Agreement between physicians and non-physician clinicians in starting antiretroviral therapy in rural Uganda

Vasan, Ashwin; Kenya-Mugisha, Nathan; Seung, Kwonjune J.; Achieng, Marion; Banura, Patrick; Lule, Frank; Beems, Megan; Todd, Jim; Madraa, Elizabeth

doi:10.1186/1478-4491-7-75

Cited by 29 publications

(22 citation statements)

References 13 publications

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“…Task-shifting may prove to be the way forward and is a recent addition to the South African HIV/AIDS National Strategic Plan. Trials of this are currently underway and there have been promising results so far (34-37). …”

Section: Discussionmentioning

confidence: 99%

Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study

Ingle

May

Uebel

et al. 2010

Aids

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Objective In South Africa, many HIV-infected patients experience delays in accessing antiretroviral therapy (ART). We examined pre-treatment mortality and access to treatment in patients waiting for ART. Design Cohort of HIV-infected patients assessed for ART eligibility at 36 facilities participating in the Comprehensive HIV and AIDS Management (CHAM) program in the Free State Province. Methods Proportion of patients initiating ART, pre-ART mortality and risk factors associated with these outcomes were estimated using competing risks survival analysis. Results 44,844 patients enrolled in CHAM between May 2004 and December 2007, of whom 22,083 (49.2%) were eligible for ART; pre-ART mortality was 53.2 per 100 person-years (95% CI 51.8-54.7). Median CD4 count at eligibility increased from 87 cells/mm3 in 2004 to 101 cells/mm3 in 2007. Two years after eligibility an estimated 67.7% (67.1% – 68.4%) of patients had started ART, and 26.2% (25.6% - 26.9%) died before starting ART. Among patients with CD4 counts <25 cells/mm3 at eligibility, 48% died before ART and 51% initiated ART. Men were less likely to start treatment and more likely to die than women. Patients in rural clinics or clinics with low staffing levels had lower rates of starting treatment and higher mortality compared with patients in urban/ peri-urban clinics, or better staffed clinics. Conclusions Mortality is high in eligible patients waiting for ART in the Free State Province. The most immunocompromised patients had the lowest probability of starting ART and the highest risk of pre-ART death. Prioritization of these patients should reduce waiting times and pre-ART mortality.

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Section: Discussionmentioning

confidence: 99%

Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study

Ingle

May

Uebel

et al. 2010

Aids

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“…Few studies have compared the performance of non-physicians with doctors, [7][8][9][10][11][12] and only three have been randomised. [7][8][9] Although incompletely described, the interventions studied invariably do not reflect what might be feasible within the constraints typical of public sector care, with all having benefited from intensive training and support from predominantly overseas-funded non-governmental organisations. Further, in these studies non-physician care is restricted to the monitoring of patients already on treatment, with initiation usually being performed by study physicians.…”

Section: Current Evidence Around Nurse-initiated Artmentioning

confidence: 99%

Expanding access to ART in South Africa: The role of nurse-initiated treatment

et al. 2010

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The South African government's recent policy decision to expand access to HIV care rapidly and 'ensure that all the health institutions in the country are ready to receive and assist patients and not just a few accredited ARV centres' 1 represents a dramatic and welcome about-turn on years of hesitation and confusion in the country's response to the HIV epidemic. In the first 6 years of the antiretroviral therapy (ART) programme, approximately 900 000 people have been started on treatment. In the next 2 -3 years, the government proposes to initiate treatment in another 1.2 million people.2 The medical and moral imperative for providing this life-saving treatment to all who need it does not need to be defended, but the limited capacity of the public health sector to achieve this scale of increase raises serious questions about the practicality of this objective. Along with raising the CD4 thresholds for access to treatment and scrapping the antiretroviral site accreditation process, nurse initiation and management of patients on ART (NIM-ART) is under discussion at the national level as a key strategy for expanding access. There are simply not enough doctors in the public sector to introduce and follow up this number of patients. The major load from this increase will therefore have to be shifted to nurses, themselves under severe pressure and in short supply.Broadening the ART delivery platform to include nurses has been debated at the national level for several years. However, the discussion has focused on understanding the legal and regulatory frameworks that govern nurse prescribing, and little attention has been paid to how to implement NIM-ART. The legal difficulties are, in fact, minimal -the Minister of Health can simply authorise nurse prescription of ART in line with the Medicines Control Act. Rather, the key questions that should concern policymakers and practitioners are whether NIM-ART will provide the solution to expanding access to antiretrovirals, and how effective and sustainable it will be. Further, what systems and resources will be required to make it work, and what impact will this major push have on the health system and the broader health needs of the country? Current evidence around nurse-initiated ARTAlthough task-shifting is widely promoted as the solution to expanding ART access, 3-6 the evidence for non-physicianprovided ART in Africa is limited. Few studies have compared the performance of non-physicians with doctors, 7-12 and only three have been randomised. 7-9 Although incompletely described, the interventions studied invariably do not reflect what might be feasible within the constraints typical of public sector care, with all having benefited from intensive training and support from predominantly overseas-funded non-governmental organisations. Further, in these studies non-physician care is restricted to the monitoring of patients already on treatment, with initiation usually being performed by study physicians. Under these conditions, all studies reported equivalent ART treatmen...

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“…In Uganda, in-service training for mid-level practitioners (MLPs) who are clinical officers and registered nurses, currently supports initiatives for the control of HIV/AIDS, [15], [16] childhood illness, [17] and malaria. [18] In this context, the Integrated Infectious Disease Capacity-Building Evaluation (IDCAP) undertook a prospective study of two different approaches to MLP training in infectious-disease care.…”

Section: Introductionmentioning

confidence: 99%

Capacity-Building and Clinical Competence in Infectious Disease in Uganda: A Mixed-Design Study with Pre/Post and Cluster-Randomized Trial Components

et al. 2012

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Trial DesignBest practices for training mid-level practitioners (MLPs) to improve global health-services are not well-characterized. Two hypotheses were: 1) Integrated Management of Infectious Disease (IMID) training would improve clinical competence as tested with a single arm, pre-post design, and 2) on-site support (OSS) would yield additional improvements as tested with a cluster-randomized trial.MethodsThirty-six Ugandan health facilities (randomized 1∶1 to parallel OSS and control arms) enrolled two MLPs each. All MLPs participated in IMID (3-week core course, two 1-week boost sessions, distance learning). After the 3-week course, OSS-arm trainees participated in monthly OSS. Twelve written case scenarios tested clinical competencies in HIV/AIDS, tuberculosis, malaria, and other infectious diseases. Each participant completed different randomly-assigned blocks of four scenarios before IMID (t0), after 3-week course (t1), and after second boost course (t2, 24 weeks after t1). Scoring guides were harmonized with IMID content and Ugandan national policy. Score analyses used a linear mixed-effects model. The primary outcome measure was longitudinal change in scenario scores.ResultsScores were available for 856 scenarios. Mean correct scores at t0, t1, and t2 were 39.3%, 49.1%, and 49.6%, respectively. Mean score increases (95% CI, p-value) for t0–t1 (pre-post period) and t1–t2 (parallel-arm period) were 12.1 ((9.6, 14.6), p<0.001) and −0.6 ((−3.1, +1.9), p = 0.647) percent for OSS arm and 7.5 ((5.0, 10.0), p<0.001) and 1.6 ((−1.0, +4.1), p = 0.225) for control arm. The estimated mean difference in t1 to t2 score change, comparing arm A (participated in OSS) vs. arm B was −2.2 ((−5.8, +1.4), p = 0.237). From t0–t2, mean scores increased for all 12 scenarios.ConclusionsClinical competence increased significantly after a 3-week core course; improvement persisted for 24 weeks. No additional impact of OSS was observed. Data on clinical practice, facility-level performance and health outcomes will complete assessment of overall impact of IMID and OSS.Trial RegistrationClinicalTrials.gov NCT01190540

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Agreement between physicians and non-physician clinicians in starting antiretroviral therapy in rural Uganda

Cited by 29 publications

References 13 publications

Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study

Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study

Expanding access to ART in South Africa: The role of nurse-initiated treatment

Capacity-Building and Clinical Competence in Infectious Disease in Uganda: A Mixed-Design Study with Pre/Post and Cluster-Randomized Trial Components

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