Nurses to Play Central Role in Managing TB Syndemic

Jason E. Farley, PhD, MPH, CRNP, knows the dangers inherent to an increasingly common and hazardous syndemic in South Africa: HIV and drug-resistant tuberculosis (TB). More problematic than a co-morbidity, a syndemic refers to two or more co-occurring epidemics that consistently result in adverse interactions and, consequently, negative health consequences. In this instance, TB remains the leading killer of people living with HIV.

"In South Africa, 60 percent to 70 percent of people with drug-resistant forms of TB also have HIV co-infection. It presents a large burden. We need to fight these diseases simultaneously," says Farley, a researcher and assistant professor at the Johns Hopkins University School of Nursing, as well as a nurse practitioner in the Division of Infectious Diseases within the Johns Hopkins AIDS Service.

The severe physician shortage in South Africa compounds the onerous challenge of combating the syndemic. "How can we work effectively and efficiently in a system when a physician can't see patients more than once a week, even when they're inpatients?" Farley questions.

He's not waiting for an answer. Farley has taken the lead on as series of studies that place nurses in a role central to attacking the complex problem. The series has been dubbed "Coordinated TB/HIV Treatment Initiative: Nurses for Effective Concurrent Therapy (Co-INFECT) Project".

One of the project's studies aims to test the health outcomes of South African patients with MDR-TB (multi-drug resistant tuberculosis) diagnosed and followed primarily by nurses in a specialty hospital setting. In May 2010, Farley received a $274,000 grant from the Medical Research Council of South Africa to fund the community-based research study, titled Co-INFECT Project: Nurse Initiation of MDR-TB; A Clinic Cohort Study.

The study will proceed as follows. Nurses in a primary care setting will be trained to diagnose MDR-TB in HIV patients and then refer them to a MDR-TB specialty center. At the specialty center (Murchison Hospital), patients will be followed by trained primary health care nurses supervised by physicians.

This represents a new paradigm of care, as nurses at South African hospitals previously have not taken the lead role in following the care of this patient population. It's a shift Farley believes makes sense.

"Patients don't do well because physicians aren't available. The longer you have to wait, the more advanced the disease becomes, the weaker the patient gets," Farley says. "If nurses can get equivalent treatment outcomes, we can improve access to care."

In another of the series' studies, a pilot project aims to determine the impact of a nurse case management (NCM) model on MDR-TB treatment outcomes by comparing cure/treatment completion rates at a control site with those at two intervention sites.

The project, titled "Co-INFECT Project: Nurse Case Management (NCM)", will evaluate MDR-TB treatment outcomes across all three sites, and will assess the relationship between the nurse case manager intervention and overall treatment outcomes.

"We're looking at how do we, without changing a single thing about treatment, take a nurse, give that nurse a specific list of tasks, and see if that model can lead to success outcomes?" Farley notes.

In this study, researchers will measure and monitor the tasks that participating nurses are required to perform. This "bundle of interventions" includes: following a patient through the care trajectory, monitoring patient-related events (such as adverse drug events, adherence to drug regimen); tracking patients from a system perspective; and other tasks.

Farley points to the proven success of this NCM model in the U.S. "We've seen this [model] be successful for women undergoing breast cancer therapy, in HIV patients, heart failurewe're going to translate this intervention into South Africa," he says.

These research projects introduce new ways to use existing resourcesnursesto manage S. African's tragic and costly syndemic of drug-resistant TB and HIV.

"It's difficult to put a sense of urgency on this issue. It has many similarities to the early 1990s here where, sometimes, the only thing you had to give someone was your hand to hold," says Farley, referring to the scores of individuals affected by outbreaks of MDR-TB and HIV in the U.S. over a decade ago.