to collaborate on cross-cutting issues that affect the establishment and sustainability of the profession through the Clinical Associates Forum.

The Forum addresses needs related to professional association building, advocacy, career-pathing, student assessment, mentoring by volunteer preceptors, data collection, and coordinated research. The Forum provides the three universities and other stakeholders with the opportunity to meet and discuss best practices and lessons learned and to coordinate strategies for the future of the programs and the profession. These and other related activities are funded by PEPFAR through CDC / South Africa.

While each university program and partnership is unique, all three partnerships focus on similar objectives, such as strategic faculty and staff development and mentoring.

Key accomplishments to date include conducting faculty development workshops for teaching staff and the placement of clinical preceptors at district hospitals. South African faculty have developed skills in teaching skills, student assessment and other key topics at visits to their U.S. partners and participation in U.S. and international conferences. Faculty development workshops initially led by the U.S. partners at WSU have now been integrated into the program and focus on their needs, especially in problem-based learning.

Through our Volunteer Healthcare Corps, AIHA also supports faculty development with long-term volunteer placements of American Physician Assistants to help strengthen the didactic and clinical training for these programs by leveraging best practices and experiences from the United States.

All partners are also working together to strengthen each university’s capacity to more effectively market, advocate, and make policy recommendations that promote the Clinical Associates profession in South Africa.

Additionally, AIHA helped establish and continues to support the Professional Association of Clinical Associates in South Africa (PACASA) as the formal representative body for all Clinical Associates working in South Africa. AIHA support focuses on strengthening PACASA’s organizational development, increasing their membership and representation, and developing a strategic business and sustainability plan. AIHA also supports PACASA’s participation in international and regional bodies, such as the African Network of Associates Clinicians, which represents the mid-level medical profession in more than 10 African countries.

To enable students to pursue more in-depth study in select disciplines, Wits and UP are working on Clinical Associates Honor’s programs in emergency medicine and community health, respectively.

AIHA continues to support the implementation and development of a standardized national exam for graduating third-year students, particularly because there is currently no mechanism for certification by an external body. The fourth annual National Exam Workshop in March 2015 provided ongoing training to faculty and tutors from the three universities in test-question writing and implementation of practical skills-based assessments (OSCEs).

AIHA is continuing our efforts to improve access to evidence-based resources for Clinical Associates students and faculty through our Knowledge Management Program.

In 2014, we helped Wits launch and implement the Digital Integration of Clinical Associates Studies (DICAS) initiative. With the aid of tablet devices, their students now have access to evidence-based resources and curricular resources while training in district hospitals.

Additionally, Wits teamed up with a local technology company, Dimagi, to create an electronic logbook for students to track their clinical experiences; Wits coordinators and faculty can now electronically monitor student performance.

At UP, AIHA is improving access to learning resource materials at rural rotation sites and helped establish a Clinical Learning Center at Tembisa Hospital, a main teaching site. The center features simulation equipment and computer tablets pre-loaded with medical databases.

Additionally, AIHA is training clinical tutors at WSU on integrating evidence-based medical resources into their training and piloting the use of tablets at district hospitals where Clinical Associates train.

To read the final closeout report of AIHA’s Twinning Center Program, click here.

Tuberculosis is the most common serious opportunistic infection in individuals living with HIV in Sub-Saharan Africa. In South Africa’s Free State Province, more than 70 percent of all patients with active TB also have HIV. Despite high rates of co-morbidity, however, only 65 percent of tuberculosis patients are tested for HIV.

With the goal of building the institutional capacity needed to translate HIV and TB research into scientific data that can effectively inform related health policies and practices, AIHA established a partnership between the University of the Free State’s Centre for Health Systems Research and Development (CHSRD) and the State University of New York (SUNY) Downstate Medical Center in 2007.

Together, partners worked to study the evolving HIV-TB epidemic in South Africa’s Free State Province and develop appropriate, effective responses to the public health challenges co-infection with both diseases presents. A key aspect of the partnership focused on strengthening CHSRD’s data management capabilities, as well as its ability to efficiently disseminate research findings in Free State and throughout South Africa.

During the summer of 2008, CHSRD faculty participated in intensive courses in epidemiology, biostatistics, and data management at Johns Hopkins University in Maryland. Free State partners then traveled to SUNY Downstate for additional professional development training. What they learned is now bolstering their ability to effectively conduct and evaluate scientific research.

In November 2008, two SUNY faculty members travelled to Bloemfontein to conduct an advanced training course on biostatistics and epidemiology for 28 researchers and public health managers from CHSRD and the University’s Department of Psychology and School of Nursing. Provincial and district level representatives of the Free State Department of Health and the Medical Research Council also attended this event.

SUNY faculty provided additional training and technical assistance on implementation science, operational research, and counseling and testing, as well as one-on-one mentoring on how to prepare and present scientific research with a particular focus on current projects being conducted by CHSRD researchers.

SUNY also provided additional training on counseling and testing in support of the implementation phase of CHSRD’s ongoing TB VCT project. Partners will also continue work on various articles for co-publication.

This partnership officially graduated from the Twinning Center’s technical assistance program in 2010, but — in large part due to the organizational capacity developed through their PEPFAR-supported partnership — CHSRD was awarded direct funding from CDC/South Africa in 2011 to implement a public health evaluation with the goal of increasing uptake of HIV testing among TB patients in Free State Province.

The CDC approved their revised protocol and released funding for initiation of the project. AIHA is supporting their efforts to manage and implement the intervention and analysis phases of the evaluation, in part through the placement of an implementation science expert and a monitoring and evaluation expert through AIHA’s Volunteer Healthcare Corps (VHC). In addition, partners at CHSRD have received funds from CDC to evaluate TB infection control and integration of TB-HIV interventions in South Africa’s Eastern Cape Province.

With the goal of increasing the institutional and human resource capacity of HIV care and treatment centers, the South Africa Preceptors Initiative placed highly skilled professionals at PEPFAR-supported sites, where they served as onsite technical experts.

Preceptors volunteered at sites for a period ranging from three months to two years with the dual goals of increasing institutional capacity to deliver and expand quality HIV/AIDS treatment and care services and increasing staff competencies in HIV-related treatment and care. Preceptors mentored staff; supported the provision of services as needed by providing technical assistance; and helped with program expansion, quality control, and other tasks beneficial to the host institution.

As of May 2011, AIHA had placed 15 volunteers at 16 different sites throughout South Africa. These highly skilled professionals included infectious disease experts, an epidemiologist, and a monitoring and evaluation specialist.

The average duration of volunteer assignments was 7.5 months. Collectively, AIHA’s VHC volunteers have contributed a more than 113 months of service toward improving health system capacity in South Africa.

While the South Africa Preceptors Initiative has officially concluded, AIHA is still actively recruiting skilled volunteers for assignments at partnership institutions throughout the country as requested.

The VHC is part of USAID’s Volunteer’s for Prosperity program and directly supports President Obama’s volunteer initiative under the 2009 Serve America Act.

As more and more South Africans commence ART, their HIV infection necessitates a long-term approach to wellness similar to other chronic diseases such as diabetes or asthma. For these patients, effective case management is a critical part of the complex care they need to help ensure their physical and emotional health.

In 2007, AIHA established a partnership linking the Pretoria-based Foundation for Professional Development (FPD) with the University of California – San Francisco (UCSF) School of Nursing to improve the coordination of HIV-related care and services by implementing a nursing case management model at ARV clinics supported by FPD.

Partners conducted a pilot training workshop on nursing care management in HIV/AIDS for nine nurses in November 2008, along with a subsequent focus group for the nine participants to explore the impact of this training. Analysis of data collected through this process demonstrated that the training was useful and provided necessary knowledge in terms of coordination of services for better case management.

To address the challenges nurses confront when trying to incorporate better case management into their day-to-day practice, partners conducted a stakeholders meeting during which attendees agreed to support the development and implementation of case management in the clinics where they work. They also focused on providing training and mentoring for nurses working with participating ARV clinics that were piloting case management and garnering political support for the nurse case management model in South Africa.

This partnership officially graduated from the AIHA Twinning Center’s technical assistance program in 2010. To read the final closeout report of AIHA’s Twinning Center Program, click here.

The partnership linking Brits District Hospital, located in South Africa’s North West Province, and the Foundation for Professional Development (FPD), located in Pretoria, graduated from the Twinning Center’s technical assistance program in September 2007.

With funding from PEPFAR and CDC / South Africa, this south-south partnership was launched in 2005. Partners worked to support the South African government’s efforts to increase access to ARV treatment and improve the quality of HIV/AIDS prevention, care, and support services provided by the Brits District Hospital HIV/AIDS Clinic and its referral sites.

Specific partnership objectives were to:

• Strengthen the operational and managerial capacity of the Brits HIV/AIDS Clinic;
• Strengthen the capacity of the Brits HIV/AIDS Clinic to provide integrated HIV/AIDS and TB prevention, care, and support services; and
• Strengthen the referral system between the Brits HIV/AIDS Clinic and selected community-based treatment facilities.

At the partnership’s close, AIHA reported that Brits HIV/AIDS Clinic and its affiliated referral sites provided ARV services to 1,831 patients, exceeding their target by nearly 400 people.

Efforts to expand VCT services to all four clinics involved in the partnership resulted in marked increases in the number of HIV cases reported, with 60 percent of those tested diagnosed as seropositive.

Other notable achievements included increased physician productivity, development of an operational toolkit that supports standardized care and continuous quality improvement, increased integration of HIV and TB care, and implementation of a wellness program.

Through the partnership, FPD and Brits staff jointly developed and implemented a new standard operating system for the clinic, including newly designed computerized filing systems. New medical and information technology equipment was installed and these new systems were supplemented by a comprehensive human resource plan that included staff training and the development of new human resource policies, job descriptions, and marketing strategies.

FPD secured a donation of mobile units from Vodacom, a South African cellular phone service provider, which were refurbished and transported to referral clinic sites. The partnership also procured mobile trailer units to address space limitations that severely hampered the ability of the clinics to provide services. These units allowed operations to continue at the clinics and helped reduce wait times for patients.

To read the final closeout report of AIHA’s Twinning Center Program, click here.