Nurse and manager perceptions of nurse initiated and managed antiretroviral therapy (NIMART) implementation in South Africa: a qualitative study

Registered nurses' experiences regarding operational factors influencing the implementation of HIV care services in the mobile health clinics of eThekwini Municipality in KwaZulu-Natal

BACKGROUND

Registered nurses working in the mobile health clinics (MHCs) play an important role in enabling HIV care access to populations in remote areas through Nurse Initiated Antiretroviral Therapy program (NIMART).

AIM

To explore and describe the nurses' experiences regarding operational factors influencing the implementation of HIV care services in the mobile health clinics (MHCs) of eThekwini Municipality in KwaZulu Natal.

METHODS

Qualitative Exploratory Descriptive (QED) method was used after permission was granted from North-West University Human Research Ethics Committee provincial and local health authorities. Data saturation informed sample size of thirteen MHCs nurses were purposefully sampled to participate. Audio-recorded, semi-structured, online, one-on-one interviews guided by open-ended questions were done for data collection, and including demographic profile. The interview transcripts were analysed using Atlas-TI and SPSS descriptive statistics was used for demographics.

RESULTS

Eleven subthemes emerged under patient-related, nurse-related, and organisational-related themes which influence the operational factors in the MHCs, namely: patient defaulting treatment, lack of privacy, unavailability of phones, stressful and demotivating MHCs, nurses feel unsafe, lack of support from management, lack of budget, unavailability of computers, shortage of medical equipment, shortage of nursing staff and absence of data capturers.

CONCLUSION

Structured contextual coaching and support program for nurses is imperative to ensure effective and strengthened operations in MHCs, further supported by improvement in human resource for health allocation for MHCs in light of expanding health care programs CONTRIBUTIONS: Evaluation of health care programmes, and human resource for health quality improvement needs in the clinical practice of HIV care of MHCs nurses which advocate for specific policy formulations.

A Conceptual Model to Strengthen Integrated Management of HIV and NCDs among NIMART-Trained Nurses in Limpopo Province, South Africa

Integrated management of human immune deficiency virus (HIV) and non-communicable diseases (NCDs) in primary health care facilities remains a challenge. Despite research that has been conducted in South Africa, it is evident that in Limpopo Province there are slits in the implementation thereof. There is a need to develop a conceptual model to guide in strengthening the clinical competence of nurse-initiated management of antiretroviral therapy (NIMART)-trained nurses to implement the integrated management of HIV and NCDs to improve clinical outcomes of patients with the dual burden of diseases in Limpopo Province, South Africa. This study aimed to develop a conceptual model to strengthen the implementation of integrated management of HIV and NCDs amongst NIMART nurses to improve clinical outcomes of patients with the dual burden of communicable and non-communicable diseases in Limpopo Province, South Africa. An explanatory, sequential, mixed-methods research design was followed. Data were collected from patient records and the skills audit of 25 Primary Health Care (PHC) facilities and from 28 NIMART trained nurses. Donabedian's structure process outcome model and Miller's pyramid of clinical competence provided a foundation in the development of the conceptual model. The study revealed a need to develop a conceptual model to strengthen the implementation of integrated HIV and NCDs implementation in PHC, as evidenced by differences in the management of HIV and NCDs. Conclusion: The study findings were conceptualised to describe and develop a model needed to strengthen the implementation of integrated management of HIV and NCDs amongst NIMART nurses working in PHC facilities. The study was limited to Limpopo Province; the model must be implemented in conjunction with the available frameworks to achieve better clinical outcomes.

HIV care and treatment models and their association with medication possession ratio among treatment-experienced adults in three African countries

OBJECTIVE

How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment-experienced adults in Tanzania, Uganda and Zambia.

METHODS

Eighteen clinics were grouped into three models of HIV care. Model 1-Traditional and Model 2-Mixed represented task-sharing of clinical services between physicians and clinical officers, distinguished by whether nurses played a role in clinical care; in Model 3-Task-Shifted, clinical officers and nurses shared clinical responsibilities without physicians. We assessed MPR among 3,419 patients and calculated clinic-level MPR summaries. We then calculated the mean differences of percentages and adjusted residual ratio (aRR) of the association between models of care and incomplete adherence, defined as a MPR <90%, adjusting for individual-level characteristics.

RESULTS

In the adjusted analysis, patients in Model 1-Traditional were more likely than patients in Model 2-Mixed to have MPR <90% (aRR = 1.60, 95% CI 1-2.48). Patients in Model 1-Traditional were no more likely than patients in Model 3-Task-Shifted to have a MPR <90% (aRR = 1.58, 95% 0.88-2.85). There was no evidence of differences in MPR <90% between Model 2-Mixed and Model 3-Task-Shifted (aRR = 0.99, 95% CI 0.59-1.66).

CONCLUSION

Non-physician-led ART programmes were associated with adherence levels as good as or better than physician-led ART programmes. Additional research is needed to optimise models of care to support patients on lifelong treatment.

Ten years of nurse-initiated antiretroviral treatment in South Africa: A narrative review of enablers and barriers

Background

The roll out of nurse-initiated and managed antiretroviral treatment (NIMART) was implemented in 2010 by the National Department of Health (NDoH) in South Africa in response to the large numbers of persons living with HIV who needed treatment. To enable access to treatment requires shifting the task from doctors to nurses, which had its own challenges, barriers and enablers.

Objectives

The aim of this narrative is to review content on the implementation of NIMART in South Africa over the period 2010–2020, with a focus on enablers and barriers to the implementation.

Method

A comprehensive search of databases, namely, PubMed, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL), yielded qualitative, quantitative and mixed-method studies that addressed various topics on NIMART. Inclusion and exclusion criteria were set and 38 publications met the inclusion criteria for the review.

Results

Training, mentorship, tailored tuberculosis (TB) and HIV guidelines, integration of services and monitoring and support have enabled the implementation of NIMART. This resulted in increased knowledge and confidence of nurses to initiate patients on antiretroviral treatment (ART) and decreased time to initiation and loads on referral facilities. Barriers such as non-standardised training, inadequate mentoring, human resource constraints, health system challenges, lack of support and empowerment, and challenges with legislation, policy and guidelines still hinder NIMART implementation.

Conclusion

Identifying barriers and enablers will assist policymakers in implementing a structured programme for NIMART in South Africa and improve access, as well as the training and mentoring of professional nurses, which will enhance their competence and confidence.

Task-shifting directly observed treatment and multidrug-resistant tuberculosis injection administration to lay health workers: stakeholder perceptions in rural Eswatini

BACKGROUND

Eswatini is facing a critical shortage of human resources for health (HRH) and limited access to multidrug-resistant tuberculosis (MDR-TB) treatment in rural areas. This study assessed multiple stakeholders' perceptions of task-shifting directly observed treatment (DOT) supervision and administration of intramuscular MDR-TB injections to lay health workers (LHWs).

METHODS

A mixed methods study comprising a cross-sectional survey using a semi-structured questionnaire with community treatment supporters (CTSs) and a focus group discussion with key stakeholders including representatives from the Eswatini Ministry of Health (MOH), donor organisations, professional regulatory institutions, nursing academia, civil society and healthcare providers was conducted in May 2017. Descriptive statistics, thematic content analysis and data triangulation aided in the interpretation of results.

RESULTS

A large majority of CTSs (n = 78; 95.1%) were female and 33 (40.2%) were older than 50 years. Most (n = 7; 70.0%) key stakeholders had over 10 years of work experience in policy-making, advocacy in the fields of HRH or day-to-day practice in MDR-TB management. Task-shifting of MDR-TB injection administration was implemented without national policy guidance and regulation. Stakeholders viewed the strategy to be driven by the prevailing shortage of professional frontline HRH and limited access to MDR-TB treatment. Task-shifting was perceived to improve medication adherence, and reduce stigma and transport-related MDR-TB treatment access barriers. Frontline healthcare workers and implementing donor partners fully supported task-shifting. Policy-makers and other stakeholders accepted task-shifting conditionally due to fears of poor standards of care related to perceived incompetence of CTSs. Appropriate compensation, adequate training and supervision, and non-financial incentives were suggested to retain CTSs. A holistic task-shifting policy and collaboration between the MOH, academia and nursing council in regulating the practice were recommended.

CONCLUSIONS

Stakeholders generally accepted the delegation of DOT supervision and administration of intramuscular MDR-TB injections to LHWs as a strategy to increase access to treatment, albeit with some apprehension. Findings from this study stress that task-shifting is not a panacea for HRH shortages, but a short-term solution that must form part of an overall simultaneous strategy to train, attract and retain adequate numbers of professional healthcare workers in Eswatini. To address some of the apprehension and ambivalence about expanding access to MDR-TB services through task-shifting, attention should be paid to important aspects such as competence-based training, certification and accreditation, adequate supportive on-the-job supervision, recognition, compensation, and expediting policy and regulatory support for LHWs.

Integrating the prevention of mother-to-child transmission of HIV into primary healthcare services after AIDS denialism in South Africa: perspectives of experts and health care workers - a qualitative study

Background

Integrating Prevention of Mother-to-Child Transmission (PMTCT) programmes into routine health services under complex socio-political and health system conditions is a priority and a challenge. The successful rollout of PMTCT in sub-Saharan Africa has decreased Human Immunodeficiency Virus (HIV), reduced child mortality and improved maternal health. In South Africa, PMTCT is now integrated into existing primary health care (PHC) services and this experience could serve as a relevant example for integrating other programmes into comprehensive primary care. This study explored the perspectives of both experts or key informants and frontline health workers (FHCWs) in South Africa on PMTCT integration into PHC in the context of post-AIDS denialism using a Complex Adaptive Systems framework.

Methods

A total of 20 in-depth semi-structured interviews were conducted; 10 with experts including national and international health systems and HIV/PMTCT policy makers and researchers, and 10 FHCWs including clinic managers, nurses and midwives. All interviews were conducted in person, audio-recorded and transcribed. Three investigators collaborated in coding transcripts and used an iterative approach for thematic analysis.

Results

Experts and FHCWs agreed on the importance of integrated PMTCT services. Experts reported a slow and partial integration of PMTCT programmes into PHC following its initial rollout as a stand-alone programme in the aftermath of the AIDS denialism period. Experts and FHCWs diverged on the challenges associated with integration of PMTCT. Experts highlighted bureaucracy, HIV stigma and discrimination and a shortage of training for staff as major barriers to PMTCT integration. In comparison, FHCWs emphasized high workloads, staff turnover and infrastructural issues (e.g., lack of rooms, small spaces) as their main challenges to integration. Both experts and FHCWs suggested that working with community health workers, particularly in the post-partum period, helped to address cases of loss to follow-up of women and their babies and to improve linkages to polymerase-chain reaction (PCR) testing and immunisation.

Conclusions

Despite organised efforts in South Africa, experts and FHCWs reported multiple barriers for the full integration of PMTCT in PHC, especially postpartum. The results suggest opportunities to address operational challenges towards more integrated PMTCT and other health services in order to improve maternal and child health.

Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study

Background

Differentiated models of care (DMOC) are used to make antiretroviral therapy (ART) accessible to people living with HIV (PLHIV). In Malawi, Lighthouse Trust has piloted various DMOCs aimed at providing quality care while reducing personal and logistical barriers when accessing clinic-based healthcare. One of the approaches was community-based provision of ART by nurses to stable patients.

Methods

To explore how the nurse-led community ART programme (NCAP) is perceived, we interviewed eighteen purposively selected patients receiving ART through NCAP and the four nurses providing the community-based health care. Information obtained from them was complemented with observations by the study team. Interviews were recorded and transcribed. Data was analysed using manual coding and thematic analysis.

Results

Through the NCAP, patients were able to save money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations (although this required care providers to set clear boundaries and stick to schedule).

Patients’ nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. Considerations for community-led healthcare programmes include the provision of transportation for care providers; the physical structure of community sites (in regard to private spaces); the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles.

Conclusions

The patients interviewed in this study preferred the NCAP approach to the facility-based model of care because it saved them money on transport, reduced waiting-times, and allowed for a more thorough consultation, while continuing to provide quality HIV care. However, when considering a community-level DMOC approach, certain factors – including staff transportation and workload – must be taken into consideration and purposefully planned.

Promoting Tuberculosis Preventive Therapy for People Living with HIV in South Africa: Interventions Hindered by Complicated Clinical Guidelines and Imbalanced Patient-Provider Dynamics

Isoniazid preventive therapy (IPT) reduces the risk of active tuberculosis among people living with HIV, but implementation of IPT in South Africa and elsewhere remains slow. The objective of this study was to examine both nurse perceptions of clinical mentorship and patient perceptions of in-queue health education for promoting IPT uptake in Potchefstroom, South Africa. We measured adoption, fidelity, acceptability, and sustainability of the interventions using both quantitative and qualitative methods. Adoption, fidelity, and acceptability of the interventions were moderately high. However, nurses believed they could not sustain their increased prescriptions of IPT, and though many patients intended to ask nurses about IPT, few did. Most patients attributed their behavior to an imbalance of patient-provider power. National IPT guidelines should be unambiguous and easily implemented after minimal training on patient eligibility and appropriate medication durations, nurse-patient dynamics should empower the patient, and district-level support and monitoring should be implemented.

Challenges influencing nurse-initiated management of antiretroviral therapy training and implementation in Ngaka Modiri Molema district, North West province

Background

The increasing number of people testing human immunodeficiency virus positive and who demand antiretroviral therapy (ART) prompted the Department of Health to adopt World Health Organization's task shifting where professional nurses (PNs) initiate ART rather than doctors. This resulted in decentralisation of services to primary healthcare (PHC), generating a need to capacitate PNs on nurse-initiated-management of ART (NIMART). The impact of NIMART was assessed and even though there was an increased number of patients on ART, the quality of care is of serious concern.

Aim

The aim of this study was to explore and describe the challenges influencing NIMART training and implementation amongst PNs and programme managers.

Setting

The study was conducted from the PHC facilities, in the rural districts of the North West province.

Methods

An exploratory programme evaluation and contextual research design was used in the study. Purposive sampling was used. Focus group discussion (n = 28) and individual interviews were used to collect data. Data was analysed using ATLAS.ti software.

Results

The results revealed two themes: inadequacy in NIMART training and the healthcare system challenges that influence NIMART training and implementation. Theme 1 included among others the lack of standardised curriculum and model or conceptual framework to strengthen NIMART training. And theme 2 included patient and district healthcare structural system.

Conclusion

There a need to improve NIMART training and implementation through the standardisation of NIMART curriculum, introduction of pre-service NIMART training in institutions of higher learning, addressing staff shortages and negative attitude of PNs providing ART.

Conceptual framework for strengthening nurse-initiated management of antiretroviral therapy training and implementation in North West province

BACKGROUND

The implementation of nurse-initiated management of antiretroviral therapy (NIMART) management training is a challenge in the primary health care (PHC). It is evident from the literature reviewed and the data obtained from the North West province that gaps still exist. There is no conceptual framework providing guidance to NIMART training and implementation.

AIM

Therefore, the aim of this study was to develop a conceptual framework to strengthen NIMART training and implementation in the North West province to improve patients and human immunodeficiency virus (HIV) programme outcomes.

SETTING

The study was conducted in the North West Province, South Africa.

METHODS

A pragmatic, explanatory, sequential, mixed-methods research design was followed. A descriptive and explorative programme evaluation design was used. Data were collected from two sources: antiretroviral therapy (ART) statistics from District Health Information System (DHIS) & Tier.net of 10 PHC facilities to evaluate and determine the impact of NIMART on the HIV programme and five focus group discussions conducted amongst 28 NIMART nurses and three HIV programme managers to describe challenges influencing NIMART training and implementation.

RESULTS

The study revealed that there was low ART initiation compared to the number of clients who tested HIV-positive. There was poor monitoring of patients on ART, which was evident in the low viral load collection and suppression, high loss to follow-up and deaths related to HIV. Challenges exist and this was confirmed by the qualitative findings, including human resource ratios, training and mentoring and the entire absence of a conceptual framework or model that guides training and implementation.

CONCLUSION

The study findings were conceptualised to describe and develop a framework needed to facilitate and influence NIMART training and implementation to improve the HIV programme and patient outcomes. Dickoff, James and Wiedenbach's practice-oriented theory and Donabedian's structure process outcomes model provided a starting point in the ultimate development of the framework. Although the study was limited to the North West province's PHC clinics and community health centres and did not include hospitals, it is of high significance as there is no such conceptual framework in the province or in even South Africa.

Recommendations to facilitate managers' compliance with quality standards at primary health care clinics

BACKGROUND

 The Republic of South Africa (RSA) is shifting towards universal health coverage and a unified health system. This milestone can be achieved through the implementation of National Health Insurance (NHI). To employ NHI, health establishments in the country are compelled to comply with quality standards. The non-compliance with quality standards at primary health care (PHC) clinics within a district in Gauteng, which was verified by quality standards' audit reports, prompted an intervention. No prior research aimed at facilitating managers' compliance with quality standards has been conducted within the context under study. This research gap necessitated an exploration on how managers' compliance to quality standards at PHC clinics within a district in Gauteng could best be facilitated.

OBJECTIVES

 To describe recommendations to facilitate managers' compliance with quality standards at PHC clinics within a district in Gauteng.

METHOD

 A qualitative, exploratory, descriptive and contextual research design was used in this study. Semi-structured, individual interviews were conducted.

RESULTS

 The recommendations to facilitate managers' compliance with quality standards at PHC clinics within a district in Gauteng were described. However, for the purpose of this article, only the recommendations seeking to address challenges with management practices as a reason for non-compliance with quality standards at PHC clinics will be discussed. These recommendations include involvement of PHC clinic managers in decision-making, adequate support from senior management and improvement of internal communication practices.

CONCLUSION

 The researcher concludes that the senior management team in the district under study should strive to embrace the described recommendations as a strategy to facilitate managers' compliance to quality standards at PHC clinics.

Identifying models of HIV care and treatment service delivery in Tanzania, Uganda, and Zambia using cluster analysis and Delphi survey

BACKGROUND

Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up of antiretroviral therapy (ART) and associated services in resource-limited settings (RLS), especially in light of expanded client populations with country adoption of WHO's test and treat recommendation.

METHODS

We characterized task-shifting/task-sharing practices in 19 diverse ART clinics in Tanzania, Uganda, and Zambia and used cluster analysis to identify unique models of service provision. We ran descriptive statistics to explore how the clusters varied by environmental factors and programmatic characteristics. Finally, we employed the Delphi Method to make systematic use of expert opinions to ensure that the cluster variables were meaningful in the context of actual task-shifting of ART services in SSA.

RESULTS

The cluster analysis identified three task-shifting/task-sharing models. The main differences across models were the availability of medical doctors, the scope of clinical responsibility assigned to nurses, and the use of lay health care workers. Patterns of healthcare staffing in HIV service delivery were associated with different environmental factors (e.g., health facility levels, urban vs. rural settings) and programme characteristics (e.g., community ART distribution or integrated tuberculosis treatment on-site).

CONCLUSIONS

Understanding the relative advantages and disadvantages of different models of care can help national programmes adapt to increased client load, select optimal adherence strategies within decentralized models of care, and identify differentiated models of care for clients to meet the growing needs of long-term ART patients who require more complicated treatment management.

Improved HIV and TB Knowledge and Competence Among Mid-level Providers in a Cluster-Randomized Trial of One-on-One Mentorship for Task Shifting

INTRODUCTION

Health worker shortages pose a challenge to the scale up of HIV care and treatment in Uganda. Training mid-level providers (MLPs) in the provision of HIV and tuberculosis (TB) treatment can expand existing health workforce capacity and access to HIV services.

METHODS

We conducted a cluster-randomized trial of on-site clinical mentorship for HIV and TB care at 10 health facilities in rural Uganda. Twenty MLPs at 5 randomly assigned to an intervention facilities received 8 hours a week of one-on-one mentorship, every 6 weeks over a 9-month period; and another 20 at 5 control facilities received no clinical mentorship. Enrolled MLPs' clinical knowledge and competence in management of HIV and TB was assessed using case scenarios and clinical observation at baseline and immediately after the 9-month intervention. The performance of the study health facilities on 8 TB and HIV care indicators was tracked over the 9-month period using facility patient records.

RESULTS

Thirty-nine out 40 enrolled MLPs had case scenario and clinical observation scores for both the baseline and end of intervention assessments. Mentorship was associated with a mean score increase of 16.7% (95% confidence interval: 9.8 to 23.6, P < 0.001) for the case scenario assessments and 25.9% (95% confidence interval: 14.4 to 37.5, P < 0.001) for the clinical observations. On-site clinical mentorship was significantly associated with an overall improvement for 5 of the 8 health facility TB and HIV indicators tracked.

CONCLUSIONS

One-on-one on-site mentorship improves individual knowledge and competence, has a downstream effect on facility performance, and is a simple approach to training MLPs for task shifting.

Registered nurses' perceptions regarding nurse-led antiretroviral therapy initiation in Hhohho region, Swaziland

BACKGROUND

Swaziland has the highest HIV prevalence globally. It faces a critical shortage of health workers for addressing the HIV pandemic. To curb this human resource challenge, Swaziland adopted a nurse-driven model for antiretroviral therapy delivery in line with the recommendations of the World Health Organization on task shifting.

OBJECTIVE

The study explored the perceptions of registered nurses on the nurse-led antiretroviral therapy initiation programme in the Hhohho region of Swaziland (NARTIS).

DESIGN

The study utilized a phenomenological design, specifically a phenomenographic design.

SETTING

The study was conducted in ten health facilities in the Hhohho region of Swaziland. These facilities comprised eight clinics, a hospital and a health centre.

PARTICIPANTS

These were registered nurses, trained and certified in the nurse-led antiretroviral therapy initiation programme. The nurses also had experience of working in a nurse-led antiretroviral therapy initiation programme. Eighteen (18) nurses were purposively selected and recruited to participate in the study.

METHODS

Data were collected through open and deep individual interviews guided by a semi-structured interview schedule. The audio-recorded interviews were transcribed and analysed thematically using Sjöström and Dahlgren's approach to data analysis.

RESULTS

Three major themes emerged from the study data: nurses' emotional reactions to the implementation of the NARTIS programme, and influences and overcoming barriers to the programme.

CONCLUSIONS

The study findings have generated insights into this program which is useful for the provision of care to people living with HIV/AIDS in Swaziland. But nurses need support to ensure effective implementation.

IMPLICATION FOR NURSING AND HEALTH POLICY

The study findings have implications for both the practice of the NARTIS programme and health policy development. The development of a health policy that alleviates the barriers to the NARTIS programme can enhance nurses' role and make care provision to people living with HIV/AIDS more effective.

Implementation and Operational Research: A Comparison of Two Task-Shifting Models of Pharmaceutical Care in Antiretroviral Treatment Programs in South Africa

BACKGROUND

The severe shortage of pharmacists is an important limitation to providing antiretroviral treatment (ART) in resource-limited countries. Two task-shifting pharmaceutical care models have been developed to address this in South Africa, namely indirectly supervised pharmacist assistant (ISPA) and nurse-managed models. This study compared pharmaceutical care quality, patient clinical outcomes, and provider staff costs between these models.

METHODS

An analysis of pharmaceutical quality audits, patient clinical data, and staff costing data collected at 7 ISPA and 8 nurse-managed facilities was undertaken. Pharmaceutical audits were conducted by pharmacists using a standardized tool. Routine clinical data were collected prospectively at patient visits, and staff human resources costs were analyzed.

RESULTS

Overall pharmaceutical care quality scores were higher at ISPA sites than nurse-managed sites; 88.8% vs. 79.9%, respectively; risk ratio (ISPA vs. nurse) = 1.11 (95% confidence interval: 1.09 to 1.13; P < 0.0001). Mean provider pharmaceutical-related human resources costs per patient visit and per item dispensed were 29% and 49% lower, respectively, at ISPA facilities. At ISPA facilities, patient attrition was observed to be lower and viral suppression higher than at nurse-managed sites.

CONCLUSION

The ISPA model had a higher quality of pharmaceutical care and was less costly to implement. Further expansion of this model or integrating it with nurse-managed ART may enhance the cost-efficient scale-up of ART programs in Sub-Saharan Africa.

Clinician perceptions and patient experiences of antiretroviral treatment integration in primary health care clinics, Tshwane, South Africa

Background

Primary Health Care (PHC) clinicians and patients are major role players in the South African antiretroviral treatment programme. Understanding their perceptions and experiences of integrated care and the management of people living with HIV and AIDS in PHC facilities is necessary for successful implementation and sustainability of integration.

Objective

This study explored clinician perceptions and patient experiences of integration of antiretroviral treatment in PHC clinics.

Method

An exploratory, qualitative study was conducted in four city of Tshwane PHC facilities. Two urban and two rural facilities following different models of integration were included. A self-administered questionnaire with open-ended items was completed by 35 clinicians and four focus group interviews were conducted with HIV-positive patients. The data were coded and categories were grouped into sub-themes and themes.

Results

Workload, staff development and support for integration affected clinicians’ performance and viewpoints. They perceived promotion of privacy, reduced discrimination and increased access to comprehensive care as benefits of service integration. Delays, poor patient care and patient dissatisfaction were viewed as negative aspects of integration. In three facilities patients were satisfied with integration or semi-integration and felt common queues prevented stigma and discrimination, whilst the reverse was true in the facility with separate services. Single-month issuance of antiretroviral drugs and clinic schedule organisation was viewed negatively, as well as poor staff attitudes, poor communication and long waiting times.

Conclusion

Although a fully integrated service model is preferable, aspects that need further attention are management support from health authorities for health facilities, improved working conditions and appropriate staff development opportunities.

Trends in task shifting in HIV treatment in Africa: Effectiveness, challenges and acceptability to the health professions

BACKGROUND

Task shifting has been suggested to meet the demand for initiating and managing more patients on antiretroviral therapy. Although the idea of task shifting is not new, it acquires new relevance in the context of current healthcare delivery.

AIM

To appraise current trends in task shifting related to HIV treatment programmes in order to evaluate evidence related to the effectiveness of this strategy in addressing human resource constraints and improving patient outcomes, challenges identified in practice and the acceptability of this strategy to the health professions.

METHOD

Electronic databases were searched for studies published in English between January 2009 and December 2014. Keywords such as 'task shifting', 'HIV treatment', 'human resources' and 'health professions' were used.

RESULTS

Evidence suggests that task shifting is an effective strategy for addressing human resource constraints in healthcare systems in many countries and provides a cost-effective approach without compromising patient outcomes. Challenges include inadequate supervision support and mentoring, absent regulatory frameworks, a lack of general health system strengthening and the need for monitoring and evaluation. The strategy generally seems to be accepted by the health professions although several arguments against task shifting as a long-term approach have been raised.

CONCLUSION

Task shifting occurs in many settings other than HIV treatment programmes and is viewed as a key strategy for governing human resources for healthcare. It may be an opportune time to review current task shifting recommendations to include a wider range of programmes and incorporate initiatives to address current challenges.

Review of the Umthombo Youth Development Foundation scholarship scheme, 1999-2013

Introduction

Staffing of rural and remote facilities is a challenge throughout the world. Umthombo Youth Development Foundation (UYDF) has been running a rurally based scholarship scheme since 1999. The aim of this review is to present data on the number of students selected, their progress, graduation and work placement from inception of the scheme until 2013.

Methods

Data were extracted from the UYDF data base using a data collection template to ensure all important information was captured.

Results

Since 1999, 430 rural students across 15 health disciplines have been supported by UYDF. The annual pass rate has been greater than 89%, and less than 10% of students have been excluded from university. All graduates have spent time working in rural areas (excluding the 32 currently doing internships) and 72% (52/73) of those with no work-back obligation continue to work in rural areas.

Discussion and conclusion

The UYDF model is built around local selection, compulsory academic and peer mentoring and social support, comprehensive financial support and experiential holiday work. The results are encouraging and highlight the fact that rural students can succeed at university and will come back and work in rural areas. With 46% of the South African population situated rurally, greater thought and effort must be put into the recruitment and training of rural scholars as a possible solution to the staffing of rural healthcare facilities. The UYDF provides a model which could be replicated in other parts of South Africa.