title: Effectiveness and acceptability of delivery of antiretroviral treatment in health centres by health officers and nurses in Ethiopia.
abstract: OBJECTIVE
  The World Health Organization (WHO) recommends shifting tasks from physicians to lower cadres for the delivery of antiretroviral treatment (ART) for countries short of physicians. Our objective was to evaluate the effectiveness and acceptability of ART delivery by health officers and nurses in Ethiopia.
  
  
  METHODS
  A retrospective cohort study to evaluate outcomes of ART services in 25 health centres staffed with health officers and/or nurses and 30 hospitals staffed with physicians in 2009. Median CD4-cell counts, mortality, loss to follow-up and retention were the primary outcomes. Interviews and focus group discussions were conducted with people living with HIV/AIDS, AIDS programme managers and health care providers to identify the types and acceptability of the tasks conducted by the health officers, nurses and community health workers.
  
  
  RESULTS
  Health officers and nurses were providing ART, including ART prescription, for non-severe cases. The management of severe cases was exclusively the task of physicians. Community health workers were involved in adherence counselling and defaulter tracing. The baseline median CD4-cell counts per micro-liter of blood were 117 (interquartiles [IQ] 64,188) and 119 (IQ 67,190) at health centres and hospitals respectively. After 24 months on ART, the median CD4-cell counts per micro-liter of blood increased to 321 (IQ 242, 414) and 301 (IQ 217, 411) at health centres and hospitals respectively. Retention in care was higher in health centres (76%, 95% confidence interval [CI] [73%-79%]) than hospitals (67%, 95% CI [66%-68%]). This difference is mainly due to the higher loss to follow-up rate in hospitals (25% versus 13%). Mortality was higher in health centres than hospitals (11% versus 8%), but the difference is not statistically significant. Service delivery by non-physicians was accepted by patients, health care providers and programme managers. However, the absence of a regulatory framework for task shifting, the lack of extra remuneration for the additional roles assumed by nurses and health officers, and the high cost for training and mentorship were identified as weaknesses.
  
  
  CONCLUSIONS
  ART delivery in health centres, based on health officers and nurses is feasible, effective and acceptable in Ethiopia. However, issues related to regulation, remuneration and cost need to be addressed for the sustainable implementation of these delivery models.
authors.affiliation: Federal HIV/AIDS Prevention and Control Office, Addis Ababa, Ethiopia. yibeltalassefa343@gmail.com
authors.forename: Yibeltal
authors.initials: Y
authors.lastname: Assefa
authors.forename: Abiyou
authors.initials: A
authors.lastname: Kiflie
authors.forename: Betru
authors.initials: B
authors.lastname: Tekle
authors.forename: Damen Haile
authors.initials: DH
authors.lastname: Mariam
authors.forename: Marie
authors.initials: M
authors.lastname: Laga
authors.forename: Wim
authors.initials: W
authors.lastname: Van Damme
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D003151:Community Health Centers; D005002:Ethiopia; D005260:Female; D017144:Focus Groups; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D011637:Public Health Nursing; D015980:Public Health Practice; D012189:Retrospective Studies
chemical_list: D044966:Anti-Retroviral Agents