Abstract
BackgroundTask-shifting is promoted widely as a mechanism for expanding antiretroviral treatment (ART) access. However, the evidence for nurse-initiated and managed ART (NIMART) in Africa is limited, and little is known about the key barriers and enablers to implementing NIMART programmes on a large scale. The STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) programme was a complex educational and organisational intervention implemented in the Free State Province of South Africa to enable nurses providing primary HIV/AIDS care to expand their roles and include aspects of care and treatment usually provided by physicians. STRETCH used a phased implementation approach and ART treatment guidelines tailored specifically to nurses. The effects of STRETCH on pre-ART mortality, ART provision, and the quality of HIV/ART care were evaluated through a randomised controlled trial. This study was conducted alongside the trial to develop a contextualised understanding of factors affecting the implementation of the programme.MethodsThis study was a qualitative process evaluation using in-depth interviews and focus group discussions with patients, health workers, health managers, and other key informants as well as observation in clinics. Research questions focused on perceptions of STRETCH, changes in health provider roles, attitudes and patient relationships, and impact of the implementation context on trial outcomes. Data were analysed collaboratively by the research team using thematic analysis.ResultsNIMART appears to be highly acceptable among nurses, patients, and physicians. Managers and nurses expressed confidence in their ability to deliver ART successfully. This confidence developed slowly and unevenly, through a phased and well-supported approach that guided nurses through training, re-prescription, and initiation. The research also shows that NIMART changes the working and referral relationships between health staff, demands significant training and support, and faces workload and capacity constraints, and logistical and infrastructural challenges.ConclusionsLarge-scale NIMART appears to be feasible and acceptable in the primary level public sector health services in South Africa. Successful implementation requires a comprehensive approach with: an incremental and well supported approach to implementation; clinical guidelines tailored to nurses; and significant health services reorganisation to accommodate the knock-on effects of shifts in practice.Trial registrationISRCTN46836853
Highlights
Task-shifting is promoted widely as a mechanism for expanding antiretroviral treatment (ART) access
The STRETCH trial showed that the expansion of primary care nurses’ roles to include ART initiation and represcription can be done safely, and can improve health outcomes and quality of care for the duration of care covered by the trial
The last four sections highlight four key factors—pharmacy, human resources, clinical support, and local management input—that affected the implementation of STRETCH
Summary
Task-shifting is promoted widely as a mechanism for expanding antiretroviral treatment (ART) access. The evidence for nurse-initiated and managed ART (NIMART) in Africa is limited, and little is known about the key barriers and enablers to implementing NIMART programmes on a large scale. Task-shifting in large-scale public ART programmes The scale-up of public sector antiretroviral treatment (ART) programmes for HIV/AIDS in Southern Africa has created additional workload and organisational challenges, deepening concerns about the ongoing shortage of human resources for health. While most programmes in South Africa have used a model of physician-initiated and managed ART, there are insufficient physicians in the public sector, which provides the vast majority of HIV/AIDS care in South Africa, to take this approach to national scale. ‘Task-shifting’ from physicians to nurses has been proposed as one response to the challenge of delivering large-scale, sustainable, and effective ART programmes in resource-constrained contexts [1,2,3,4]. There is limited evidence, on the feasibility and effectiveness of NIMART on a large-scale within weak health systems and much of the available evidence is of limited applicability to resource-constrained settings [1,7]
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