3 July 2014
Are nurses and community workers as good as doctors in delivering HIV treatment?
The South African Medical Research Council’s (SAMRC) Cochrane Centre has undertaken a systematic review which suggests that specially trained and supported health care workers, other than doctors, are probably equally efficient in delivering antiretroviral therapy (ART) in certain settings. The need for this review is particularly significant in lower- and middle- income settings, such as in Africa, where access to antiretroviral therapy is severely limited by health care worker shortages and where the HIV burden is at its highest.
The Cochrane Review, which was commissioned by the World Health Organization (WHO) HIV Guideline Development Group, informed the WHO Guidelines on the use of antiretroviral drugs for treating and prevention HIV infection. Through comprehensive searching, the review authors identified four randomised studies and six cohort studies. When they considered the evidence from the randomised studies, they found that the risk of death when antiretroviral therapy was delivered by specially trained nurses was no different to doctor-led care, and there were probably fewer patients lost to follow up.
The researchers included data from cohort studies, in contrast to the findings from the higher quality RCT evidence, actually suggested that nurse-led management was more harmful. Dr Tamara Kredo, South African Cochrane Centre Deputy Director explained, “We can be less confident about the results from the cohort studies because they compare results in populations who are not identical. Data from cohort studies has inherent risks of under or over-reporting the results, hence the quality of the data is regarded lower than randomised controlled trial data. However, the included cohort studies provided information from antiretroviral programmes in countries where this strategy is being implemented and provides useful insights into the pragmatic issues regarding feasibility and implementation.”
Another strategy explored, was the provision of antiretroviral therapy by trained and supervised field workers in the community, to people’s homes. In this setting, there was also probably no difference in deaths or losses to follow up compared to doctor-led care.
Dr Tamara Kredo says that several suggestions for overcoming the challenges of health care worker shortages and access to HIV care have already been suggested and in many cases implemented in settings of greatest need. “Decentralising care from centralised hospitals to facilities closer to the community as well as task-shifting HIV management to nurses or clinical officers, rather than doctors so as to expand access to care have been recommended,” she says. “Our review team found that, in the setting of appropriate organisational support and specific clinical training, task-shifting of care from doctors to other health care providers could provide both high quality and safe care for patients requiring antiretroviral treatment.”
Prof Glenda Gray, President of the South African Medical Research Council says that “task-shifting is imperative in low- and middle- income countries heavily burdened by HIV. This review has unequivocally demonstrated that nurses are highly capable of delivering state of the art antiretroviral care and are pivotal in treatment roll out”
Link to the full review: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007331.pub3/abstract
The review was supported in part by funding received from the Cochrane HIV/ AIDS Review Group, University of California, San Francisco; the World Health Organization, Geneva and from DFiD to the Effective Health Care Research Consortium, Liverpool School of Tropical Medicine.
Authors involved with the review are based at the following institutions: South African Cochrane Centre, South African Medical Research Council; Centre for Evidence-based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa; and the University of Washington, Department of Global Health, Seattle, United States.
Note to the Editors
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Dr Tamara Kredo
South African Cochrane Centre
Tel: + 27 21-9380508; Mobile: +27 84 5880 388 (cell)
Head of Corporate Communications
South African Medical Research Council (SAMRC)
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