The monitoring of antiretroviral therapy (ART) by trained nurses in primary health care seems to be similarly safe and effective as doctor-monitored care, according to an Article published in this week's edition of The Lancet. The results of this randomised trial add to the observational evidence of successful "task-shifting" in HIV care that could help ease the critical shortage of health-care workers while expanding access to ART for the millions in urgent need of treatment.
A worldwide shortage of 4.3 million health-care workers means that many people do not have access to the HIV therapy they need. In order to meet universal access targets by 2010, WHO proposed "task-shifting" from doctors to other lower level health-care workers, enabling nurses and community workers to deliver ART, so that more patients might be treated.
South Africa has the world's largest national ART programme but just 17.4 medical practitioners per 100 000 people. To tackle this shortage, it plans large-scale task shifting— increasingly using nurses for HIV care and the monitoring of ART. However, little research has been done to investigate if this approach is safe and effective.
To provide more evidence, the Comprehensive International Program for Research in AIDS in South Africa (CIPRA-SA) study team compared the outcomes of nurse versus doctor management of doctor-initiated ART care* for HIV patients in two South African primary care clinics. Between 2005 and 2007, 812 HIV patients were randomly assigned to nurse-managed ART care (408) or doctor-managed ART care (404). The composite endpoint was defined as failure of the treatment strategy to maintain patients on ART and measured using death rate, viral failure, treatment-limiting toxic effects, and whether patients attended scheduled visits.
Overall, 192 patients (48%) experienced treatment failure in the nurse group and 179 (44%) in the doctor group. After 2 years, deaths (10 vs 11), viral failure (44 vs 39), toxicity failures (68 vs 66), and programme loses (70 vs 63) were found to be similar between the nurse and doctor groups.
The findings, say the authors: "Lend support to the strategy of task shifting, and suggest that HIV management by nurses can be safe and effective, probably even for those starting therapy with advanced HIV infection."
However, they point out that: "Widespread task shifting will need increased training, a redefinition of scope of practice for nurses, and a clinical support structure."
In an accompanying Comment, Mark Boyd from the University of New South Wales, Sydney, Australia, and Chidi Nwizu from University of Maryland School of Medicine, Baltimore, USA, say: "There have been many calls for clinical and operational research to help to better inform policy and guidelines for routine HIV care. In view of the enormous amount of resources ploughed into the effort to achieve universal access to HIV care, including antiretroviral therapy, it is marvellous to see the results of a practical and innovative study which helps propel the field forward and improves our collective confidence that despite all the obstacles we can succeed."
Professor Ian Sanne, University of the Witwatersrand, Johannesburg, South Africa. T) +27 82 457 5223 (mobile) or +27 11 702 1046 E) isanne@witshealth.co.za
Dr Catherine Orrell, University of Cape Town, Cape Town, South Africa. T) +27 83 456 1969 E) Catherine.orrell@hiv-research.org.za
Dr Mark Boyd, University of New South Wales, Sydney, Australia. T) +61 2 9385 0900 E) mboyd@nchecr.unsw.edu.au
For full Article and Comment see: http://press.thelancet.com/nursehiv.pdf
Notes to Editors: *The study did not examine nurse-initiated ART because South African law requires the prescription of drugs by doctors.
Journal
The Lancet