Task-shifting key to achieving South Africa's treatment goal

Task-shifting is the key to helping to reach South Africa’s goal of treating at least 80% of those in need of antiretroviral therapy (ART) by 2011, according to a joint statement by Médecins sans Frontières (MSF), Reproductive Health and Research Unit (RHRU) of University of the Witwatersrand, the Southern African HIV Clinicians Society, and Treatment Action Campaign (TAC), released at the Fourth South African AIDS Conference in Durban earlier this month.

The group called on the South African government to issue, without delay, clear directives for nurse-initiated and managed ART together with expanded roles for pharmacy assistants and lay counsellors in the comprehensive delivery of HIV/AIDS services.

Task-shifting is the reallocation of tasks among available staff. For example, doctors focus on providing care at hospitals for inpatients and complicated cases rather than handling all clinical management of patients, while nurses assess patients to diagnose and treat opportunistic infections and start and monitor ART rather than solely supporting doctors.

ART services have been primarily hospital-based and doctor-led. The rapid roll-out of ART has resulted in overburdened ART clinics, revealed considerable gaps in access and left many without the appropriate follow-up that ART management requires.

Currently 200,000 people start treatment each year in South Africa. This number needs to double, to 420,000 each year, if the goal of 80% coverage is to be reached by 2011. In 2007, 34% of those in need were on treatment. An estimated 1000 deaths due to HIV/AIDS-related complications are recorded daily. More than five million people in South Africa are living with HIV.

To date, an estimated 700,000 have started ART and it is anticipated that an additional 1.2 million will need ART by 2011.

Legislation already supports the following the HIV/AIDS National Strategic Plan recommendations:

• A decentralisation of comprehensive HIV/AIDS services to the primary health level
• Professional nurses to initiate and manage ART for adults and children (at present only doctors do)
• Trained lay counsellors to administer HIV rapid tests (at present only nurses do); and
• Supervised pharmacy assistants to dispense ARVs (at present only allowed by pharmacists).

Task-shifting can provide more points of care, improving access to treatment, increasing adherence and allowing better management of those currently on ART. Evidence from MSF programmes in Khayelitsha and in rural Lusikisiki supports the effectiveness of task-shifting. MSF built on these experiences in Lesotho where, as in Malawi and Mozambique, regulatory guidelines have already changed, enabling nurses to initiate and manage ART and allowing all levels of nurses broad clinical and prescribing powers.

Uptake of voluntary testing and counseling would be improved if trained lay counsellors were able to administer HIV rapid tests and free up nurses to see more patients.

"The 2008 National PMTCT Guideline recommends dual therapy to prevent mother-to-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 authorisation [to initiate and manage antiretroviral therapy]," said Dr Eric Goemaere, Medical Co-ordinator for MSF in South Africa and Lesotho. "Pharmacy assistants must be able to dispense ARVs, with distance supervision from pharmacists."

Incomprehension as to why these apparent regulatory blockages persist in South Africa was expressed by 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 National Department of Health (NDOH) will be able to cut through the stalemate,” he said.

The group called 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, and to issue guidelines to allow trained lay counsellors 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) to hold a mid-term review of the NSP, highlighting the issue of task-shifting as no progress has been made
• The 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.

Anecdotal reports at the conference suggested that, in the meantime, these barriers might be overcome by approaching the respective provincial Departments of Health and submitting a proposal outlining a pilot nurse-initiated and managed ART project for approval.