The provision of HIV treatment and care in resource-limited settings is expanding rapidly. Health-worker training is one of many factors critical to the rapid scale-up of high-quality care [1–6]. Large numbers of health workers require HIV training; yet, few countries have a comprehensive training plan, a clear assessment of ongoing training needs, a plan to operationalize training on a large scale, or adequate funds budgeted for training. In this setting, an extensive variety of HIV-related training programs have sprung up over the past few years. Unfortunately, there are limited data measuring their effectiveness, and there is no consensus about what constitutes effective training.

Underlying the looming challenge in health-worker training, most resource-limited countries face a chronic shortage of trained health-care providers; chronic understaffing impedes the ability to adequately train health workers in HIV care. First, removing clinicians and nurses from active clinics for training purposes intensifies the strain on clinical care systems. Second, professional programs for physicians and other health workers are commonly lacking. For example, several countries in Africa and the Caribbean—including Botswana, Lesotho, and the Bahamas—do not have medical schools, and must send students outside of the country for basic professional training (see http://imed.ecfmg.org/main.asp; Table 1). Finally, trained workers (and potential recruits) commonly leave the public health sector for better compensation, benefits, working conditions, and job satisfaction found in other sectors and other countries—the “brain drain” phenomenon—further exacerbating the human resource crisis [7–12].

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Table 1. Medical Schools in Selected Countries

https://doi.org/10.1371/journal.pmed.0030304.t001

Faced with these challenges, and with the rapid pace of HIV-treatment expansion, few resource-limited countries have sufficient internal resources to address their training needs. As a result, most countries have collaborated with external partners to develop health-care-worker training programs, and/or to bring in expatriate specialists to provide training, at least in the initial phase of scale-up. Often, these training efforts are poorly coordinated with national training priorities, lack evidence to support their effectiveness, and are driven largely by foreign partners. As a result, many training redundancies exist alongside large, unmet training needs.

We gathered information on global HIV training through a thorough review of the published peer-reviewed literature, internet sites, program reports related to training for HIV treatment in resource-limited countries, a survey of HIV training efforts in high-burden countries, and discussions with appropriate professionals in selected countries. Here, we review challenges and approaches to clinical HIV training, and suggest an agenda for implementation research—defined here as research into how proven interventions can be implemented to accelerate high-quality HIV-treatment scale-up—to address the question: what is the optimal approach to training the health workforce for an expanding HIV-treatment program in a resource-limited setting?

Training Appropriate to the Model of Care

The design of a national health-worker training program to support the expansion of quality HIV treatment should be tightly linked to the way in which HIV care and treatment are delivered in the respective country. Many national programs, such as those of the Bahamas [4], Botswana [5], and Uganda [13], initiated HIV treatment by following a “vertical” specialty HIV-clinic model in which the majority of HIV treatment is provided by HIV specialists. Training according to this approach targets the creation of multidisciplinary HIV-care teams who provide care predominantly, or exclusively, for patients with HIV.

At the other end of the spectrum is the public health model of care delivery [14, 15], where HIV care and treatment are provided by primary health-care providers who are trained in basic aspects of HIV care for adults and children and to recognize conditions that warrant referral to a specialized setting [16]. Training in advanced aspects of HIV care is reserved for a small cadre of specialists. A hybrid of these two models occurs when a national program starts its treatment program in the specialty model, but decentralizes HIV services to peripheral facilities. In this case, HIV care and treatment may be provided in a primary health-care setting by primary health clinicians, or by an HIV-care specialist.

In the vertical model, training in HIV care relies on a highly centralized training program driven by a small group of expert trainers, with a core curriculum that can be quickly and easily updated to keep pace with changes to practice and guidelines, and short intensive trainings for small groups of trainees. Parallel systems are often established for training in laboratory methods, counseling and patient education, data collection, and pharmacy and supply management. As programs decentralize into a public health model, training decentralizes accordingly. Short, intensive trainings in a central setting become less practical. The cadre of trainers and curricula must be expanded, and systems must be implemented to allow for curricula review, updates, and distribution of continuing medical education (CME) materials.

Training Decisions amidst a Crisis in Human Resources for Health

The human-resources-for-health crisis in resource-limited countries is a substantial obstacle to scaling up HIV-treatment programs and is directly relevant to health-workforce training. Neither Mozambique, Rwanda, nor Tanzania, for example, has more than five physicians, 42 nurses, or three pharmacists for every 100,000 people (Table 2) [17]. The United States, by comparison, has a density of 256 physicians, 937 nurses, and 88 pharmacists for every 100,000 people [17]. Chen et al. have linked low national staffing ratios to poorer health outcomes [18], and it is likely that this link extends to HIV care.

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Table 2. Human Resources per 100,000 People in Selected Countries

https://doi.org/10.1371/journal.pmed.0030304.t002

The HIV health workforce includes doctors, clinical officers, nurses, pharmacists, laboratory technicians, phlebotomists, counselors, program managers, data clerks, ancillary staff, and community health workers. The function of each category of health worker depends on the local model of care delivery, and is influenced by tradition, legislation, and local regulations. Variation in health-care-worker roles can be an obstacle to adapting generalized training tools and curricula to a specific setting. A recent study in the US found that nurse practitioners and physician assistants who specialize in HIV care provide better care than non-HIV expert physicians and comparable care to HIV-specialist physicians—a finding which could support the expanded role of nurses and clinical officers in HIV treatment in resource-limited settings [19].

As noted, many countries lack adequate pre-service training institutions for health-care workers, and must send clinicians outside of the country for professional training (see http://imed.ecfmg.org/main.asp). Postgraduate migration to other countries is common, exacerbating the human resource crisis [7]. In a setting where the need for health workers outweighs the number of health workers who are available, it can be difficult to entice workers to staff underserved areas, such as rural sites.

Advantages and Disadvantages of Training Methodologies

There is scant evidence to support the effectiveness of one training methodology over another. Below, we present some of the advantages and disadvantages of the predominant training methodologies that have emerged ad hoc in the past few years. In Box 1, we briefly describe aspects of the training programs in Botswana, China, and the Dominican Republic.

Establishing a National Training Plan

More data on the effectiveness and program costs of training are needed to help planners determine which options are optimal given a program's unique circumstances, including the size of the population requiring treatment, the care delivery model, the extent of local expertise, the existing public health infrastructure, health-care worker/population ratios, political will, nongovernmental organization involvement, and resources. Training programs would also benefit greatly from accurate forecasts of the demand for health workers [4]: the number of necessary staff needed immediately, the number of staff needed over time as programs scale up treatment, site locations, and the optimal number and mix of staff at each site. Such forecasts allow planners to determine the extent to which an investment in hiring and training additional health workers would affect HIV care and the extent to which it is critical to budget and resource-allocation decisions.

Training plans should anticipate common experiences—such as the permanent loss of trained health workers who take more lucrative jobs or burn out, the temporary loss of health workers who take leave or attend trainings, and worker illness and death from HIV infection. Some programs have chosen to train two individuals for every position, assigning each to spend half of their time at the HIV clinic and half elsewhere in the hospital or clinic. This reduces reliance on one individual, allowing each to miss clinical time without significant disruption. Without a buffer system to replace trained individuals, or the flexibility to train additional staff quickly, unexpected staff shortages create bottlenecks in clinic operation, slowing down the flow of patients and straining other staff. A forward-thinking national training plan will not only anticipate job loss but will also incorporate ways to avoid it. Approaches might include augmented salary, recruitment of staff to work in their home districts, improved staff-to-patient ratio, and adequate supplies.

Other considerations to be addressed when designing a training plan include the site of training, target audience, and content material. Training plans need to consider the optimal components of a training site, e.g., proximity to a health-care facility and an environment similar to what the trainee will experience at their home clinic. Training plans need to assess training previously received by workers, and decide whether to train one health cadre at a time or to train multidisciplinary teams together. Content material should match the reality on the ground, reflect local practice, and account for availability of drugs and diagnostic capabilities.

Toward a More Evidence-Based Training Program

Decisions as to how best to train the health workforce in resource-limited countries are being made with limited data to support them. Few programs measure the impact of training on clinical outcomes. We have identified critical questions in Box 2 that correspond to key topics: model of care, human resources, and training delivery. We recommend that an implementation research agenda be established to address these questions.

Conclusions

Training a robust health workforce is critical for sustainable HIV-treatment programs. The care delivery model, the roles played by different health workers, the number of workers needing training, resources available for training, and the phase of program development all significantly affect training design. Evidence to support these decisions must come from implementation research to answer the overarching question: what is the optimal approach to training the health workforce for an expanding HIV-treatment program in a resource-limited setting?

Acknowledgments

We are grateful for the thoughtful comments provided by Cassia van der Hoof Holstein and Kimberly Zeller, which contributed to the direction of the paper. We are grateful for the input of the Clinton Foundation HIV/AIDS Initiative country teams for providing insight into the national training programs. Some of the ideas presented in this report were discussed at a World Health Organization meeting on clinical mentorship for the care and treatment of HIV/AIDS in June, 2005, in Kampala, Uganda, and attended by E. McCarthy.