title: Outcomes of a nurse-managed service for stable HIV-positive patients in a large South African public sector antiretroviral therapy programme.
abstract: OBJECTIVE
  Models of care utilizing task shifting and decentralization are needed to support growing ART programmes. We compared patient outcomes between a doctor-managed clinic and a nurse-managed down-referral site in Cape Town, South Africa.
  
  
  METHODS
  Analysis included all adults who initiated ART between 2002 and 2011 within a large public sector ART service. Stable patients were eligible for down-referral. Outcomes [mortality, loss to follow-up (LTFU), virologic failure] were compared under different models of care using proportional hazards models with time-dependent covariates.
  
  
  RESULTS
  Five thousand seven hundred and forty-six patients initiated ART and over 5 years 41% (n = 2341) were down-referred; the median time on ART before down-referral was 1.6 years (interquartile range, 0.9-2.6). The nurse-managed down-referral site reported lower crude rates of mortality, LTFU and virologic failure compared with the doctor-managed clinic. After adjustment, there was no difference in the risk of mortality or virologic failure by model of care. However, patients who were down-referred were more likely to be LTFU than those retained at the doctor-managed site (adjusted hazard ratio, 1.36; 95% CI, 1.09-1.69). Increased levels of LTFU in the nurse-managed vs. doctor-managed service were observed in subgroups of male patients, those with advanced disease at initiation and those who started ART in the early years of the programme.
  
  
  CONCLUSIONS
  Reorganization of ART maintenance by down-referral to nurse-managed services is associated with programme outcomes similar to those achieved using doctor-driven primary care services. Further research is necessary to identify optimal models of care to support long-term retention of patients on ART in resource-limited settings.
authors.affiliation: Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Anna
authors.initials: A
authors.lastname: Grimsrud
authors.forename: Richard
authors.initials: R
authors.lastname: Kaplan
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.forename: Landon
authors.initials: L
authors.lastname: Myer
mesh_terms: D000328:Adult; D000554:Ambulatory Care Facilities; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003695:Delivery of Health Care / Q000458:organization & administration*; D005260:Female; D006678:HIV; D015658:HIV Infections / Q000188:drug therapy* / Q000821:virology; D006295:Health Resources; D006296:Health Services; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D009726:Nurses; D010820:Physicians; D011057:Politics; D011320:Primary Health Care; D016016:Proportional Hazards Models; D017150:Public Sector; D012017:Referral and Consultation; D013019:South Africa; D017211:Treatment Failure; D000078329:Workforce
chemical_list: D019380:Anti-HIV Agents
keywords: Terapia antirretroviral (altamente activa); antiretroviral therapy (highly active); decentralization; descentralización; décentralisation; délégation des tâches; loss to follow-up; perdu au suivi; programme outcomes; pérdida durante el seguimiento; resultados de programa; retención; retention; rotación de tareas; résultats du programme; rétention; task shifting; thérapie antirétrovirale (très active)