Nurses should be backbone of ARV treatment

Doctors, researchers and activists at the Fourth South African AIDS Conference in Durban requested the South African Department of Health to urgently expand the roles of health care workers.

Although South Africa's National Strategic Plan for HIV Prevention and Care 2007-2011 allows the expansion of the role of nurses to include ARV management and care, the national health department has been reluctant to give nurse-led treatment the official nod, because it would involve a massive training of health workers and restructuring of the primary health system.

This had to do with "lack of political will" rather than regulations, the Reproductive Health and HIV Research Unit Inner City Programme director Winnie Moleko told IPS, adding that "nurses are the backbone of our health system and therefore need to take full charge of ARV services, like any other chronic disease managed at primary care level."

Moleko believes that providing nurse-led ARV management in primary health care clinics in addition to hospitals will increase people's access to the life-saving treatment. In a nurse-led model, once a patient has been initiated onto ARVs by a doctor, nurses can take over and manage the patient's chronic care for the months and years to come.

If the South African health department continues to be reluctant to decentralise ARV services and shift some of the tasks of ARV management from doctors to nurses, it will be difficult to scale up treatment access.

"Without clear leadership from the national Department of Health and expedited co-operation of regulatory professional councils, we will continue to be stuck," said Victor Lackay, the Treatment Action Campaign (TAC) national community health advocacy co-ordinator. "There is still no directive from the health department clarifying that trained professional nurses can initiate ARV treatment."

Treatment bottleneck

Since the South African government began rolling out ARV treatment in 2004, ARV services have been predominantly hospital-based and doctor-led. For the large part, they continue to be limited to over-burdened, centralised treatment centres, Lackay explained. As a result, HIV-positive patients sometimes have to wait for many months get access to treatment.

HIV/AIDS causes 1,000 deaths a day in South Africa, and there are more than five million people living with the virus in the country, according to TAC. Currently, about 700,000 people are on ARV treatment, but a further 1.2 million people will need access to the drugs by 2011.

In 2007, only 34% of those who needed ARVs were able to access them, TAC said.

The South African health department is worried, however, that nurses are not well enough trained to manage the treatment of HIV-positive patients. "Government's main concerns are competency and [lack of] skills of nurses," explained Linda van Blerk, USAID ART2Scale director at Jhpiego, an international non-profit health organisation affiliated with Johns Hopkins University in the United States.

She said it was therefore of key importance to find best practices for launching nurse-led ARV care and train health workers accordingly.

"We have enough policies and guidelines to support nurse-led services. It's about their interpretation," van Blerk explained. "There is a lot of confusion [among politicians as well as health workers], so we need to educate people about the [meaning of the] frameworks."

Apart from shifting treatment management from doctors to nurses, another way of unburdening the system is to train community members as lay counsellors for adherence and continuous counselling services as well as to lead support groups, health experts suggested. That way, professional nurses will manage and possibly initiate ARV treatment for adults and children - now the domain of doctors only - while trained lay counsellors can administer HIV rapid tests and counsel HIV-positive patients.

"We need to strengthen primary health clinics. ARV provision in rural clinics can save many lives," said Monty Nyakane, district nurse manager at Khutso Kurhula clinic in Mopani, Limpopo. "We don't have enough capacity. But even if you expand existing ARV initiation sites [at hospitals], the problem won't be solved. We need many sites, close to where people live, that provide ARVs."

Because many South Africans who live in townships and rural areas struggle to pay for public transport, they have difficulties to travel to the nearest public hospital to access HIV services.

Some donor funded ARV programmes in South Africa have already proven that nurse-led ARV management works. "Our experience in Khayelitsha and Lusikisiki [townships in Cape Town and KwaZulu-Natal] show that unless we are able to utilise the skills and capacity of professional nurses at clinics, the congestion and overwhelming demand will negatively impact on patient care," explained Doctor Eric Goemaere, medical co-ordinator for Médecins Sans Frontières in South Africa and Lesotho.

He recommended the national health department should follow the example of some of South Africa's neighbours, such as Malawi, Mozambique and Lesotho, which have already started to decentralise their health services by giving nurses more responsibilities in ARV management and care.

"Other countries have changed their regulations to allow nurses to start patients on ARV treatment and lay counsellors to administer HIV tests," Goemaere said. "When will South Africa wake up?"

Article published courtesy of IPS Africa