Nursing in the HIV/AIDS Pandemic: The Difference One Nurse Can Make

December 07, 2005

Editor's Note:
The AIDS pandemic is nearing its fourth decade, and the need for innovative strategies to help people living with HIV/AIDS has become increasingly important. There are 40 million people infected with the AIDS virus around the world. Almost 90% of them live in resource-poor countries. In this eLetter, you will meet one nurse who supports and educates other nurses in their struggle to keep up with the ever-changing demands of AIDS nursing. Anne Sliney, RN, ACRN, is an educator, negotiator, and "bridge-builder." Almost a year ago, she went to work for the Clinton Foundation, where she travels the world bringing knowledge and resources to some of the countries most impacted by HIV. Here is Anne's story:

Question: Can you please tell us about the overall mission of the Clinton Foundation?

Response: When President Clinton left office, he wanted to create a nongovernmental organization to address issues he felt passionate about and where he believed he could have some impact. So with that in mind, the Clinton Foundation was formed, with 4 major areas of focus: health security; economic empowerment; leadership development and citizen service; and racial, religious, and ethnic reconciliation. President Clinton is very involved in the day-to-day operations of the Foundation and provides remarkable leadership and a strategic vision.

I work in the area of health security in the Clinton Foundation's HIV/AIDS Initiative. Our approach to fighting the AIDS pandemic is to assist developing countries to plan and implement large-scale integrated care and treatment and prevention programs. In some countries, we work closely with government health officials in writing the national plan. We work at the invitation of the host government and are guided by the identified needs of that government. Therefore, each country's program is somewhat different.

Our most successful and well-known initiative is negotiating the price of generic antiretroviral (ARV) medications. By negotiating with Indian South African generic pharmaceutical companies and guaranteeing them a significant market, we were able to get the price of a first-line regimen of ARVs down to less than $140 per year (compared with about $15,000 per year in the United States.) This makes it affordable for governments to purchase drugs and to supply them to hospitals and clinics. We have also provided governments with technical assistance related to transport, storage, inventory management, and quality control of their drug supply.

A similar approach is taken to HIV-specific laboratory equipment. We have assisted governments in the purchase of laboratory equipment to measure T-cell counts by bundling the equipment, reagents, training, and maintenance to ensure the best price possible. If requested, we will provide laboratory experts to assist with the placement of equipment, planning for transport of specimens, and appropriate training of staff. We also assist with developing quality control procedures.

In approximately 18 of the 48 countries we work with, we have permanent staff and more extensive programs. The government health officials identify gaps in their effort to scale-up comprehensive HIV/AIDS care, and we try to find a way to fill the gap. We do not provide direct clinical care. We support and provide training for healthcare workers, we help mobilize financial resources from other donors, and we provide business and management systems and training. All these projects are aimed at assisting these governments to implement their own comprehensive HIV/AIDS plan in the most efficient way possible. Additionally, the Foundation provides "on-the-ground" technical assistance even in countries where we do not have any offices.

Our most recent initiative is our global pediatric program. We have purchased and donated pediatric formulations of ARVs for 10,000 children. This is meant to kick-start pediatric ARV treatment, guarantee a market for the generic companies to produce these formulations, and bring down the price. Because treatment of children has been so limited, we are sponsoring training for healthcare staff and supporting some infrastructure improvement necessary to scale-up pediatric treatment.

Question: What is your role at the Foundation?

Response: I am the only nurse employed by the Clinton Foundation. I have been with the Foundation for 10 months. In some countries, we have a "care partner," a university-based HIV/AIDS program that supplies the clinical expertise for our country teams. For example, Brown University is our partner in India, Harvard in Tanzania, and Columbia University in the Dominican Republic. When a government identifies nursing issues as an area that needs attention, I gather information on the problem, meet with those countries' nursing leaders, and do site visits. Together, we design an approach to deal with the problems they have identified. It may be training of nurses in specialized areas of HIV care, updating hospital-based nurses on HIV care, or addressing the overall nursing shortage. This is an ever-changing role. In developing countries, nurses provide the majority of healthcare. We need to help countries train, support, and retain their nurses.

Question: How did you become involved with the Clinton Foundation?

Response: I became involved with the Foundation through some volunteer work I was doing in Belize (Central America). I had read articles about the dramatic price reductions the Clinton Foundation had negotiated, and I approached the Foundation about Belize getting access to these dramatic price reductions of ARVs. As a result of those conversations, I began to volunteer for the Foundation, and eventually was offered a full-time job. I am not assigned to any one country, but I am a "shared resource" among the countries where we have programs. To date, I have been to India, China, Kenya, Lesotho, and Uganda. My home is in Providence, Rhode Island. I travel for 2-5 weeks at a time, and then spend several weeks at home. The Internet allows me to communicate quite well with my colleagues around the world.

I have been a nurse for 27 years, working in a variety of settings -- inpatient adult medicine, home care, urgent care, and outpatient clinics. Several years ago, I accepted a position in a hospital-based HIV clinic. Once I started HIV nursing, I was hooked. It is intellectually challenging, nurse-intensive, and tremendously rewarding. I loved the challenge, the patients, and the collaborative working relationship with the physicians, case managers, and support staff.

Prior to this position, I was a community adherence nurse in Rhode Island. In 2001, the Rhode Island Department of Health funded a program to assist people on ARV therapy to be more successful in taking their medications. I was hired to develop a state-wide adherence program. After consulting with all of the physicians and nurse practitioners who were providing HIV care in Rhode Island, I developed a community-based program that was quite flexible and responsive to the needs of the individual patient. Clinicians referred patients to me when the patient was starting or switching therapy, failing a regimen, or leaving prison or drug rehabilitation. Case managers called me to see their clients. Most of my work was done in the patient's home, assessing their barriers to adherence, educating, supporting, intervening with other providers, identifying and managing side effects, and dealing with all the psychosocial issues surrounding HIV/AIDS. By the time I left that position in January 2005, there was a staff of 4 nurses providing adherence support.

I had thought for some time that I would like to be involved in nursing in a resource-poor setting. Once I developed skills in HIV nursing, I knew there could be a role for me somewhere. My youngest child is now 20 years old, so I thought it was time to spread my wings. My husband and children are my biggest supporters. They are very proud, but I think a little worried at times.

I have a BS in Nursing. I'm also an AIDS Certified Registered Nurse (ACRN). When I speak to nursing students, I tell them, "I'm no superstar nurse. I don't have any advanced degrees. I just take all the lessons I've learned and all the skills I've acquired over the years and use them in a different setting."

Anne Sliney RN, ACRN, with nurses in Kunming, Yunnan Province, China, after completing a 4-day training course in HIV/AIDS nursing sponsored by the Clinton Foundation.

Question: Please describe the most rewarding or difficult moments in this job. What are the stresses involved in your position?

Response: The most rewarding and difficult moments actually occur at the same time. Visiting a rural health facility in Kenya or India is extremely difficult when you see the physical structures, the overcrowding, the lack of supplies and clean water, and the infection control disasters. For example, I have seen 1 nurse caring for 62 pediatric patients by herself. I have seen a pediatric ward with 3 beds and 15 patients in that ward.

Then you meet the nurses, and you want to cry. These nurses work for very little pay, often live in substandard housing, and rarely get a day off. They may be the nurse, the counselor, the drug dispenser, and the manager of the medical supplies. But they are gracious to a visitor like me and anxious to upgrade their skills. I am so proud to say I'm a nurse too. They are heroic.

President Clinton is well loved around the world. We find ourselves welcomed and trusted by government officials. We work hard to maintain that trust. Although I have met President Clinton several times, I do not work directly with him. He handles the diplomacy and the fund raising, and he provides the vision of a world where every person has access to HIV/AIDS treatment.

Anne Sliney with President Clinton at Brown University in Rhode Island. Anne was conveying many good wishes to President Clinton from the people she had worked with on a recent trip to China.

Question: Are there opportunities for other nurses to get involved with this initiative or with similar projects, either as volunteers or in other ways?

Response: At this time, we do not have any paid positions available, but we may have a need for volunteer nurses in the future. More information on the Clinton Foundation and how to volunteer can be found at the Web site.

The Association of Nurses in AIDS Care is working on ways to support global HIV/AIDS nursing and encourage membership in resource-limited countries. The International Center for Equal Healthcare Access also has a program for experienced HIV/AIDS physicians and nurses to volunteer as clinical mentors.

The work I have been privileged to do around the world is very rewarding. I am humbled by the work of nurses globally, and it is an honor to work with them.

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