title: Task shifting and integration of HIV care into primary care in South Africa: the development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention.
abstract: BACKGROUND
  Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial.
  
  
  METHODS
  DEVELOPING THE INTERVENTION: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services.
  
  
  RESULTS
  COMPONENTS OF THE INTERVENTION: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process.
  
  
  CONCLUSIONS
  Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout.The STRETCH trial is registered with Current Control Trials ISRCTN46836853.
authors.affiliation: Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Cape Town, South Africa.
authors.forename: Kerry E
authors.initials: KE
authors.lastname: Uebel
authors.forename: Lara R
authors.initials: LR
authors.lastname: Fairall
authors.forename: Dingie Hcj
authors.initials: DH
authors.lastname: van Rensburg
authors.forename: Willie F
authors.initials: WF
authors.lastname: Mollentze
authors.forename: Max O
authors.initials: MO
authors.lastname: Bachmann
authors.forename: Simon
authors.initials: S
authors.lastname: Lewin
authors.forename: Merrick
authors.initials: M
authors.lastname: Zwarenstein
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Colvin
authors.forename: Daniella
authors.initials: D
authors.lastname: Georgeu
authors.forename: Pat
authors.initials: P
authors.lastname: Mayers
authors.forename: Gill M
authors.initials: GM
authors.lastname: Faris
authors.forename: Carl
authors.initials: C
authors.lastname: Lombard
authors.forename: Eric D
authors.initials: ED
authors.lastname: Bateman
mesh_terms: D000554:Ambulatory Care Facilities / Q000458:organization & administration; D019380:Anti-HIV Agents / Q000627:therapeutic use; D003695:Delivery of Health Care / Q000379:methods* / Q000458:organization & administration; D004509:Education, Nursing, Continuing; D015658:HIV Infections / Q000188:drug therapy / Q000451:nursing / Q000628:therapy*; D006801:Humans; D024802:Nurse's Role; D011320:Primary Health Care / Q000458:organization & administration*; D013019:South Africa
chemical_list: D019380:Anti-HIV Agents