Abstract

The Streamlining Tasks & Roles to Expand Treatment and Care for HIV (STRETCH) program was developed to increase the reach of antiretroviral therapy (ART) for HIV/AIDS patients in Sub-Saharan Africa by training nurses to prescribe, initiate, and maintain ART. Fairall and colleagues conducted a cluster-randomized trial to determine the effects/impact of STRETCH on patient health outcomes in South Africa between 2008 and 2010. The purpose of our replication study is to evaluate Fairall and colleagues’ findings. We conducted push button and pure replication studies and measurement and estimation analyses (MEA). Our MEA validates the original findings: (1) overall, time to death did not differ between intervention (STRETCH) and control (ART) patients; (2) in a subgroup analysis of patients with CD4 counts of 201–350 cells per μL, the intervention group patients had a 30% lower risk of death than those in the control group, when controlling for baseline characteristics; (3) in a subgroup analysis of patients with CD4 counts of ≤200 cells per μL, time to death did not differ between the two groups; and (4) rates of viral suppression one year after enrollment did not differ between the intervention and control groups. This set of results have more caveats in the MEA. Although the intervention did not lead to improvements in the main outcomes, the effectiveness of STRETCH was proven to be similar to standard care while increasing the pool of prescribers, expanding their geographical range, and improving the quality of care for patients. Therefore, our analyses support the implementation of task shifting of antiretroviral therapy from doctors to trained nurses, which enhances confidence in the implementation of the intervention program and policymaking not only in South Africa but also in other developing countries that have similar circumstances.

Highlights

  • The paper Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic parallel, cluster-randomised trial by Fairall and colleagues [1] addresses a critical challenge to widespread treatment of HIV/AIDS in Sub-Saharan Africa

  • In subgroup analysis with CD4 counts of 201–350 cells per μL, the intervention group patients had a 30 percent lower risk of death than those in the control group when controlling for baseline characteristics (p = 0.019)

  • Based on the generalized estimating equation (GEE) result for Cohort 1, shown in Table 4, the measurement and estimation analyses (MEA) generated the same conclusion as the original analysis: for the primary analysis and subgroup analysis with baseline CD4 count 200 cells per μL, time to death did not differ between intervention and control patients

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Summary

Introduction

The paper Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic parallel, cluster-randomised trial by Fairall and colleagues [1] addresses a critical challenge to widespread treatment of HIV/AIDS in Sub-Saharan Africa. Antiretroviral therapy (ART) regimes have proven efficacious in slowing the onset and symptoms of HIV/AIDS [2], dispensation of ART is hampered by the limited availability. STRETCHing HIV treatment and analysis, decision to publish, or preparation of the manuscript

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