Nurse prescribing of ARVs: evidence of success in Rwanda and Lesotho

Nurses in Rwanda and Lesotho are successfully prescribing antiretroviral drugs and managing HIV treatment, two studies published this month show.

Both Rwanda and Lesotho face a serious shortage of doctors, and in order to increase the capacity of the health system to treat people with HIV the World Health Organization recommends "task shifting"— the delegation of many medical tasks including ARV prescription and management to nurses and clinical officers.

Some countries have been quicker than others to adopt task-shifting as a means of increasing capacity. In some countries, such as South Africa, the policy remains controversial despite the existence of legislation that permits nurse-prescribing.

Task shifting in Rwanda

In September 2005, Rwanda launched a pilot programme of task shifting. One nurse in each of three rural primary health centres was trained to examine patients with HIV and prescribe antiretroviral therapy (ART) in simple cases (complex cases were referred to a doctor). Nurses had to complete at least 50 consultations with patients eligible for ART under the observation of a doctor before being allowed to treat patients independently.

The new study, by Fabienne Shumbusho (Family Health International, Kigali, Rwanda) and colleagues, published in PLoS Medicine, evaluates the success and safety of the programme.

Shumbusho and colleagues reviewed the medical records of 1,076 patients enrolled in the programme between September 2005 and March 2008. They examined whether the nurses had followed national guidelines on ART prescription and monitored the patients correctly. They also looked at patients' health outcomes, such as their death rate, changes in body weight and CD4 cell count (a marker of how healthy the patient's immune system was), and whether patients maintained contact with caregivers.

The researchers found that by March 2008, 451 patients had been eligible for ART, of whom 435 received treatment. None of the patients were prescribed ART when they should not have been. Only one prescription did not follow national guidelines. At every visit, nurses were supposed to assess whether patients were taking their drugs and to monitor side-effects. They did this most of the time (in 89% of clinic visits, nurses assessed adherence, and in 85% of visits they assessed side-effects).

By March 2008, 390 (90%) patients were alive on ART, 29 (7%) had died, only one (under 1%) was lost to follow-up, and none had stopped treatment. Most patients gained weight in the first six months and their CD4 cell counts increased.

Outcomes, including death rate, were similar to those from the doctor-led Rwandan national ART program and other African national doctor-led programmes.

The study, say the authors, "demonstrates the feasibility and suggests effectiveness of nurse-centred task shifting for decentralised ART services without compromising the quality of care."

But there are also several limitations to the study, which the authors discuss in their paper. For example, the authors say that they did not directly compare outcomes from this nurse-centered model of care with those from traditional physician-centered models. This makes it difficult to ascertain if patients' outcomes were as a result of the nurses' role or due to doctors' intensive supervision.

Task shifting in Lesotho

Médecins sans Frontières reported two-year outcomes from a nurse-driven antiretroviral treatment programme in the Scott district of Lesotho, a very poor country with one of the most severe shortages of doctors in sub-Saharan Africa. Lesotho has just five doctors per 100,000 inhabitants, most of them visiting foreigners, compared to 74 doctors per 100,000 inhabitants in South Africa.

MSF began providing antiretroviral treatment in partnership with the Ministry of Health in the Scott district, a mountainous rural area with a population of around 200,000, using a nurse-driven model of care supported by community health workers. Nurses are also in very short supply in Lesotho due to the attraction of higher wages in South Africa and attrition due to AIDS.

The model of care is described in full in a paper published in the Journal of the International AIDS Society, which is freely accessible. In brief, one or two nurses provide care at each of the 14 health centres, and receive a supervisory visit once every week or two from a doctor or nurse clinician.

Nurses began prescribing ART after intensive in-service training, as well as quarterly training based on the World Health Organization’s Integrated Management of Adolescent and Adult Illness guidance.

Soon after the introduction of ART in 2006 it was discovered that nurses were seeing up to 45 patients a day, and in order to relieve their workload a cadre of paid lay counsellors, predominantly people living with HIV, was recruited in order to carry out pre-treatment counselling, defaulter tracing and clinic organisation.

By July 2009 13,243 patients had been enrolled on ART, and 76.5% of patients still remained in care after two years, compared with an African average of 61%.

The service has also been successful in retaining children in care, and providing antiretroviral treatment without paediatric specialists, but the number of children receiving treatment remains small – 116 in 2008 – despite the fact that 56% of deaths in children in Lesotho are estimated to be HIV-related.

MSF is now in the process of handing over the programme to the Ministry of Health.

The authors highlight a number of ongoing challenges for task-shifting in the programme:

• How to increase nurse confidence and skills in paediatric care?
• How to increase the role of lay counsellors in screening stable patients on ART without compromising the standard of care?
• How to sustain the high rate of enrolment on treatment without compromising the quality of care?
• How to improve diagnosis and management of TB?
• How to retain staff, maintain staffing levels and ensure adequate supervision and clinical mentorship?
• How to scale up the use of lay counsellors at the national level while ensuring consistent policy and standards?

Nevertheless the authors conclude that experience in Lesotho shows that “HIV care and treatment can be provided effectively at the primary care level,” while validating the approach of task shifting in several areas, including paediatric treatment and lay counsellor-supported adherence and case management.

Three editions of HIV & AIDS Treatment in Practice published in 2008 reviewed recent successes and challenges in task shifting.