title: Non-physician clinician provided HIV treatment results in equivalent outcomes as physician-provided care: a meta-analysis.
abstract: BACKGROUND
  A severe healthcare worker shortage in sub-Saharan Africa is inhibiting the expansion of HIV treatment. Task shifting, the transfer of antiretroviral therapy (ART) management and initiation from doctors to nurses and other non-physician clinicians, has been proposed to address this problem. However, many health officials remain wary about implementing task shifting policies due to concerns that non-physicians will provide care inferior to physicians. To determine if non-physician-provided HIV care does result in equivalent outcomes to physician-provided care, a meta-analysis was performed.
  
  
  METHODS
  Online databases were searched using a predefined strategy. The results for four primary outcomes were combined using a random effects model with sub-groups of non-physician-managed ART and -initiated ART. TB diagnosis rates, adherence, weight gain and patient satisfaction were summarized qualitatively.
  
  
  RESULTS
  Mortality (N=59,666) had similar outcomes for non-physicians and physicians, with a hazard ratio of 1.05 (CI: 0.88-1.26). The increase in CD4 levels at one year, as a difference in means of 2.3 (N=17,142, CI: -12.7-17.3), and viral failure at one year, as a risk ratio of 0.89 (N=10,344, CI: 0.65-1.23), were similar for physicians and non-physicians. Interestingly, loss to follow-up (LTFU) (N=53,435) was reduced for non-physicians with a hazard ratio of 0.72 (CI: 0.56-0.94). TB diagnosis rates, adherence and weight gain were similar for non-physicians and physicians. Patient satisfaction appeared higher for non-physicians in qualitative components of studies and was attributed to non-physicians spending more time with patients as well as providing more holistic care.
  
  
  CONCLUSIONS
  Non-physician-provided HIV care results in equivalent outcomes to care provided by physicians and may result in decreased LTFU rates.
authors.affiliation: Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada. connor.emdin@mail.utoronto.ca
authors.forename: Connor A
authors.initials: CA
authors.lastname: Emdin
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Chong
authors.forename: Peggy E
authors.initials: PE
authors.lastname: Millson
mesh_terms: D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D001835:Body Weight; D015658:HIV Infections / Q000150:complications / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D009726:Nurses; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D010820:Physicians; D016019:Survival Analysis; D016896:Treatment Outcome; D014376:Tuberculosis / Q000175:diagnosis; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents
keywords: ART; HIV treatment; antiretroviral therapy; non-physician; substitution of physicians; task shifting