Strategies to improve the implementation of nurse-initiated management of antiretroviral therapy (NIMART) training: a systematic review

Background Nurse-Initiated Management of Antiretroviral Therapy ( NIMART) training was introduced with the purpose of improving the knowledge, skills and competence of nurses in providing comprehensive quality care to people living with HIV (PLWH) and facilitating World Health Organisation task-shifting where nurses initiate antiretroviral therapy (ART) rather than doctors to meet the increasing demand of ART drugs. The aim of this review was to identify evidence of training strategies that can improve the implementation and deals with challenges that hinder quality. Methods A measurement tool to assess systematic reviews methodological systematic review tool was used to critically assess selected studies. Studies were sought using multiple databases including CINAHL (EBSCO), Google Scholar, ProQuest, academic journals, SA publications, electronic resources and OAISTER published from January 2012 to February 2017. The initial review of studies yielded 535 results excluding duplications. The screening of full-text articles was conducted, and 33 articles met the eligibility criteria and were included for quality assessment. The rest were excluded. The quality assessment research instrument was used to analyse and synthesise selected full-text articles (n=33). Results The studies indicate that NIMART or HIV training is used interchangeably and has the potential to empower nurses with knowledge and skills. It also has a positive impact on increasing ART uptake; however, nurses still lack con�dence and competence to provide comprehensive quality patient-centred care. Studies suggest that a shift from the traditional didactics of lectures or slide presentation methods during training to the use of interactive training strategies that stimulate critical thinking in making decisions about HIV care, followed by mentoring and continuous professional development. Conclusion and recommendation This study reveals that the use of effective training techniques during NIMART training has a positive impact on the learning outcomes, implementation and performance of HIV programmes. The health care system should focus on dealing with barriers that negatively in�uence NIMART implementation. Given the lack of a framework or model related to NIMART or HIV training, the study recommends the development of a conceptual framework to strengthens the implementation of NIMART training.


Background
This researcher analysed the process of conducting a systematic literature review in studies done in South Africa and globally, from January 2012 to February 2017, on Nurse-Initiated Management of Antiretroviral Therapy (NIMART) or Human Immunode ciency Virus (HIV) training.The two are used interchangeably in most literature.NIMART training was introduced in response to World Health Organisation (WHO) recommendations of task shifting to tackle the shortage of skilled health care workers, where nurses initiate ART rather than doctors with the aim of achieving the goal of universal access to comprehensive prevention programmes, treatment, quality care and support globally [1].However, the implementation of NIMART after training and quality is of serious concern in the North West districts.There is a need to increase access to ART to meet the demand according to the South African guidelines and the current universal test and treat (UTT) policy introduced in September 2016 to achieve the 90-90-90 strategy and eventually better health for all people living with HIV (PLWH).

Problem Statement
The Regional Training Centres (RTC) were established to improve the skills of health care workers in order to respond effectively to HIV and AIDS care.The clinical mentorship programme had been introduced to strengthen the knowledge, skills, competencies and con dence of health care workers after training.In addition, guidelines were developed and reviewed according to research ndings as well as in-service training was conducted to promote proper NIMART implementation.However, gaps still exist.This was observed during the quarterly and annual monitoring and review of HIV programmes using ART indicators which included HIV/tuberculosis (TB) co-infected, antenatal (ANC) pregnant women, new adults and children initiated on ART and a total number of patients remaining on ART, viral load completion and suppression rate.
The general performance of these indicators is uctuating, and no signi cant impact is observed despite the increasing number of nurses trained and certi ed competent.Therefore, this prompted the researcher to conduct a systematic investigation of literature to obtain a better understanding of the problem.Preferred Reporting Items for Systematic and meta-Analyses (PRISMA) was followed to ensure justi cation for further research and to address several conceptual and practical advances in science.The ow diagram summarised in Figure 1 of the systematic review phases was used [2].

Aim of the study
The purpose of this study was to review the literature to obtain a broader perspective of strategies that can be adopted for training and identifying challenges that hinder implementation and ways to deal with such factors.The objective of the study was to review and analyse primary studies that would provide an in-depth understanding of the facilitation strategies that can be used to strengthen NIMART training and to improve quality in the implementation and management of HIV programmes.
The following review questions were used: Implementation is a process of moving an idea from concept to reality (dictionary)., Implementation is also de ned as the process needed to bring new practices into widespread use [3].Therefore, in this study, implementation refers to the process of acquiring knowledge and skills obtained from NIMART training to increase access to antiretroviral drugs (ARVs) and to provide quality comprehensive care through evidencebased practice.
NIMART training had been de ned in accordance to the National Department of Health, it was nurses who initiated and managed antiretroviral therapy training in order to increase access to ART [4].This is an organised process or activity of teaching nurses about nurse-initiated and management of ART by imparting knowledge about the HIV and AIDS, Sexual transmitted infections (STI) and Tuberculosis (TB) (HAST) programme, the provision of clinical mentorship to improve practical skills, con dence and competence in the delivery of comprehensive quality care, treatment and support within primary health care (PHC) level.

Contribution of the study to NIMART training
This study contributes to a broader understanding of training strategies that can be used by the RTC, facilitators and curriculum developers to improve the knowledge, skills, competency and con dence of nurses to provide comprehensive and quality care to PLWH, including being aware of challenges in uencing implementation in the health care system.This will also provide a basis for improvement in training and implementation of NIMART, through the ndings and recommendations made by researchers.The study also provides guidance to policymakers and district health care system management teams on ways to deal with challenges affecting the implementation and quality of HIV programmes.

Search Strategy
The methodological quality of the systematic review process was critically assessed using the eleven components of the AMSTAR tool or checklist [5].The following components were assessed by indicating yes, no, can't answer or not applicable: the design used, the removal of duplicates and data extraction, the performance of a comprehensive literature search, indication of studies that met inclusion and exclusion criteria and the reason, providing the list of included and excluded studies, providing a table with characteristics of included studies, the use of a quality scoring tool to assess studies and be documented, appropriate use of rigour and scienti c quality in analysing and formulating conclusions, the use of appropriate tests, reduction of bias and disclosure of con ict of interest (refer to Annexure A).

Information sources and search
A manual search using selected terms was conducted with the help of an experienced librarian and researcher to ensure that the studies were critically analysed.The search terms were divided into three words and later combined.Different databases were searched, including CINAHL (EBCO), scholar Google, ProQuest, academic journals, SA publications, electronic resources and OAISTER.The nominated search terms are shown in Table 1 and databases in Table 2.Both qualitative, quantitative and mixed studies were reviewed for meta-analysis.The search strategy was documented, saved and stored online.

Inclusion and exclusion criteria
Literature with the following topics, published between Jan 2012 and Feb 2017 was included: NIMART OR HIV training, HIV management, factors in uencing performance and the impact of NIMART OR HIV training.
The following types of papers were excluded: informal literature surveys with no de ned research question or search, data extraction and data analysis process and papers not subjected to peer reviews.When a paper had been published in more than one journal, the most complete version of the study was used.

Primary study selection
After conducting the search, primary or original full-text studies were selected using the PICOS review protocol or criteria.These studies were assessed based on participants, phenomena of interest, context and type of studies as indicated in Table 3.The list of rejected studies was compiled indicating reasons for rejection, checked, discussed and agreed upon with an independent researcher.Most of the studies excluded were abstracts, magazines and newspaper articles.

Quality assessment
The quality of the original studies chosen for the review was critically screened using the Quality Assessment Research Instrument (QUARI), developed by the Joanna Briggs Institute (JBI) in 2014, as indicated in Table 4.The QUARI has ten evaluation criteria, which include author, name, year, country, and purpose of the study, participants, design, data collection, data analysis and key ndings [6].Studies that had scored 5 or fewer points were excluded from the review to ensure quality.

Data extracted and synthesis
Full-text studies were extracted (n=33) and considered for systematic review and analysis.Five were excluded, however, they were used in reference.Data from each paper was checked by another researcher.
Microsoft Excel was used to capture, sort and arrange papers in alphabetical order according to the rst authors and duplicates were removed (See Figure 1).The studies indicated on Table 4 was reviewed to answer the research questions and to identify interesting trends.Thematic analysis was used to synthesise data.Data were coded, categorised and themes were developed.

Results
The studies selected for analysis were conducted in South Africa, USA, Australia, Kenya, Uganda, Nigeria and Central African countries.Most of the studies were from the rural PHC of South Africa (45%), followed by USA (30.3 %%), Australia (3%) and other African countries (15%).The studies used different methods which included quantitative (n=13), qualitative (n=14) and mixed methods (n=6).A total number of 33 studies were reviewed.Participants among the reviewed studies varied from 15 to 386 and they were mainly nurses, midwives, students, managers in health care, clinical documents, patients and nursing educators.Studies focused on the impact of NIMART or HIV training strategies (n=15), factors in uencing NIMART or HIV implementation and management (n=13) as well as those that focused on both training and implementation (n=5).The following themes were developed: The Impact of NIMART/HIV training strategies on the implementation of HIV programmes Studies have con rmed that the strategy of nurses initiating ART rather than doctors has a positive impact on increasing ART uptake, although there are still challenges in NIMART training and implementation which affect the performance of HIV programmes as indicated in Table 5. NIMART training can have both positive and negative impacts depending on the strategies used during training [7,8,9,10].Studies have revealed that nurses feel that NIMART training has empowered them with knowledge and skills to manage PLWH, however, there are still factors that in uence implementation, competency and con dence to provide comprehensive quality care.This study's ndings show that the use of ineffective, passive, traditional didactics methods of lecturing or slides presentation has no impact on learning and results in inadequate NIMART training.The use of multiple, interactive techniques that stimulate critical thinking to make sound decisions in care is recommended.These strategies include problem-based, re ective and case-based learning, seminar, clinical simulation, group discussions, practice and feedback.It increases knowledge and con dence in caring for PLWH.Some studies have indicated that, in service, onsite or facility-based clinical training, continuous professional development, creating a pool of trainers and mentoring have a potential to improve the knowledge, competency and performance of indicators [11,12,13,14,15,16].Pre-service training in the institutions of higher learning is necessary to prepare nurses to care for HIV patients immediately when they enter the health care system [17].Additional training on Primary care 101 also has the potential of improving the quality of clinical records and the integration of the management of chronic diseases in the PHC clinics.This includes NCD and ART patients [18].NIMART training includes paediatric HIV and TB /HIV co-infection management, adverse drug reaction, switching therapy and dealing with defaulters.However, nurses still call the hotline to request assistance in dealing with such cases or refer them to doctors.Very few nurses are competent to initiate ART to children and TB/HIV and some still need more practice and mentoring [19,20,21].Another gap identi ed in NIMART is the lack of training in data management, data elements de nition, ART, HTS, TB and other registers.This results in over-or under-reporting [22].Consequently, inter-professional education, practice, ethics and professionalism are not emphasised in the clinical years of training and need sensitisation including enhancement of mentorship and the use of innovative training strategies [23].

Factors in uencing the implementation of NIMART/ HIV training
Studies have revealed different factors, classi ed as patient, human resource (HR), environmental and structural/health system factors as indicated in Table 5. Nurses who have been trained on NIMART/HIV are reported to have gained knowledge and skills but face the burden of being overworked by high volumes of patients demanding ART.This results in exhaustion and dissatisfaction.High staff turnover leading to a shortage of skilled nurses and unveri ed data by OPM in the facilities affect the performance of indicators [11,12,13,22,24].
The patients' factor also adds pressure to the implementation and management of ART.Studies have indicated that poor adherence to ART or TB treatment is associated with poor outcomes.Patients still have challenges regarding modi cation of lifestyle, e.g. the use of alcohol and it undermines adherence, leads to risky behaviour, alters the immune system and the physiological and effective functioning of drugs.Poor adherence was also evident with a high rate of loss to follow up especially patients who were on pre-ART care or wellness and need tracing and link to care [25,26].Some studies have revealed that the health care system or structural factors have negatively impacted NIMART implementation, especially in sub-Saharan Africa, including South Africa.This includes poor integration of services, lack of support, lack of supervision, long waiting hours, inadequate nancial resources, equipment and drugs stock-outs, supply chain system, overcrowding, staff attitudes, monitoring and evaluation programmes and poor organisation of work schedules and processes (see Table 6) [13,27,28,29,30].There are only three sub-Saharan countries are implementing ART according to WHO guidelines of treatment for all to achieve the 90-90-90 targets, including the universal test and treat policy [31].Decentralisation of NIMART services increases ART uptake in PHC and rural clinics although it also increases workload [14,31].NIMART is widely practised and authorised in policy but not reinforced in regulations, e.g.SANC, pre-service education [32].a review of ART guidelines has resulted in early ART initiation and has public health bene ts in reducing HIV incidences, morbidity and mortality [33].However, facility-based inservice training before implementation and mentoring should be prioritised and provided compulsorily.
Environmental factors such as stigma, discrimination and staff attitudes impact negatively on NIMART /HIV implementation and management and contribute to poor adherence to treatment.Studies also support that poor infrastructure, a lack of space and overcrowding expose both clients and staff to cross-infection and affect HIV and TB management.Inadequate security poses a risk to staff, drugs and equipment.Poor clinical leadership role models, support and supervision by unit managers in developing student nurses also exist [34,35].

Discussion
Studies have indicated that NIMART training has positively increased ART initiations by nurses, however, there are still challenges to improve training and in dealing with factors hindering quality implementation.Most studies have con rmed that the implementation of WHO recommendations of task-shifting on nurse-led ART programme in PHC have yielded a positive impact [9,29].Hence, South Africa has the largest ART programme worldwide with about 3.4 million people [36].Nurses have been reported to have gained knowledge and skills through NIMART training, but gaps still exist regarding competence, con dence and attitude necessary to sustain patients on lifelong ART and to ensure adherence to achieve viral load (VL) suppression.This has a negative impact in reducing new HIV and TB infections, drug resistance and death.Findings from this review suggest numerous barriers that have a negative impact on training and recommends various effective strategies to improve, as indicated in Table 5.The review has illustrated consistently that there are several factors that continue to impact NIMART implementation and hinder the performance of HIV and ART indicators.These include patient social, physical and psychological factors, environmental, structural or health care systems and human capital factors, as indicated in Table 6.Future studies need to consider identifying and nding ways to deal with barriers and should further develop a conceptual framework that will help to improve NIMART training and implementation as there was no framework in the literature reviewed.

Practical implications
Based on the ndings and recommendations of the studies analysed, integration of theory and practice can be practically achieved by means of interactive critical thinking and training strategies.On the other hand, nurses would improve their decision-making skills and render quality HIV care to PLWH, thus improving the performance of the programme.

Limitations of the studies
The study only focused on full text, reviewed and published studies.Other studies were excluded as they did not comply with the approaches, even though it has valuable information.No conceptual framework or model related to NIMART/HIV training was identi ed.

Conclusions
Although task-shifting and NIMART training have helped to increase ART uptake, more should be done to provide quality care to PLWH and to strengthen adherence, to reduce loss to follow up and to keep them virally suppressed.Again, measures to improve continuity of HIV care should include the use of interactive training strategies that stimulate critical thinking in decision making about HIV care.Dealing with factors that hinder implementation is of great importance and the development of a comprehensive integrated framework is necessary to guide NIMART training and implementation.
The study has revealed recommendations that can be used to improve the quality of training using strategies that stimulate critical thinking and integrate theory with practice.It is also recommended the introduction of NIMART as a pre-service training to nursing students, providing continuous in-service training on the current development and dealing with barriers affecting the implementation of HIV programmes in the PHC facilities to achieve better outcomes.
What is the impact of NIMART/HIV training on HIV management?What are the training strategies used in NIMART /HIV training?What are the factors affecting or in uencing the implementation of HIV programmes?
Abbreviations AIDS-Acquired Immune De ciency Syndrome Figure 1

Table 1 :
Search terms or keywords *After duplications removed

Table 3 :
Inclusion criteria according to the PICOS review protocol

Table 4 :
Extracted data from original with quality assessments scores