Time for task-shifting: 999 days to close the HIV/AIDS treatment gap

03 Apr 2009 | Press Release

Nurse-initiated and managed ART and other interventions can help meet South Africa's national HIV/AIDS care and treatment goals

1 April 2009 (Durban, South Africa) – At the IV South Africa AIDS Conference, Médecins Sans Frontières (MSF), Reproductive Health and HIV Research Unit (RHRU) of University of Witwatersrand, the Southern African HIV Clinicians Society, and Treatment Action Campaign (TAC), called upon government to urgently implement expanded roles for health care workers in the delivery of comprehensive HIV/AIDS services, through task-shifting, in order to achieve the treatment targets set forth in the South African National Strategic Plan (NSP) for HIV/AIDS 2007-2011.

"Nurse-led HIV/AIDS treatment at primary care level is non-negotiable if the NSP goal of providing ART for 80% of people in need is to be met," said Dr Francois Venter, President of the Southern African HIV Clinicians Society. "The evidence supports that quality is maintained, so what are we waiting for? The current inflexibility shown by the professional councils and trade unions is illogical at best and damaging for patient care at worst. Only leadership from the NDOH will be able to cut through the stalemate."

Re-allocating HIV-specific tasks among the health care team can improve access to treatment, as it opens up more points of care, and will have a direct impact on adherence. Task-shifting can also help with the chronic management of people already on ART. Quality is not compromised according to evidence that exists and task-shifting may also provide cost-efficiencies, which are very important given the current economic climate.

While surrounding countries such as Malawi, Mozambique, and Lesotho have embraced the delegation of treatment initiation and management of ART to nurses, South Africa has not adopted a larger role for nurses.

“Our experience in Khayelitsha and Lusikisiki, as well as from other countries shows that unless we are able to utilise the skills and capacity of professional nurses at the primary health clinics, the congestion and overwhelming demand will negatively impact patient care," said Dr Eric Goemaere, Medical Coordinator for MSF in South Africa and Lesotho. "Other countries have changed their regulations to allow nurses to start patients on ART and lay counsellors to administer HIV tests. When will South Africa wake up?"

At the close of the AIDS conference taking place in Durban, there will be 999 days until the NSP targets are supposed to be met.

"Without clear leadership from National Department of Health, and expedited cooperation of regulatory professional councils, we will continue to be stuck," said Victor Lakay. "While the NSP supports decentralising HIV/AIDS treatment to the primary care level, and for 80% of new patients on ART to be initiated by nurses, there is still no directive from National Department of Health clarifying that trained professional nurses can initiate ART. For the large part, ART continues to be limited to over-burdened centralised treatment centres."

"We've been here before. In the face of overwhelming evidence to implement an intervention that is proven to work, we can no longer be dragging our heels. The TAC calls upon leadership from NDOH and cooperation from professional councils and trade unions," said Lakay.

" Nurses are the backbone of our health system, and therefore need to take full charge of ART services like any other chronic disease managed at primary level of care. In our clinics in Johannesburg, Professional Nurses are providing chronic management of people on ART," said Winnie Moleko, Director Innercity Programme, Reproductive Health and HIV Research Unit (RHRU). "Now, it's time to allow these trained nurses to prescribe ARVs, just as nurses are able to do to treat TB."

"The 2008 National PMTCT Guideline recommends dual therapy to prevent mother of child transmission of HIV and triple therapy for pregnant women that are in clinical need, but midwives and nurses working in ANC services need the training and authorization," said continued Dr Goemaere. "Pharmacy assistants must be able to dispense ARVs, with distance supervision, from pharmacists."

The groups call for:

The National Department of Health (NDOH) to issue a directive clarifying that trained professional nurses can initiate and manage ART for adults and children; issue guidelines to allow trained lay counselors to administer HIV rapid tests, and supervised pharmacy assistants to dispense ARVs
Provincial Departments of Health and district managers to issue a clarifying directive allowing trained professional nurses to initiate and manage ART.
The South Africa National AIDS Council (SANAC) hold a mid-term review of the NSP, highlighting the issue of task-shifting as no progress has been made.
South Africa Nursing Council (SANC) to expedite legislation pertaining to scope of practice for Professional Nurses to initiate and manage ART and the South African Pharmacy Council to revise scope of practice for pharmacy assistants to dispense ARVs.
Professional associations, including the Democratic Nursing Organisation of South Africa (DENOSA), the South African Medical Association (SAMA), and the Pharmaceutical Society of South Africa (PSSA), to support task-shifting, as described above.

Background:
The South African National Strategic Plan (NSP) for HIV/AIDS 2007-2011.calls for decentralisation of comprehensive HIV/AIDS services to the primary health care level, a larger role for nurses in the provision of life-saving antiretroviral therapy (ART), and ART coverage for 80% of people in urgent clinical need.

The NSP recommends professional nurses initiate and manage ART for adults and children (now the domain of doctors only); trained lay counselors to administer HIV rapid tests (now the domain of nurses only), and supervised pharmacy assistants to dispense ARVs (now only allowed by pharmacists).

HIV/AIDS is responsible for an estimated 1,000 deaths each day in South Africa. There are more than 5 million people living with HIV/AIDS in the country. Currently an estimated 700,000 people have been initiated on ART, and a further 1.2 million people will need ART by 2011. For 2007, the coverage of ART for those with an AIDS-defining illness is only 34%. Currently, South Africa is initiating 200,000 people on ART per year. To reach the targets of the NSP, 420,000 people per year would need to be initiated on ART.

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