Shumbusho F, van Griensven J, Lowrance D. Task shifting for scale-up of HIV care: Evaluation of nurse-centered antiretroviral treatment at rural health centers in Rwanda. PLoS Med. 2009 Oct;6(10):e1000163.
Task-shifting has been recommended by the World Health Organization (WHO) and the US President's Emergency Plan for AIDS Relief (PEPFAR) to help address the shortage of human resources for health. This shortage is a major impediment to achieving universal access to HIV care and treatment.(1, 2) However, little data have been published on sub-Saharan Africa regarding the quality of care when task-shifting is implemented.
To evaluate the feasibility and effectiveness of using nurses to prescribe ART in rural settings
Pilot intervention of a delivery model for health services, and retrospective review of patients' medical charts
Three rural primary health centers (PHCs) in Nyanza and Muhunga Districts, Rwanda. Selection criteria for clinics included: a) comprehensive HIV care services already in place; b) available supervision and support by a district hospital already providing ART; c) presence of nurses with at least two years of clinical experience
Medical records of patients enrolled in HIV care and treatment from September 2005 through March 2008 at the three pilot health centers
Two nurses at each PHC were trained to prescribe first-line antiretroviral therapy (ART) for treatment-naïve adult patients with uncomplicated disease, and to organize referral of complex cases to a physician. Pediatric patients, adults previously on treatment, those with opportunistic infections (e.g. tuberculosis), severe laboratory abnormalities or side effects, patients suspected of ART failure and non-adherent patients were considered complex. Nurses were trained on physical examination and HIV staging, assessment of ART eligibility, follow-up, ordering and interpreting lab tests, ART initiation and follow-up, contraindications to specific drugs, drug substitution, medication refills, completion of medical records, and reporting. Regimens were based on national guidelines, mostly fixed-dose combinations. Training included didactic teaching, a five-day practicum at an ART site, and a 5-10 day bedside training under physician observation. A minimum of 50 physician-observed consultations among the ART-eligible and -ineligible patients were required before nurses could see patients independently. Ongoing physician support was available at a distance. During once weekly onsite supervision and mentoring, physicians managed complex cases and verified nurse prescriptions. Algorithms and checklists were developed for nurses, and a standardized evaluation form was used to guide supervision. Nurses continued with their general patient care duties, and did not receive salary increases or incentives. Primary outcomes assessed included completeness of patient data; appropriate screening, treatment, follow-up and side effect management; patient retention; clinical status; and mortality.
A total of 1076 adult patients were newly enrolled into HIV care; 435 (40%) were eligible for ART and initiated treatment. Most starting treatment were WHO clinical stage II (39%) or stage III (35%); 2% were stage IV. No ineligible patients were started on treatment, although 16 who were eligible did not initiate ART, mostly for reasons unrelated to nursing care. The median time from HIV testing to ART initiation was 27 days. Intake assessments were 93% to 100% complete; 83% of patients were screened for side effects at every follow-up visit, and 89% were assessed for adherence at every visit. Median follow-up time on treatment was 8.3 months. All drug prescriptions were consistent with national guidelines, except for one patient given efavirenz without excluding pregnancy. Twenty-three patients (5.3%) required treatment modification, mostly single-drug substitution for toxicity. At the time of assessment, 29 patients (7%) had died, only one was lost to follow-up, and 15 (3%) had transferred care. Estimated retention at the facility level was 92% at six months but it had dropped to 80% by 24 months.
With adequate support and training, nurses can effectively prescribe first-line ART and monitor noncomplex patients. Nurse-centered task shifting is feasible and effective for decentralized ART services without compromising the quality of care. Patient outcomes (mortality and retention) were similar or better compared to historical data in Rwanda and to other programs in sub-Saharan Africa.(3, 4)
This was a good quality study. Because the program was funded as a pilot intervention, the authors indicate that limited resources precluded a comparative evaluation design.
Nurse-initiated ART may be a viable strategy for expanding access to AIDS treatment. The authors state that this evaluation prompted Rwanda to incorporate nurse task shifting into its national ART scale-up plan. It should be noted that nurses in this model had intensive physician supervision and were responsible only for uncomplicated adult cases. In addition, only PHCs that were well managed and had adequate staff were part of the pilot program. Similar circumstances may not be the case at other rural sites. Whether nurses can be trained to manage second-line treatment, pediatric cases, and treatment failure has not been determined. The use of structured guidelines, algorithms, checklists, and regular supervision likely contributed to quality patient care. Other countries developing task-shifting models should take into account the need for adequate training and regular oversight and be sure to collect and evaluate data on the quality of care delivered and on patient outcomes.
- Van Damme W, Kober K, Laga M. The real challenges for scaling up ART in sub-Saharan Africa. AIDS Patient Care STDS 2006;20:653-6.
- World Health Organization (2006) Taking stock: health worker shortages and the response to AIDS. Geneva: World Health Organization. Accessed 2 September 2008.
- World Health Organization. Towards universal access: scaling up priority HIV/AIDS interventions in the health sector: progress report. Geneva:World Health Organization. Accessed 2 September 2008.
- Stringer JSA, Zulu I, Levy J, et al. Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes. JAMA 2006;296:782-93.