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SIKO implementation phase

The study preparation period began in mid-2012 with eight

primary care sites, four sites in rural/small towns and four

sites in the Harare urban area. Training materials were

developed using principles of adult education and were then

piloted at the Parirenyatwa Family Care Clinic. Feedback

from the faculty, house officers and nursing staff was used to

refine the design and individual elements of the training

materials as needed, and then training of the two SIKO

teams took place. This "training of trainers" served to train

the SIKO monitoring team (who were trained in site

monitoring) and the SIKO implementation team (who were

trained in the delivery of the SIKO interventions). During the

preparation phase, SIKO personnel travelled to the sites to

meet with all care providers and other site staff to inform

them of the purpose and general plan of the study to engage

them in the study, asking for their assistance in the

documentation of all KS diagnoses, and for their

participation in the SIKO interventions. The latter were not

described in explicit terms.

During the monitoring period, starting in January 2013,

the monitoring team visited all the sites training them to

keep a daily log of the total number of HIV-positive patient

visits, the number of new KS diagnoses (incident cases) made

that day and the number of patients already diagnosed with

KS seen that day (prevalent cases). All KS patients seen at

the sites were asked to participate in the study and the

quality of life questionnaire was distributed. All sites

continued to deliver their usual standard of care to patients.

At the writing of this article the monitoring period was

ongoing for all eight sites.

During the intervention period, begun in May 2013, the

sites were randomly assigned to start the SIKO

interventions. One additional site will begin the SIKO

interventions every seven weeks. The single intervention

team consists of a physician experienced in KS care, a

palliative care doctor and a specialist nurse, and a KS

specialist nurse. The intervention team will visit the site for a

half day at the assigned start of the intervention, two weeks

later and then every four weeks throughout the study. Care

will be taken to ensure that the intervention team and the

monitoring teams and their site visits remain mutually

exclusive in order to ensure that data collection is not biased

by the implementation of the intervention. During the

intervention period, the three interventions will be

implemented at the sites and follow-up provided as needed.

At the writing of this article the intervention period had

commenced at four sites.

Outcomes of the SIKO training interventions

We expect that implementation of the KS-SE as part of the

SIKO intervention will lead to more active surveillance for

KS disease by primary care providers. This in turn will lead to

a greater number of overall KS diagnoses and, more

importantly, a greater number of early stage diagnoses in

primary care settings. This should lead to a broad

improvement in the treatment of KS. It is expected that the

SIKO intervention will enhance access to palliative care via

knowledgeable primary care providers in rural and urban

Zimbabwe, resulting in decreased physical and emotional

symptoms of distress and, therefore, improved quality of life

for patients with AIDS-KS. The outcome measure for this

analysis will be the change in the FLI-C score before and

after the SIKO training interventions.

We expect that the overall impact of all the interventions

included in the SIKO package will be improved AIDS-KS

survival and increased retention in care.

Conclusion

We have proposed interventions to improve AIDS-KS

diagnosis and treatment in primary care settings in

Zimbabwe. These interventions are currently being

evaluated in a community-based clinical trial. If the

evaluation of the SIKO interventions does indeed provide

evidence for improved KS outcomes in Zimbabwe we will

immediately begin a programme to disseminate this

knowledge to a broad spectrum of primary care providers

across the country in a stepped approach.

In coordination with the Zimbabwean Ministry of Health,

we would conduct training in the use of the KS-SE through a

series of training courses targeted at primary care providers

in each of Zimbabwe's provinces and begin work with the

Ministry of Health to develop sustainable plans for

expanding the distance and mobile KS and palliative care

consultative services. It may be that this model would serve

as a template for earlier diagnosis of other AIDS-related

cancers which could possibly be prevented, and certainly

better treated, if diagnosed at an early stage. l

Acknowledgements

This work was supported by a grant from the United States

National Institutes of Health and the President's Plan for

Emergency AIDS Relief (CA172050).

Dr Margaret Borok, FRCP is an experienced clinician and teacher

at the UZCHS. Since 1998 she has worked with Dr Tom Campbell

of the University of Colorado Denver, in collaborative operational

DISEASE-SPECIFIC CANCER CONTROL

96 CANCER CONTROL 2014

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