The mental health screening is particularly important but often overlooked when focusing on medical management of HIV/AIDS. However, people living with HIV are more likely to develop anxiety, depression, or other mental health conditions. The clinic has a peer-support group called StART Club which helps patients to start treatment and stick with it, and an advisory group which further empowers patients to take the lead in decisions about their own care, both of which improve engagement with services.
Diagnosing and treating HIV infections in Eastern Europe is a major challenge.
To develop effective services, healthcare workers must share responsibilities and their skills must be used to their full potential.
Anna Maria Żakowicz is part of the AIDS Healthcare Foundation in Europe, which in partnership with the Ukrainian government funded a Test&Treat Clinic in Ukraine that offers a range of comprehensive services in one place.
Expanding the roles of nurses in HIV clinics, such as Test&Treat, means that more patients can be supported using a people-centred approach, and more patients remain engaged with care.
In 2021, over 38 million people were infected with human immunodeficiency virus (HIV) across the globe. If not well managed, HIV infection can lead to the development of acquired immune deficiency syndrome (AIDS), a condition that makes people extremely vulnerable to infections and illnesses due to an impaired immune system. Thanks to the availability of live-saving treatments, HIV infection has now become a chronic disease.
One of the main challenges in HIV care is making sure that people continue to attend medical appointments to continue their life-long treatment, as well as ensuring the medical team work together as effectively as possible to guarantee the best care is provided.
Nurses are often the first healthcare professionals that people meet and the ones who play the biggest role in managing their care. However, the skills and abilities of nurses aren’t always used to their full potential due to barriers in the legislative system of a country, organisation of health work, and structural and educational challenges.
Anna Maria Żakowicz at the AIDS Healthcare Foundation (AHF) highlights how the role of nurses in HIV care can be optimised in a Test&Treat Clinic in Odesa, Ukraine. Eastern Europe is one region that is disproportionally affected by a rise in HIV cases; therefore, there is an urgent need to develop innovative, effective services, provide access to HIV treatment, reduce deaths among people who live with HIV, and provide quality care for these clients in this region.
“Nurses can, and should, play a bigger role in HIV care.”
AHF launched the Test&Treat Clinic in Ukraine in 2017, and it now functions as a central hub for treating people with HIV. Here, anti-retroviral therapy (ART) is started as soon as someone tests positive for HIV infection. Different services are being offered alongside each other, so that patients can be referred to other specialities as required. The clinic represents a new way of working to offer care to people living with HIV and was the first in Eastern Europe to use this novel approach. Test&Treat Clinic in Odesa, Ukraine.While the team includes doctors, nurses, social workers, receptionists, and other support workers, responsibilities are shared. For example, nurses are able to dispense ART to stable patients, a job which is often done by doctors or more senior nurses. This allows more effective use of time, meaning that doctors have the capacity to see more complex patients and that more patients benefit from the expert clinical skills of nurses.
Żakowicz’ work has shown that clinics such as Test&Treat in Odesa promote people-centred care by integrating services and making pathways more efficient to reduce waiting times, ensuring all patients get the individual support that they need and that they are retained in care. A people-centred way of working means adjusting treatment pathways to suit individual beliefs, wishes, and values, rather than using a one-size-fits-all approach. This includes GP services, family-planning support, mental health screening, and community involvement to encourage a person to start and continue treatment.
The mental health screening is particularly important but often overlooked when focusing on medical management of HIV/AIDS. However, people living with HIV are more likely to develop anxiety, depression, or other mental health conditions. The clinic has a peer-support group called StART Club which helps patients to start treatment and stick with it, and an advisory group which further empowers patients to take the lead in decisions about their own care, both of which improve engagement with services. Client’s pathway related to HIV and STI screening, diagnosis, and care at Test&Treat Clinic. The pathway is designed to provide a clear overview of the roles and responsibilities of the staff for effective care and retention of new HIV patients.
Żakowicz believes that nurses are capable of taking certain duties from doctors, and that communication is key to reaching joint decisions. Furthermore, care must be accessible to patients; the clinic is therefore open until late, even on the weekend.
This innovative approach to HIV care works: over 92% of patients registered with the clinic and receiving treatment continue to be engaged with the service. This is a huge percentage of patients, especially when compared to other studies which suggest around 80% of patients with diagnosed HIV have sought treatment.
“Using a people-centred approach builds trusting relationships between patients and staff and increases engagement with healthcare services.”
The future of HIV care
Nurses can, and should, play a bigger role in HIV care. Żakowicz emphasises the role of clinical guidelines when implementing changes and says that Ukrainian legislation needs to be updated to reflect the diverse range of roles that a nurse can fulfil. There is often an unwritten hierarchy within healthcare systems; however, shared duties between doctors and nurses would be more time and cost effective and allow all professions to focus on supporting those that require their specialist input. Standard operations procedures on TB screening and diagnostics for HIV positive clients at the Test&Treat Clinic.Żakowicz explains that maximising the potential of nurses will help lead Ukraine, and neighbouring countries in Eastern Europe, to a universally accessible, equitable, and sustainable public health system.
Data from the clinic show that in August 2020, 97% of the clients in care were on ART and 96% of those on treatment achieved undetectable viral load, meaning they cannot pass on the virus. These targets, set out by the UN Programme on HIV and AIDS, aim to diagnose 90% of all people with HIV infection, treat 90% of those diagnosed with ART, and show that the virus is supressed in 90% of all those receiving treatment.
The benefits of using such a system are clear. Using a people-centred approach builds trusting relationships between patients and staff, based on mutual respect, and increases engagement with healthcare services. This is reflected in the high number of patients that return for treatment. Sharing tasks also improves motivation of staff, as they feel valued and able to use their knowledge and skills to the best of their abilities.
In an ideal world, where time and money are no object, what would HIV care look like?
HIV care, which right now is still life long, should be a place of care, safety and informed choice for a person who lives with HIV and either starts HIV treatment or has been on treatment for a long time. Such a people-centred approach encompasses welcoming spaces for clients, including the physical space that a person wants to come to regularly, a supportive and respectful team of providers who are able to acknowledge the person’s daily routine and any challenges related to treatment the person might have, and lastly, the possibility to get quality treatment that matches the person’s needs. This includes being able to choose daily pills or long-acting injectable solutions for treatment, proper regular screening including HIV viral load level, and support with any other co-morbidities.
In many countries, the populations that live with HIV are affected by tuberculosis, hepatitis C, hepatitis B, and sexually transmitted infections. Therefore, there is a need for holistic care, an approach that addresses the needs of different populations. We cannot forget about family care and support, and proper family planning for couples who live with HIV and serodifferent couples where one person lives with HIV and the other does not.
Making time for the client and understanding the challenges a person faces is even more important right now, as the population who lives with HIV is ageing; in some countries, more than 50% of the population of people who live with HIV are over 60 years old. Now more than ever, there is a need for holistic care that addresses coinfections and non-communicable diseases (such as heart disease and kidney disease), and also focuses on mental health and issues related to loneliness.
We need to think more about the concept of co-location of different services that a client is able to receive in one place. For example, a former user of opioids could receive HIV care at an OST (opioid substitution therapy) distribution site, which they attend regularly. Tuberculosis care, viral hepatitis care, STI care, and mental health screening and support can be co-located in one physical space to provide an opportunity to receive all the needed support at one appointment.
As HIV care is a chronic care there is a need to implement digital solutions to support communication between the client and healthcare professionals to reduce the burden of physical appointments and screening. The appointments at healthcare facilities, including pick up of medications, should not be a burden for the client.
How can the roles of nurses be promoted in other areas of healthcare?
Nurses are the largest group of healthcare providers and they are frontline health educators responsible for health promotion and awareness. They are the ones who can work with the clients on establishing healthy habits; therefore, their communication skills are of significance. At the same time, nurses are the ones that can provide a link between different healthcare providers.
The nurses can support equity of access to services by providing out-of-facility care and support in rural areas. They are crucial in addressing the needs of an ageing population. After COVID-19, the need of mental health support and behavioural interventions could also be supported by the cadre of nurses.
Increasing the number of qualified cadres that are available is of crucial importance. Due to the insufficient number of doctors available, tasks that a doctor would usually complete would need to be shared among nurses as well. At the same time, equitable remuneration, time to rest, promotion of diversity, preparation of the workforce, co-production (ie, working jointly with doctors to address challenges), and respect are important issues to consider.
Can you explain what the StART Club is?
StART Club is a space for people who live with HIV, who either just started HIV treatment or have challenges with adherence, keeping up the schedule of appointments, or need any kind of support related to HIV treatment, care, or legal issues.
At the time of introduction of StART Clubs, the meetings were held in person. They usually consist of two parts, one with an invited professional, a doctor, nurse, medical professional or any expert that is needed for the group, and the second part which is a get-together with peers which can be done in an informal, supportive way. StART Clubs are facilitated by a coordinator who reaches out to the participants to understand their needs and then organises the meetings at non-medical, community places.
An online option of the StART Club was introduced during the COVID-19 pandemic. The introduction of the online format was meant to address regular challenges clients had with adherence and HIV care and challenges related to lockdowns and restriction of movement, loneliness, and solitude. It also provided a means to communicate and engage with peers.
Żakowicz, AM, (2021) Nurses in HIV care in Eastern Europe: Past, present and future. In Croston, M & Hodgson, I, (eds), Providing HIV Care: Lessons from the Field for Nurses and Healthcare Practitioners, (93–104). Springer Nature, Switzerland. Slomynska, A, et al, (2021) Role of online AHF StART Club in adherence to antiretroviral treatment and retention in care in the times of COVID-19 in Ukraine. In Abstracts of the 18th European AIDS Conference (EACS 2021), Online & London, UK, October 27–30, 2021. HIV Medicine, 22, 275–275. Anna Maria Żakowicz
Anna Maria Żakowicz, MA, MIH, is Deputy Bureau Chief and Programme Director at AHF Europe, where she works on implementing people-centred care for populations affected by HIV in Europe, including Eastern Europe. With a background in humanities and public health, Anna promotes integration of services, user-driven care and task shifting to strengthen human resources in health.
Funding AIDS Healthcare Foundation (AHF)
AHF Test&Treat Clinic in Odesa, Ukraine
Odesa Regional Center For Socially Significant Diseases of Odesa Regional Council
Dr Yaroslava Lopatina
Dr Yaroslav Basarab