Nurse-led HIV care benefits patients

By Helen Albert

Expansion of the role of primary care nurses to allow them to initiate and represcribe antiretroviral therapy (ART) to HIV patients improves health outcomes and quality of patient care, write researchers in The Lancet.

"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," commented study author Max Bachmann (University of East Anglia, Norwich, UK) in a press statement.

"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," he added.

The study was carried out between January 2008 and June 2010 across 31 primary care ART clinics in South Africa. The clinics were randomly assigned to implement an intervention programme (Streamlining Tasks and Roles to Expand Treatment and Care for HIV [STRETCH]) or to continue with standard care (controls).

In total, 4943 patients completed the STRETCH intervention and 3407 continued with standard care.

All the treated patients were divided into two cohorts depending on whether they were initiating ART (cohort 1; CD4 count of 350 cells/µL or less) or continuing ART after treatment of at least 6 months (cohort 2).

Patients were followed up for 16.3-18.0 months depending on their cohort. Of the patients in cohort 1, 20% of the intervention and 19% of the control group had died at the end of follow up. Time to death did not differ between the two groups.

The team noticed a small mortality benefit of the intervention for patients with CD4 counts ranging from 201-350 cells/µL (hazard ratio=0.73), but no difference between the two groups was seen for patients with baseline CD4 counts of 200 cells/µL or less.

In cohort 2, viral suppression at 12 months was similar between the intervention and control groups, at 71% and 70%, respectively.

"Our encouraging evidence supports task shifting of ART from doctors to nurses and other health workers, which seems essential for ART expansion in South Africa and elsewhere in Africa," conclude the authors.

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