Task shifting and integration of HIV care into primary care in South Africa: The development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention

Abstract

BackgroundTask shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial.Methods: Developing the interventionThe intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services.Results: Components of the interventionThe intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process.DiscussionThree important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout.The STRETCH trial is registered with Current Control Trials ISRCTN46836853.

Educational Outreach with an Integrated Clinical Tool for Nurse-Led Non-communicable Chronic Disease Management in Primary Care in South Africa: A Pragmatic Cluster Randomised Controlled Trial

“…Since 2007 it has included provision for nurse initiation and re-prescription of ART. This inclusion was based on the results of a large pragmatic randomised controlled trial performed in the Free State Province that showed that nurses were as effective as doctors in providing ART care [9,11,12], and on a second trial in the Western Cape and Gauteng Provinces that evaluated nurse re-prescription of ART [43]. This development was prompted by the urgent need to expand ART services in South Africa.…”

“…Consistent with our previous experience with PALSA PLUS, some variation in uptake of the management tool by nurses was reported. There was a tendency for nurses who formerly used PALSA PLUS to adopt PC101 and use it regularly, whereas nurses who had not used PALSA PLUS were less likely to begin to use the new management tool routinely [11,12]. Uptake by the trainers was considered excellent, and trainers completed planned sessions in all intervention clinics, some repeating sessions to ensure coverage of most staff.…”

Combination implementation for HIV prevention: moving from clinical trial evidence to population-level effects

“…However, early results from a larger cluster RCT shifting care to nurses in South Africa are also promising and final reporting should add substantively to the evidence-base. 134, 135 …”

Development of a framework to measure health profession regulation strengthening

“…At the opposite end, the highly functional “optimizing” stage, the regulatory processes are sophisticated and efficient and include the use of technology and data to continuously improve regulatory processes. The ARC CMM delineates stages of functional maturity with real world examples using national regulations, recommendations, and stated obstacles to strengthening nursing and midwifery practices that are referenced in the peer-reviewed and grey literature (ICN, 2007; Miles, Seitio, & McGilvray, 2006; PEPFAR, 2012; Uebel, Fairall, Van Rensburg, Mollentze, & Bachman, 2011; USAID, 2010; Zachariah et al, 2009). Literature which included specific challenges and recommendations for nursing and midwifery regulatory reform in the context of HIV scale-up in the ECSA region was considered highly relevant.…”