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Outcomes of antiretroviral treatment programmes in rural Lesotho: health centres and hospitals compared
– Reported, May 22, 2014
Scarce human resources for health are a major obstacle to the scale-up of antiretroviral therapy (ART) in rural Africa. In response, the World Health Organization (WHO) recommends that, whenever possible, tasks should be shifted to less specialized health workers, in line with the WHO’s public health approach to ART in resource-limited settings.
Nurses may partly or completely take over the provision of ART to HIV-infected patients. To compensate for the additional workload, other tasks, such as HIV testing and counselling or adherence and psychosocial counselling, may be shifted to lay personnel. Such task shifting allows the decentralization of ART provision to nurse-led primary
healthcare clinics.
Through task shifting and decentralization, several countries in sub-Saharan Africa, such as Zambia, Ethiopia and Malawi, managed to scale up ART provision substantially. A systematic review concluded that task shifting offers high-quality and cost-effective HIV care to more patients than physician-centred models. The results of two clinical trials confirmed these findings by showing that nurse-monitored ART was non-inferior in terms of virological suppression and retention in care and that nurse-based initiation and follow-up (FUP) of ART resulted in a similar mortality rate as compared to physician-based care. Cohort studies in settings with decentralized HIV care have uniformly reported favourable outcomes, including improved retention in care.
However, most studies assessed short-term clinical outcomes in pilot programmes focusing on a single district, and the generalizability of these findings is unclear. Data on the outcomes of full decentralization in regard to start and FUP of ART at the health centre (HC) level are still scarce. A recent Cochrane Review, including two cluster-randomized trials and 14 cohort studies, found moderate quality of evidence that partial decentralization (ART started by physicians at hospitals and FUP decentralized to nurse-led HCs) probably reduces attrition. For full decentralization (start and FUP of ART at the HC level), their analysis was inconclusive due to very low quality of evidence.
Lesotho has the third-highest HIV prevalence in the world and is particularly hit by the shortage of human resources for health. In 2007, it was one of the first countries to decentralize the initiation and FUP of ART to nurse-led HCs on a national scale. This was facilitated by the development of national guidelines tailored to nurses who work in primary healthcare settings. In a recent study of ART outcomes in rural southern Africa, we showed that among patients treated in Lesotho, only 55% were alive and in care three years after enrolment. cial for men: those treated at HCs had a higher three-year retention compared to men in hospitals, mainly because they were less likely to be LTFU in these facilities. Although this may be explained partly by the lower proportion of patients with advanced clinical disease in HCs, other reasons such as a lower number of patients per caregiver, the proximity of the treatment facility and lower transport costs might play important roles.
CREDITS:
Niklaus Daniel Labhardt, Olivia Keiser, Motlalepula Sello, Thabo Ishmael Lejone, Karolin Pfeiffer, Mary-Ann Davies, Matthias Egger, Jochen Ehmer, Gilles Wandeler, and the SolidarMed
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