Abstract
BackgroundThe most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in sub-Saharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources.MethodsWe conducted a time-series intervention trial in two HIV clinics in central Mozambique to discern whether expanding the role of basic-level nurses to stage HIV-positive patients using CD4 counts and WHO-defined criteria would lead to more rapid information on patient status (including identification of HAART eligible patients), increased efficiency in the use of higher-level clinical staff, and increased capacity to start HAART-eligible patients on treatment.ResultsOverall, 1,880 of the HAART-eligible patients were considered in the study of whom 48.5% started HAART, with a median time of 71 days from their initial blood draw. After adjusting for time, expanding the role of nurses to stage patients was associated with more rational use of higher-level clinical staff at one site (Beira OR 1.9, 95% CI 1.1–3.3; Chimoio OR 0.2, 95% CI 0.1–0.5). In multivariate analyses, the rate of starting HAART in patients with CD4 counts of less than 200/mm3 increased over time (HR = 1.07, 95% CI 1.02–1.13), as did the total number of new patients initiating HAART (β = 7.3, 95% CI 1.3–13.3). However, the intervention was not independently associated with either of these outcomes in multivariate analyses (HR = 0.9, 95% CI 0.7–1.2) for starting HAART in patients with CD4 counts of less than 200/mm3; (β = -5.2, p = 0.75) for the total number of new patients initiating HAART per month. No effect of the intervention was found in these outcomes when stratifying by site.ConclusionThe CD4 nurse intervention, when implemented correctly, was associated with a more rational use of higher-level clinical providers, which may improve overall clinic flow and efficient use of the limited supply of human resources. However, this intervention did not lead to an increase in the number of patients starting HAART or a reduction in the time to HAART initiation. Study month appears to play an important role in all outcomes, suggesting that general improvements in clinic efficiency may have overshadowed the effect of the intervention. The lack of observed effect in these outcomes may be due to additional health systems bottlenecks that delay the initiation of treatment in HAART-eligible patients.
Highlights
The most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in subSaharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out
In multivariate analysis controlling for study month, the proportion of initial MD/MO visits with HAART-eligible patients was significantly higher after the CD4 nurse intervention in Beira while in Chimoio the effect was reversed
Our findings do suggest that the introduction of the CD4 nurse intervention, when implemented correctly, did increase the proportion of HAART-eligible patients seen by MD/MOs
Summary
The most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in subSaharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources. Logistical and operational challenges exist which impede poorer countries' abilities to train, absorb and retain adequate numbers of health workers in public health systems. Political factors, such as macro-level fiscal policies, which restrict hiring of public sector workers, have contributed to the deterioration of human resource capacity and inhibited the rapid scale-up of HIV care and treatment [6,7]. New models of care provision are needed to improve efficiency of existing health services that provide HIV care and treatment including those which rationalize the use of the limited higher level providers through the maximum delegation of tasks within the formal health care team
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