Clinical staging of HIV-related illness in Mozambique: performance of nonphysician clinicians based on direct observation of clinical care and implications for health worker training.

INTRODUCTION: In Mozambique, clinical staging may be the primary determinant of HIV/AIDS treatment decisions, and the task of staging commonly falls to nonphysician clinicians (técnicos de medicina). Two years after the first Mozambican técnicos were trained in HIV/AIDS care, the quality of their performance in clinical staging was unknown.
METHODS: Expert clinicians observed 127 clinical encounters conducted by a randomly selected national sample of 44 técnicos and compared observed clinical staging decisions to World Health Organization and Mozambican national norms. They also reviewed relevant Mozambican in-service training curricula in HIV/AIDS care.
RESULTS: Observers agreed with fewer than half (44.1%) of the técnicos' stage-defining diagnoses. Misclassification or misdiagnosis of 3 complaints (weight loss, fever, and diarrhea) accounted for the majority of the observed errors. Review of health worker curricula determined that observed staging errors reflected content errors and omissions in the técnicos' in-service HIV/AIDS training and constraints in local laboratory and imaging capacity. DISCUSSION: In response to these findings, the Mozambican Ministry of Health has revised the técnicos' scope of work and has developed new guidelines, curriculum materials, and training strategies to improve the quality of clinical staging and opportunistic infection diagnosis in Mozambique.