BackgroundSubstantial resources and patient commitment are required to successfully scale-up antiretroviral therapy (ART) and provide appropriate HIV management in resource-limited settings. We used pharmacy refill records to evaluate risk factors for loss to follow-up (LTFU) and non-adherence to ART in a large treatment cohort in Nigeria.Methods and FindingsWe reviewed clinic records of adult patients initiating ART between March 2005 and July 2006 at five health facilities. Patients were classified as LTFU if they did not return >60 days from their expected visit. Pharmacy refill rates were calculated and used to assess non-adherence. We identified risk factors associated with LTFU and non-adherence using Cox and Generalized Estimating Equation (GEE) regressions, respectively. Of 5,760 patients initiating ART, 26% were LTFU. Female gender (p<0.001), post-secondary education (p = 0.03), and initiating treatment with zidovudine-containing (p = 0.004) or tenofovir-containing (p = 0.05) regimens were associated with decreased risk of LTFU, while patients with only primary education (p = 0.02) and those with baseline CD4 counts (cell/ml3) >350 and <100 were at a higher risk of LTFU compared to patients with baseline CD4 counts of 100–200. The adjusted GEE analysis showed that patients aged <35 years (p = 0.005), who traveled for >2 hours to the clinic (p = 0.03), had total ART duration of >6 months (p<0.001), and CD4 counts >200 at ART initiation were at a higher risk of non-adherence. Patients who disclosed their HIV status to spouse/family (p = 0.01) and were treated with tenofovir-containing regimens (p≤0.001) were more likely to be adherent.ConclusionsThese findings formed the basis for implementing multiple pre-treatment visit preparation that promote disclosure and active community outreaching to support retention and adherence. Expansion of treatment access points of care to communities to diminish travel time may have a positive impact on adherence.

With 24% global disease burden and 3% global health workforce, the World Health Organization (WHO) designates the African region a critical workforce shortage area. Task shifting is a WHO-recommended strategy for countries with severe health worker shortages. It involves redistribution of healthcare tasks to make efficient use of available workers. Severe physician shortages, increasing HIV disease burden, and the need for improved access to antiretroviral treatment (ART) posed serious challenges for Africa. Shifting ART management from physicians to nurses was adopted by many countries to increase access to treatment. Growing evidence from Africa supports this model of care but little is known about its impact on African nurses. A PubMed literature search was conducted for most recent task-shifting studies in Africa between January 2009 and August 2012. Thirty-four studies were identified but 11 met criteria for "task shifting from physicians to nurses in HIV settings." The methodologies and findings related to patient outcome, nurses' perceived self-efficacy, and job satisfaction were summarized. Patient outcomes were measured in 10 of the studies and all demonstrated comparable results. Seven of eight studies showed no difference in mortality while five found better retention and lower client loss to follow-up in nurse-managed groups. Four studies showed that nurses built on existing nursing and HIV knowledge; improved HIV and other disease management skills; and had increased comfort levels with using treatment guidelines. Results of job satisfaction from three studies showed that nurses expressed "feelings of emotional rewards, accomplishment, prestige, and improved morale." In six studies, nurse-managed care was acceptable to patients in five studies, nurses in two studies, and majority of physicians and program managers in one study. Nurse-managed care had comparable outcomes and retained more patients but only two studies "directly" assessed nurses' perceptions. Research exploring nurses' response, self-efficacy, and job satisfaction are critically to sustainability.

BackgroundIn HIV programs, mentor mothers (MMs) are women living with HIV who provide peer support for other women to navigate HIV care, especially in the prevention of mother-to-child transmission of HIV (PMTCT). Nigeria has significant PMTCT program gaps, and in this resource-constrained setting, lay health workers such as MMs serve as task shifting resources for formal healthcare workers and facility-community liaisons for their clients. However, challenging work conditions including tenuous working relationships with healthcare workers can reduce MMs’ impact on PMTCT outcomes. This study explores the experiences and opinions of MMs with respect to their work conditions and relationships with healthcare workers.MethodsThis study was nested in the prospective two-arm Mother Mentor (MoMent) study, which evaluated structured peer support in PMTCT. Thirty-six out of the 38 MMs who were ever engaged in the MoMent study were interviewed in seven focus group discussions, which focused on MM workload and stipends, scope of work, and relationships with healthcare workers. English and English-translated Hausa-language transcripts were manually analyzed by theme and content in a grounded theory approach.ResultsBoth intervention and control-arm MMs reported positive and negative relationships with healthcare workers, modulated by individual healthcare worker and structural factors. Issues with facility-level scope of work, workplace hierarchy, exclusivism and stigma/discrimination from healthcare workers were discussed. MMs identified clarification, formalization, and health system integration of their roles and services as potential mitigations to tenuous relationships with healthcare workers and challenging working conditions.ConclusionsMMs function in multiple roles, as task shifting resources, lay community health workers, and peer counselors. MMs need a more formalized, well-defined niche that is fully integrated into the health system and is responsive to their needs. Additionally, the definition and formalization of MM roles have to take healthcare worker orientation, sensitization, and acceptability into consideration.Trial registrationClinicaltrials.gov number NCT01936753, registered September 3, 2013.