Effect of task-shifting HIV testing from laboratory personnel to nurses on paediatric and adolescent HIV testing rate and yield in rural Nigeria: a prospective before-and-after study

Abstract

Background Nigeria has the second highest burden of HIV in children younger than 15 years (220 000) and adolescents 10-19 years (230 000) in the world. Unfortunately, fewer than a quarter of these children and adolescents are identified and given access to treatment. Decentralisation of HIV testing services to high-yield service delivery points can facilitate identification of undiagnosed HIV-positive children and adolescents. However, decentralisation of testing services is still uncommon, partly due to existing health-care professional boundaries. We evaluated the effectiveness of task-shifting HIV testing services from specialised laboratory personnel to nurses to improve HIV case identification in paediatric and adolescent clients. Methods We established a testing point for patients aged 0-19 years in the inpatient ward at a secondary health-care facility in a rural district with high prevalence of HIV in north-central Nigeria. Paediatric nurses were trained by laboratory personnel to provide HIV testing to children and adolescents admitted to the ward. We reviewed the hospital ward admission records and laboratory HIV testing records for patients aged 0-19 years to establish a pre-intervention baseline. Findings In the 3 months before the intervention when HIV testing services were provided only by laboratory personnel, 276 children and adolescents were admitted (mean 92•0 admissions/month), of whom only 22 patients (8%) underwent HIV testing and no positive cases were identified. However, in the 4-month intervention period between April and July, 2018, 179 paediatric or adolescent clients were admitted (44•8 admissions/month), of whom 169 (94%) were tested for HIV by nurses and four HIV-positive children were newly identified (a 2•4% yield). Linkage to care and antiretroviral therapy initiation was achieved for all newly identified children within 24 h of diagnosis. Interpretation Task-shifting of paediatric and adolescent inpatient HIV-testing services to nurses was more effective in HIV case identification than was testing by laboratory personnel. In settings where limited human resources remains a major challenge, implementation and scale-up of task shifting for testing services can significantly improve HIV case identification and, therefore, treatment coverage in children and adolescents. Funding CDC-PEPFAR.

Confronting power in low places: historical analysis of medical dominance and role-boundary negotiation between health professions in Nigeria

“…As might be expected, task-shifting efforts met with initial resistance from Medical Laboratory Scientists that was only resolved as more sophisticated laboratory technology tasks for HIV care became available (eg, early-infant diagnosis, viral load testing, etc) became available. 73 This willingness of Medical Laboratory Scientists to let go of HIV testing to non-laboratory healthcare providers to expand to new niches is in keeping with the theory of negotiated order in which the willingness to let go of particular tasks depends on the availability of other types of work to occupy. Concurrent events that facilitated BMJ Global Health this horizontal blurring of boundaries was the coming together of individual healthcare professions to form JOHESU as a strategic resource to gain clinical and managerial autonomy from medicine.…”

“…As might be expected, task-shifting efforts met with initial resistance from Medical Laboratory Scientists that was only resolved as more sophisticated laboratory technology tasks for HIV care became available (eg, early-infant diagnosis, viral load testing, etc) became available. 73 …”

Nursing Contributions to Ending the Global Adolescent and Young Adult HIV Pandemic

“…Whether it be family-based HIV prevention for ethnic and racial minority groups, parents, or heterosexual or lesbian, gay, bisexual, transgender and queer or questioning youth (Flores et al, 2020;Guilamo-Ramos et al, 2012Randolph et al, 2017;Villarruel et al, 2010), nurses consider often ignored ecological factors and understand the deficits caused by undifferentiated approaches. Monyatsi et al, 2012;Ofem et al, 2019).…”

“…With commensurate education and supplementary training being devised and made available (ICAP, n.d.; ICAP, 2018b; Michaels-Strasser et al, 2018), nurses can and have been responding to the emergent needs of AYA across the continuum of care. Currently, many settings have seen the successful implementation of programs because of capacity-building and task-shifting efforts cognizant of nurses' ever-expanding ranges of expertise (MacKenzie et al, 2017; Monyatsi et al, 2012; Ofem et al, 2019).…”

Nurses at the frontline of public health emergency preparedness and response: lessons learned from the HIV/AIDS pandemic and emerging infectious disease outbreaks

“…23 For example, decentralised testing delivered by nurses in a rural Nigerian health facility improved testing rates among attending children and adolescents younger than 20 years to 94%, from a baseline of 8% with the previous testing approach based on laboratory personnel. 24 Similarly, community-based HIV testing, such as an initiative in Tanzania delivered by nurses and lay counsellors, 25 , 26 has led to higher testing rates in countries with both generalised and concentrated epidemics and is recommended by WHO. 9 , 27 …”