Expanding Access to ART in South Africa: The Role of Nurse-Initiated Treatment (Issues IN Medicine) (Antiretroviral Therapy )
The South African government’s recent policy decision to expand access to HIV care rapidly and ‘ensure that all the health institutions in the country are ready to receive and assist patients and not just a few accredited ARV centres’ (1) represents a dramatic and welcome about-turn on years of hesitation and confusion in the country’s response to the HIV epidemic. In the first 6 years of the antiretroviral therapy (ART) programme, approximately 900 000 people have been started on treatment. In the next 2 – 3 years, the government proposes to initiate treatment in another 1.2 million people. (2) The medical and moral imperative for providing this life-saving treatment to all who need it does not need to be defended, but the limited capacity of the public health sector to achieve this scale of increase raises serious questions about the practicality of this objective. Along with raising the CD4 thresholds for access to treatment and scrapping the antiretroviral site accreditation process, nurse initiation and management of patients on ART (NIM-ART) is under discussion at the national level as a key strategy for expanding access. There are simply not enough doctors in the public sector to introduce and follow up this number of patients. The major load from this increase will therefore have to be shifted to nurses, themselves under severe pressure and in short supply. Broadening the ART delivery platform to include nurses has been debated at the national level for several years. However, the discussion has focused on understanding the legal and regulatory frameworks that govern nurse prescribing, and little attention has been paid to how to implement NIM-ART. The legal difficulties are, in fact, minimal–the Minister of Health can simply authorise nurse prescription of ART in line with the Medicines Control Act. Rather, the key questions that should concern policymakers and practitioners are whether NIM-ART will provide the solution to expanding access to antiretrovirals, and how effective and sustainable it will be. Further, what systems and resources will be required to make it work, and what impact will this major push have on the health system and the broader health needs of the country?