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
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