Task-sharing of HIV care and ART initiation: evaluation of a mixed-care non-physician provider model for ART delivery in rural Malawi.
BACKGROUND
Expanding access to antiretroviral therapy (ART) in sub-Saharan Africa requires implementation of alternative care delivery models to traditional physician-centered approaches. This longitudinal analysis compares outcomes of patients initiated on antiretroviral therapy (ART) by non-physician and physician providers.


METHODS
Adults (≥15 years) initiating ART between September 2007 and March 2010, and with >1 follow-up visit were included and classified according to the proportion of clinical visits performed by nurses or by clinical officers (≥ 80% of visits). Multivariable Poisson models were used to compare 2-year program attrition (mortality and lost to follow-up) and mortality by type of provider. In sensitivity analyses only patients with less severe disease were included.


RESULTS
A total of 10,112 patients contributed 14,012 person-years to the analysis: 3386 (33.5%) in the clinical officer group, 1901 (18.8%) in the nurse care group and 4825 (47.7%) in the mixed care group. Overall 2-year program retention was 81.8%. Attrition was lower in the mixed care and higher in the clinical officer group, compared to the nurse group (adjusted incidence rate ratio [aIRR]=0.54, 95%CI 0.45-0.65; and aIRR=3.03, 95%CI 2.56-3.59, respectively). While patients initiated on ART by clinical officers in the mixed care group had lower attrition (aIRR=0.36, 95%CI 0.29-0.44) than those in the overall nurse care group; no differences in attrition were found between patients initiated on ART by nurses in the mixed care group and those included in the nurse group (aIRR=1.18, 95%CI 0.95-1.47). Two-year mortality estimates were aIRR=0.72, 95%CI 0.49-1.09 and aIRR=5.04, 95%CI 3.56-7.15, respectively. Slightly higher estimates were observed when analyses were restricted to patients with less severe disease.


CONCLUSIONS
The findings of this study support the use of a mixed care model with well trained and regularly supervised nurses and medical assistants to provide HIV care in countries with high HIV prevalence.
Epicentre, Paris, France ; Médecins sans Frontières, Medical Unit, New York, New York, United States of America.
Megan
M
McGuire
Jihane
J
Ben Farhat
Gaelle
G
Pedrono
Elisabeth
E
Szumilin
Annette
A
Heinzelmann
Yamikani Ntakwile
YN
Chinyumba
Sylvie
S
Goossens
Simon
S
Makombe
Mar
M
Pujades-Rodríguez
D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003695:Delivery of Health Care / Q000706:statistics & numerical data*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008295:Malawi; D008297:Male; D016896:Treatment Outcome
D019380:Anti-HIV Agents