Nurses to fill the gaps

South Africa continues to lose skilled healthcare professionals as it rolls out the national treatment programme, leaving severe shortages in an already overstretched public health system. To alleviate the situation, researchers are calling on the government to optimise existing capacity by giving nurses greater responsibility in dispensing antiretrovirals (ARVs). "The legal constraints that limit nurses from prescribing ARVs need to be reconsidered if [the government] wants to [reach] the level of rollout [it is targeting]," said Terence Moodley, research clinician at the Centre for the AIDS Programme of Research in South Africa (CAPRISA). According to Moodley, it was feasible for nurses to screen HIV-positive patients to determine whether they were eligible for treatment, and monitor patient adherence to medication. With adequate training, nurses should also be permitted to prescribe ARVs. Only doctors are currently permitted to prescribe and administer the life-prolonging medication; they also handle most aspects of the ARV screening and treatment process. The nurse-driven approach would make it possible to provide anti-AIDS drugs in rural clinics, which are often run by primary healthcare nurses. "We don't need to have centralised provision of ARVs at tertiary health facilities in South Africa," Moodley commented. Moodley is heading a CAPRISA research project investigating a nurse-driven ARV rollout at a clinic in Vulindlela, a poverty-stricken rural area 35 km north of the KwaZulu-Natal province's capital, Pietermaritzburg. The district lacks adequate infrastructure and has been hard-hit by the pandemic. With funding from the United States President's Emergency Programme for AIDS Relief (PEPFAR), CAPRISA began scaling up ARV treatment at the Mafakatini primary healthcare clinic in Vulindlela in June 2004. At present, Vulindlela residents requiring treatment have to travel over 65 km to Edendale Hospital or Greys Hospital in Pietermaritzburg to benefit from the government's free ARVs. Distance was not the only problem, Moodley explained, as "both hospitals have about three-month waiting lists, which is very demoralising". In contrast, patients at Vulindela's ARV clinic received their medication in two to three weeks and in some instances it took only four days to get the drugs. The ARV clinic has four nurses, a doctor, a pharmacist, an administrator and several counsellors, but "more than two-thirds of patient visits are dealt with by nurses", Moodley noted. Nurses draw blood for CD4 count tests (which measure the strength of the immune system), run ARV training sessions and a drug adherence support programme, and provide patients with HIV/AIDS and health education. HIV-positive patients were seen by nurses on a weekly basis in the first month of treatment and then once a month, while doctors only examined patients on a quarterly basis, Moodley commented. "We work much more efficiently and see many more patients a day because we don't have to wait for the doctor all the time," said Patricia Mchunu, who works as one of the primary healthcare nurses at Mafakatini clinic. The clinic staff see an average of 50 patients per day. CAPRISA's nurse-driven ARV clinic is integrated with the existing primary care services provided at Mafakatini clinic, which include voluntary counselling and testing (VCT), family planning, treatment of sexually transmitted infections, prophylaxis and treatment for opportunistic infections. Most people living with HIV/AIDS in Vulindlela are between 15 years and 55 years old. The majority are unemployed and almost 75 percent are financially dependent on a family member receiving one or more state social grants. The Mafakatini clinic staff has screened almost 1,000 patients since June last year, of whom 239 were found to be eligible for ARV treatment and 192 have begun ARV therapy. According to Moodley, the clinic had a patient retention rate of 99.5 percent and drug adherence of better than 90 percent. CAPRISA's study is to run for at least another year, but preliminary results show that the nurse-driven approach to scale up the ARV rollout has so far been effective. Nevertheless, Moodley admitted there was still a need for more healthcare professionals, particularly pharmacists, to make the nurse-driven, clinic-based approach work.