Published today in The Lancet, the research shows that neither survival rates nor virus suppression reduced when nurses administered antiretroviral drugs to patients in South Africa. Health benefits included: significantly improved detection of tuberculosis; increased white blood cell count; increased weight; and improved adherence with the treatment programme.
More than 15,000 patients took part in the two-year randomised controlled trial in Free State, South Africa. All 31 clinics in the province took part in the study which was conducted by UEA in partnership with UCT and other universities.
South Africa has around six million people infected with HIV – more than any other country in the world. Of those patients who would benefit from antiretroviral treatment, less than one in three receive it. In the West, this figure is nearer to 100 per cent.
It is a priority of the World Health Organisation to expand access to antiretroviral treatment, but in South Africa access to the right drugs in limited by a chronic shortage of trained doctors. The South African government is trying to shift healthcare provision from doctors to primary care nurses who are more plentiful. This policy has been resisted by some HIV physicians and nurses, however, who feel administration of these drugs is the proper domain of doctors.
Joint lead author Prof Max Bachmann, of Norwich Medical School at UEA, said: “Our findings show that with very little extra training and support nurses can deliver HIV care that is just as safe and effective as that provided by doctors. Indeed, we found that this model of nurse-centred care had a number of important health benefits.
“There is a critical need to improve access to antiretroviral drugs – not only in South Africa but in other low to middle income countries where infection rates are high and doctors are in short supply. HIV programmes worldwide should now consider expanding nurse-centred care, safe in the knowledge that there need not be detrimental effects on patient health or mortality rates if done carefully.”
The study is the first to explore ‘task-shifting’ from doctors to nurses on such a large scale. It ran from 2008 to 2010 and was funded by the UK Medical Research Council, Development Co-operation Ireland, and the Canadian International Development Agency. The project was limited to South Africa, but the findings could have relevance in the West where antiretroviral treatment is usually provided by specialist hospital doctors.
Prof Bachmann and colleagues are currently undertaking further research to explore the cost-effectiveness of task-shifting HIV care from doctors to nurses, as well as strengthening the primary care of other chronic diseases.
‘Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial’ by L Fairall (University of Cape Town), M Bachmann (UEA), C Lombard (Medical Research Council, South Africa), V Timmerman ( University of Cape Town), K Uebel (University of Cape Town), M Zwarenstein (University of Cape Town), A Boulle (University of Cape Town), D Georgeu (University of Cape Town), C Colvin (University of Cape Town), S Lewin (Medical Research Council, South Africa), G Faris (University of East Anglia), R Cornick ( University of Cape Town), B Draper (University of Cape Town), M Tshabalala (Free State Department of Health), E Kotze (Free State Health Department), C van Vuuren (University of the Free State), D Steyn ( University of the Free State), R Chapman (Free State Health Department) and E Bateman (University of Cape Town) is published online by The Lancet on August 15 2012.
The paper will be available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60730-2/abstract
University of East Anglia –