Abstract
BackgroundTask shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial.Methods: Developing the interventionThe intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services.Results: Components of the interventionThe intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process.DiscussionThree important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout.The STRETCH trial is registered with Current Control Trials ISRCTN46836853.
Highlights
Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART)
Despite policy guidelines recommending that comprehensive HIV care be incorporated into existing primary care services [4], the initial public sector ART rollout in South Africa was implemented as a vertical programme with separate funding, facilities, staff, medical records, and reporting requirements [5]
Senior management, middle management, and clinic staff were involved in an iterative process of assessing the barriers facing patients and staff with regard to accessing ART, and tailoring the intervention to be relevant and implementable
Summary
Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). Despite policy guidelines recommending that comprehensive HIV care be incorporated into existing primary care services [4], the initial public sector ART rollout in South Africa was implemented as a vertical (stand alone) programme with separate funding, facilities, staff, medical records, and reporting requirements [5]. There are several reasons to justify such an initial vertical approach to comprehensive HIV care, including the need for a rapid response in a weak health system and the need for highly skilled staff to implement a new, complex intervention [6,7]. There are, two powerful reasons for moving away from vertical HIV care programmes in high HIV-burden countries: that such vertical programmes will be unable to achieve universal ART access because of the sheer numbers of people needing treatment; and that they could draw away financial and human resources from already struggling public health systems in these countries [8,9]
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