Objective: To assess the impact of an interprofessional case-based training program to enhance clinical knowledge and confidence among clinicians working in high HIV-burden settings in sub-Saharan Africa (SSA)

Setting: Health professions training institutions and their affiliated clinical training sites in 12 high HIV-burden countries in SSA.

Participants: Cohort comprising pre-service and in-service learners, from diverse health professions, engaged in HIV service delivery.

Intervention: A standardized, interprofessional, case-based curriculum designed to enhance HIV clinical competency, implemented between October 2019 and April 2020.

Main outcome measures: The primary outcomes measured were knowledge and clinical confidence related to topics addressed in the curriculum.  These outcomes were assessed using a standardized online assessment, completed before and after course completion.  A secondary outcome was knowledge retention at least six months post-intervention, measured using the same standardized assessment, six months after training completion. We also sought to determine what lessons could be learned from this training program to inform interprofessional training in other contexts.

Results: Data from 3027 learners were collected: together nurses (n=1145, 37.9%) and physicians (n=902, 29.8%) constituted the majority of participants; 58.1% were pre-service learners (n=1755) and 24.1% (n=727) had graduated from training within the prior year. Knowledge scores were significantly higher, post -participation compared to pre-participation, across all content domains, regardless of training level and cadre (all p<0.05). Among 188 learners (6.2%) who retook the test at >6 months, knowledge and self-reported confidence scores were greater compared to pre-course scores (all p<0.05). 

Conclusion: To our knowledge this is the largest interprofessional, multi-country training program established to improve HIV knowledge and clinical confidence among HCP workers in SSA. The findings are notable given the size and geographical reach and demonstration of sustained confidence and knowledge retention post course completion. The findings highlight the utility of interprofessional approaches to enhance clinical training in SSA.

The study was conducted using data from the STRIPE HIV program.  The program was launched across 20 health professions training institutions in 14 countries in October 2019. All learners who completed a pre and post-test assessment for an in-person training conducted between October 1, 2019 and March 31, 2020, were included in the study. After April 2020, all training transitioned to online format given widespread restrictions on in-person learning related to the COVID-19 pandemic; these learners were excluded from this analysis. As previously described, training included 17 case-based modules, typically presented over two days, and was designed to foster interprofessional discussion and facilitate learning related to HIV clinical management, quality improvement and interprofessional collaborative practice. Training content included required modules on initiating HIV therapeutics in women of childbearing age (“HIV and Women”), management of opportunistic infections (“HIV-TB”), prevention of mother to child transmission (“PMTCT”) and pediatric HIV (“Paediatric Care”), in which all learners participated regardless of the stage of their career or professional cadre. These modules were all created by the study team which included local HIV practitioners and international and local educational experts. In addition to creation of the learning materials, the study team provided local educators at each partner institution with training resources to implement the course. These local partners were encouraged to ensure that each training course included a diverse mix of professional cadres and, where feasible, a mix of health professionals at different stages of their career (pre-service, post-graduate but within 12 months of graduation, and greater than 12 months post-graduation). The study team also provided training resources to facilitate training of local facilitators. The frequency of training courses offered, the ratio of learners to facilitators, mix of cadres and course timing were all determined by local partner institutions. Given scarcity of training resources, some health professions training institutions had to decline access for eligible candidates; in such circumstances, participation of early career professionals was prioritized over pre-service learners. 

Cohort: This was a convenience sample, including all learners who participated in the STRIPE HIV training program and had completed both pre- and post-training assessments during the study period.  In addition to capturing learner demographic information, the assessment assessed learner (1) clinical and technical knowledge related to the learning objectives outlined in the program and (2) self-reported confidence in skills and abilities covered in the program, including (a) confidence to participate in HIV service delivery, specific to each cadre’s scope of practice, in the domains addressed in the course, (b) confidence to employ quality improvement tools and (c) confidence to practice as part of an interprofessional team. Knowledge was assessed using a series of domain-specific multiple-choice questions; all questions were the same for all participants regardless of training context, participant cadre, training institution, and country. Confidence was assessed on a four-point Likert-type scale, ranging from 1= “I feel uncomfortable with this topic/need supervision from my supervisor” to 4= “I feel very comfortable with this topic/without supervision as though in independent practice.” (Supplemental digital appendix).

All learners completed the initial assessment at the time of program enrollment, typically within 24 hours of starting training. They then completed the same assessment immediately after completing the course, typically within 48 hours. For most participants, these pre and post program assessments were accessed on the training program’s website. However, for a small subset that did not have internet or computer access, assessments were completed on paper, and subsequently uploaded into the project database by local research staff. Starting in October 2020, we invited all participants to retake the same assessment at least six months after when they had participated in the program. This repeat assessment was administered electronically via email (Qualtrics, version XM; Provo, Utah; 2013). To increase uptake of this repeat assessment, all individuals who completed it were entered into a lottery to receive a US $50 prize voucher for internet data or airtime. 

Analysis: We only included data on learners for whom we had both pre-course and post-course assessment data, excluding those participants for whom we did not have both data points. For these eligible learners, we used descriptive statistics to summarize demographic characteristics of program participants, stratifying results by gender, health profession cadre and professional career stage (RStudio Version 1.3.1093). We separately analyzed (1) differences in pre-course and post-course knowledge and self-reported confidence using Wilcoxon signed-rank tests and (2) differences in knowledge and self-reported confidence between cadres and career stage using ANOVA and Tukey’s HSD test. For the subgroup of learners for whom both pre- and post-course assessment results were available, and who had also completed the post-course assessment >6 months after completion of the course, we calculated the change in levels of knowledge and self-reported confidence between the post > 6 months assessment and the pre-course assessment sores using Wilcoxon signed-rank test. We applied Wilcoxon signed-rank tests because distributions of assessment response variables were not normally distributed. All reported P values were two sided.