SA government policy gets support from researchers at UCT and University of East Anglia, who identify nurses as preferred health providers for ART programmes.
Nurse-centred care of HIV patients can be just as safe and effective as care delivered by doctors and has a number of specific health benefits, according to a new study led by the University of Cape Town (UCT) and University of East Anglia (UEA).
Published on 15 August 2012 in The Lancet, the research shows that neither survival rates nor virus suppression reduced when nurses prescribed antiretroviral therapy (ART) drugs to patients in South Africa. Health benefits included: significantly improved detection of tuberculosis, increased white blood cell count and weight, and adherence with the treatment programme.
It is a priority of the World Health Organisation to expand access to ART, but in South Africa access to the right drugs is limited by a chronic shortage of trained doctors. The government is trying to shift healthcare provision from doctors to primary care nurses, who are more plentiful. This policy has been resisted by some HIV physicians and nurses, however, who feel administration of these drugs is the proper domain of doctors.
More than 15,000 patients took part in the two-year randomised controlled trial in the Free State. All 31 clinics providing ART in the province at the time of the study took part. The study was conducted by UCT in partnership with UEA and other universities.
South Africa has around 6 million people infected with HIV - more than any other country in the world. Of those patients who would benefit from ART less than one in three receive it. In the West, this figure is nearer to 100 percent.
Joint lead author Dr Lara Fairall of UCT said: "The findings profile nurses not just as an alternative when no doctors are available, but as the preferred health provider for ART programmes, delivering better quality care and health outcomes for patients. But we caution against viewing task-shifting as a panacea for the ART access problem. This trial showed no impact on ART access, in part because it was a pragmatic trial designed to test out task-shifting under real-world conditions, which included disruption of control conditions and a three-month moratorium on ART initiations."
Professor Max Bachmann, of Norwich Medical School at UEA, said: "There is a critical need to improve access to antiretroviral drugs - not only in South Africa but in other low- to middle-income countries where infection rates are high and doctors are in short supply. HIV programmes worldwide should now consider expanding nurse-centred care, safe in the knowledge that there need not be detrimental effects on patient health or mortality rates if done carefully."
The study is the first to explore "task-shifting" from doctors to nurses on such a large scale. It ran from 2008 to 2010 and was funded by the UK Medical Research Council, Development Co-operation Ireland, and the Canadian International Development Agency. The project was limited to South Africa, but the findings could have relevance in the West where antiretroviral treatment is usually provided by specialist hospital doctors.
Dr Fairall, Professor Bachmann and colleagues are currently undertaking further research to explore the cost-effectiveness of task-shifting HIV care from doctors to nurses, as well as strengthening the primary care of other chronic diseases.