As in many other African countries, Rwanda has a shortage of doctors, which implies that many patients with HIV aren't receiving the treatment they need. To tackle this crisis, the World Health Organization recommends "task shifting"—whereby the task of prescribing ART is shifted from doctors to nurses so that more patients can be treated.
The new study by Family Health International other scientists – which has been published this week in the journal PLoS Medicine, evaluates the success and safety of the ‘task shifting’ program.
"Task shifting" refers to a process of delegation of tasks to health workers with lower qualifications. It may include task shifting between different groups of professional workers or from professional to lay health workers.
Lead researcher Fabienne Shumbusho and colleagues reviewed the medical records of 1,076 patients enrolled in the program between September 2005 and March 2008. The researchers examined whether the nurses had followed national guidelines on ART prescription and monitored the patients correctly.
They also looked at patients' health outcomes, such as their death rate, changes in body weight and CD4 cell count (a marker of how healthy the patient's immune system was), and whether patients maintained contact with caregivers.
The researchers found that by March 2008, 451 patients had been eligible for ART, of whom 435 received treatment. None of the patients were prescribed ART when they should not have been. Only one prescription did not follow national guidelines.
At every visit, nurses were supposed to assess whether patients were taking their drugs (known as "adherence") and to monitor side effects. They did this most of the time (in 89% of clinic visits, nurses assessed adherence, and in 85% of visits they assessed side effects).
By March 2008, 390 (90%) patients were alive on ART, 29 (7%) had died, only one (under 1%) was lost to follow-up, and none had stopped treatment. Most patients gained weight in the first six months and their CD4 cell counts increased.
The study "demonstrates the feasibility and suggests effectiveness of nurse-centered task shifting for decentralized ART services without compromising the quality of care," the authors say.
However, medical charity Médecins Sans Frontière (MSF) has accused the World Bank and IMF of imposing a wage-bill which blocks instead of facilitating the rollout of this program in Rwanda and other countries. The curb discourages people from joining the profession because the salaries are too small.
The main hurdles here, according to MSF, are wage-bill restrictions or salary freezes dictated by the International Monetary Fund, Ministers of Finance, the World Bank, or health-reform strategists that "block employment of extra health staff as well as the use of international funds for salary increases in the public sector".
An estimated 70 percent of people living with HIV/AIDS who need antiretroviral therapy (ART) are still not receiving it, and MSF says the growing numbers of those who have been started on ART have only increased the burden on existing health care staff.
Rwanda, Zambia, Kenya, and Tanzania are said to have substantial numbers of unemployed clinicians and nurses in their capitals. In these countries, MSF says recruitment of extra qualified staff available on the local market would seem a rational adjunct, which could be coupled with task-shifting initiatives to achieve a stronger strategic skills mix.