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New treatment options become available to HIV patients every few months. These options are increasing the life span of patients and delaying the time to the onset of AIDS. The new treatment regimens offer hope for patients, but the increasing complexity of such regimens as highly active antiretroviral therapy makes it difficult for case managers to keep abreast of clinical issues vital to maintaining the overall health of HIV patients.
Case managers in California no longer have to struggle alone to understand the complex clinical and social issues surrounding the management of HIV/AIDS patients. The San Francisco Department of Public Health offers a three-day certification course for nonclinical providers who work directly with HIV/AIDS patients. The course helps case managers identify inappropriate or conflicting drug therapies.
The goal of the Treatment Education Certification Program (TECP), says TECP trainer and coordinator Claire Wingfield, BA, is to offer comprehensive and fundamental information about HIV treatment so case managers can help clients make informed decisions about their health care. "HIV management means more than taking medication. It also includes information on eating better, getting more sleep, exercising. We want to help case managers empower people to manage their own health."
HIV experts’ still have something to learn
The TECP helps case managers build an understanding of the nature of HIV. "Many case managers come to us thinking they don’t need training," she notes. "But they leave thinking they’ve gained a new understanding. We take what can be stale scientific information and help case managers see how they can use information coming from ongoing HIV research to enhance their practice."
Topics covered in the three-day course include:
• The immune system in the absence of HIV. "We review the immune system and its normal function. We want to make sure that case managers understand how the immune system works before talking about how immunity is affected by HIV," says Wingfield.
• The effect of HIV on the immune system. "This material fascinates most participants," notes Wingfield. "We clarify how HIV turns the immune system and uses it against the patient. We go over how HIV turns the body’s cells into factories and the importance of trying to reduce co-infections," she notes. "Case managers gain a new understanding of how, for example, contracting a sexually transmitted disease on top of HIV increases viral replication."
• The life cycle of HIV. "It’s very difficult for case mangers to appreciate how the new treatment options work without understanding the life cycle of the virus," Wingfield says. "If you understand the life cycle, it’s much easier to appreciate how the new medications work to disrupt that life cycle."
• The consequences of immune suppression and opportunistic infection. "We try to give case managers a language to use when working with patients and providers, and the red flags that signal there has been a change in the patient’s immune system," Wingfield says. "The case manager is not the clinical provider making the diagnosis and prescribing treatment," she notes, "but is the person monitoring the progress of the patient. The case manager is more likely than the physician to be the one first to learn that the patient has had diarrhea for three days straight." Wingfield explains that the TECP trains the case manager how to direct the patient back to the primary care provider and enhance the provider/patient relationship.
• The diagnostic tests. The TECP also covers the diagnostic tests necessary to effectively monitor the health of HIV patients. "We cover how often they should be repeated as well as parameters that signal significant changes in health status," says Wingfield. "We also explain the need for specialized gynecologic care for women with HIV."
• The new antiretroviral strategies. Trainers cover not only available treatment options but also their side effects and how to enhance patient compliance, Wingfield notes. "We cover the latest research and clinical trials and how case mangers can find clinical trials their patients may want to participate in," she says.
• The available resources. The TECP also covers community resources and referral information. "Case mangers new to the HIV community often aren’t familiar with the food pantries and wide range of social services available to patients," says Wingfield, who once worked as an HIV/AIDS case manager in New York City. "These services are vital to maintaining the nutritional status and overall health of patients."
Participants take a pre-test on the first day of the three-day course. "We do this just to get a sense for what case managers already know about HIV," says Wingfield. "If anyone scores a 90% or higher, we give them the option to test out of the course and still become certified. So far, no one who has qualified has left."
Additional tests are given on days two and three. Participants must score an average of 90% or higher to become certified, says Wingfield, adding that 85% of participants pass at the end of the three-day course. "We offer one-on-one training for anyone who doesn’t pass. We’ve never had anyone who couldn’t pass the test after the one-on-one training."
The TECP is free to case managers living in the San Francisco Department of Public Health service area and costs $400 to case managers outside the three-county area that includes San Francisco, San Jose, and Marin counties in northern California. In addition, the TECP provides course participants with a manual that includes materials and resources covered in the three-day course. The manual includes copies of slides used in training and fact sheets case mangers can copy and give to patients. The binders are available for $25.
In addition to the TECP, the San Francisco Department of Public Health sponsors three-hour monthly provider work groups, notes Wingfield. "We bring in experts to talk for several hours on new issues in HIV and hepatitis in an interactive group setting."
TECP trainers are also developing a one-day post-training course that covers new treatment options and issues such as the metabolic problems now cropping up in HIV patients such as diabetes, elevated lipids, and fat redistribution.
(Editor’s note: The TECP was one of five programs recently recognized for exemplifying the principles of coordinated pharmaceutical care by the National Pharmaceutical Council in Reston, VA. Information on the other recognized programs is available at www.npcnow.org. Information on the TECP is available at www.dph.sf.ca.us.)