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IAPAC Monthly - Vol. 8, No. 4, April 2002
José M. Zuniga
Each day the HIV/AIDS pandemic deepens to the toll of an estimated 16,000 new infections. Roughly 95 percent of these infections, as well as AIDS-related deaths, occur in the least developed countries (LDCs) of the world, most notably those of sub-Saharan Africa and the Caribbean. Many of these countries, crippled by the double burden of HIV disease and staggering international financial debt, stand at a critical crossroads: that of potential recovery, health and prosperity down one path, or increased death and debilitation down the other. Not only do individual lives and vibrant cultures hang in the balance but so, too, is our very humanity called into question as this insidious disease continues to be visited upon our brothers and sisters in these resource-limited settings.
Throughout most of the world, physicians and allied health professionals work within a robust network of care providers, advocates, social activists, donors and policy makers whose collective energies have generally yielded strong policy and financial responses to HIV/AIDS. In the particular case of LDCs, however, massive inequities and widespread poverty have limited the capacity of governments and civil-society groups to buttress and support the healthcare system through such broadbased advocacy and policy measures; measures whose objectives would include redress of the numerous political, social, and economic factors that fuel the epidemic in these countries. The burden of responsibility for both prevention andtreatment of HIV in resource-limited settings has and continues to fall, therefore, most heavily upon physicians and alliedhealth professionals working within skeletal primary healthcare settings.
Although one of our primary goals must remain pursuit of a truly global commitment to addressing and redressing the global inequities that drive the pandemic, and to entrenching an understanding of HIV disease as related to broader issues of sustainable development, it is imperative that we attend equally to the practical needs of those very healthcare practitioners in resource-limited settings who are our greatest beacons of hope in these times. For those of us who have witnessed the far too common images of wasted bodies, orphaned children, and devastated families scattered throughout these countries— largely due to the lack of basic healthcare services and therapies—there is no question that we must act immediately to ensure quality care and treatment.
Among the more pressing needs of physicians providing HIV/AIDS care within resource-limited settings, are standardized HIV clinical management training, and media through which they may obtain updated information, accreditation, and continuing education. More than mere common sense, the potential impact of such training and accreditation is substantiated by way of literature from many areas of medicine, including HIV medicine, which has established that specialized education and level of experience among physicians predicts patient outcomes. Furthermore, medical fields with rapidly developing technology and an evolving standard of care are those in which specialized education and experience have the most profound impact on morbidity, mortality, and the use of healthcare resources. So, while there remain a plethora of macro-political and -economic questions that must be answered with a view to fully reversing HIV/AIDS trends, there are very concrete and immediate remedies available to us which may have a great impact in resourcelimited settings, thus greatly reducing avoidable death and suffering.
The need for improved education in HIV clinical management is especially important and must be prioritized in sub-Saharan Africa. Deserving particular mention, in this regard, is our deepening appreciation of one very frightening possibility: that bank vaults of money which have been committed to HIV/AIDS programming by the global donor community and international lending institutions may very well fail, under current conditions, to achieve their intended impact.
This warning has come from a number of sources, among them Ebrahim Samba, World Health Organization (WHO) Regional Director for Africa. During a recent joint WHO/World Bank consultation, convened to address the dramatic shortage on the African continent of health sector staffing due both to poor training programs and healthcare worker migration, Samba reiterated that “there is a risk that the contributions soon to be committed in Africa by the new [Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)] will not even have a serious possibility of achieving their goals.”
Foremost, during this February 2002 WHO/World Bank consultation, held in Addis Ababa, Ethiopia, delegates from 17 African nations agreed that the challenges posed by lagging infrastructure, lack of healthcare training, and migration have made Africa’s healthcare facilities “barely able to function for lack of qualified, motivated doctors, nurses, and other health workers.” Mirroring the thoughts of many others, Samba has, therefore, urged African health ministers to address these challenges in cooperation with other government leaders in their respective countries, professional associations, private sector healthcare providers, donor countries, and institutions.
In view of the critical shortage of adequate and standardized physician care in LDCs, and the very practical and immediate impact that improved training in HIV care can yield, the International Association of Physicians in AIDS Care (IAPAC) has been embarked upon a journey to realize what will be known as the Global AIDS Learning & Evaluation Network (GALEN). In the not too distant future, GALEN, an HIV/AIDS care training program for physicians in resource-limited settings, will provide a means through which physicians may avail themselves of nationally administered, and WHO-endorsed training for certification as “HIV care specialists.” We are convinced that this network of HIV care specialists will not only be a significant means of increasing and improving the quality of patient care and life, but will also assist in fostering further professional coordination and technical leadership within these beleaguered countries.
Aside from its ultimate goal of improving patient outcomes and strengthening healthcare delivery infrastructure, what particularly excites me about this network is that, in relative terms, it will not place a huge financial demand on governments, nor already strapped health systems, since extra burden can be ill-afforded. Rather, GALEN promises its outcomes most fully in consequence of the concerted and collective energies of IAPAC, the WHO, allied partners, and national health authorities to harmonize and clarify HIV clinical management education. As a result, GALEN will be highly cost-effective, and should yield further benefits for countries by both reducing the financial burden placed upon health systems and making for healthier, more productive populations.
In its design, content, and delivery, GALEN is intended to account for the particular challenges faced by physicians practicing in environments with limited physical infrastructure and reduced treatment options. This is critical to GALEN’s ultimate success, and reflects the thinking of international bodies such as the Pan American Health Organization (PAHO), whose comprehensive care guidelines for persons living with HIV/AIDS make explicit that while there must be critical attention given to ensuring adequate healthcare infrastructure, “local standards should reflect the best care obtainable in current local circumstances.”
Further in this regard, GALEN training will be tiered, in order to accommodate both those who require basic and advanced levels of training, and will be provided by a select group of locally trained, IAPACcertified trainers. This first cohort of trainers, whose members will most likely act in a regional capacity as IAPAC-contracted trainers, will ensure that each locale, beginning in Southern Africa and then gradually spreading to other regions globally, will have local, certified trainers in place.
Evaluation of physicians receiving training will be conducted, in cooperation with local health authorities, through national and local boards, and in strict compliance with standards outlined in the GALEN protocols established by IAPAC, and endorsed by the WHO. It is perhaps this evaluation component that best distinguishes GALEN from numerous other training programs that exist for physicians in developing world settings. GALEN will ensure that through the examination and certification process, the core clinical competencies of physicians are evaluated and documented. This, in turn, will not only ensure that physicians are adequately and ethically prepared to provide basic and/or advanced HIV care, but will provide a means of determining GALEN’s success and the need for revisions in the training regimen on an ongoing basis.
Ultimately, physicians certified as HIV care specialists in these resource-limited settings will have received highly standardized training. What is more, however, these physicians will then surely diffuse their knowledge and expertise throughout the vast system of healthcare providers working in the field of HIV/AIDS. It is my hope that this ripple effect will come to occupy an important place, on what we will eventually look back upon as the timeline along which the pandemic, in Africa and elsewhere, was brought to a halt. If we are to achieve this, of course, our collective effort is required. Toward this end, I welcome and look forward to establishing strong collaborative efforts and partnerships with nurses, community health workers, and other allied health personnel who have a vested interest in what GALEN offers.
GALEN’s training curriculum, divided into basic and advanced components requiring either more basic or advanced instruction, includes information ranging from epidemiology and prevention of HIV, to best practices in diagnosis, screening, and treatment of patients across the range of important gender, age, and infection/co-infection categories faced by physicians in resource-limited settings. The core curriculum contains 14 learning modules, to which is appended a comprehensive train-the-trainer module, in further support of IAPAC-certified trainers and examiners (Table 1).
While a program of GALEN’s sort is long overdue, IAPAC has worked tirelessly to bring it to bear in the global arena. We have always seen ourselves as being strategically positioned to bring a global network of its desperately needed type to fruition. Most importantly, IAPAC is a catalyst for creating strong public-private health partnerships, having the flexibility to move quickly, as an honest broker between government agencies, nongovernmental organizations, and the private sector in order to create new working alliances to meet the challenges of HIV. We also bring to the mix the unparalleled energy, experience, and talent of our physician members, spread over 83 countries worldwide. I am thrilled to finally announce with certainty that GALEN will soon be a reality.
Of particular importance to GALEN’s development have been the contributions of our various members and partners. The ongoing direction and guidance provided by GALEN Curriculum Committee Co-Chairs D. William Cameron (University of Ottawa, Ottawa, Ontario, Canada) and Elly Katabira (Makrere University, Kampala, Uganda), for example, has been of inestimable value. Equally deserving of mention is John G. Bartlett (Johns Hopkins University, Baltimore) who has provided both programmatic guidance and impressive authorship of two of GALEN’s 14 learning modules. Looking to the future, GALEN will be guided through its final stage of development and implementation, by Scott Wolfe, IAPAC’s Director of Communications and International Relations, who will coordinate the GALEN Curriculum Committee’s efforts as well as communicate with academic institutions and health ministries throughout LDCs worldwide.
As I thank our staff and members who have been critical in breathing life into GALEN, it is also important for me to mention that GALEN, as it will be implemented in the not too distant future, will have benefited in its design and implementation, from multiple stages of peer review and assessment. Of greatest significance is the fact that GALEN will not only have been endorsed by the WHO, but will have been presented to health authorities with the backing and approval of a truly international GALEN Curriculum Committee. Members of this committee reflect the collective experience of physicians at the vanguard of clinical HIV practice, as well as those best attuned to the challenges of preventing and managing HIV disease in resource-limited settings.
Further to this, a short-course GALEN package will soon undergo piloting in South Africa in order to provide a first assessment of its reception by practicing physicians and its amenability to the protocols and capacity of health authorities and professional associations. The level of cooperation, consensus, and support that GALEN will ultimately have, therefore, is truly remarkable and gives us ample reason to be enthusiastic.
As IAPAC embarks upon the next stages of our journey to realize GALEN, I wish to offer up the following reminder and message of appreciation and collegiality to our membership, partners, colleagues, and friends: GALEN does not exclusively represent the vision and commitment of IAPAC. Rather, this critical program reflects the cumulative effort and energies of disparate individuals, groups and agencies who, over the past 20 years, have struggled to foster harmonization and cooperation among global actors working in the HIV/AIDS care field. Where so often our hope for the future prospect of reversing the global pandemic is outweighed by apprehension and dread, GALEN offers a much-needed boost and reason to redouble our efforts.
José M. Zuniga is President of the International Association of Physicians in AIDS Care and Editor-in-Chief of the IAPAC Monthly.
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