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Shifting HIV care from doctors to non-doctors to improve access to therapy for people living with HIV

Kredo T, Adeniyi FB, Bateganya M, Pienaar ED
Published Online: 
1 July 2014

Background

High levels of healthcare worker shortage has limited HIV infected patients access to antiretroviral therapy in lower and middle-income countries. This occurs most where the burden of HIV disease is greatest and where access to trained doctors is limited. We wanted to assess if task shifting of care from doctors to non-doctors provides both high quality and safe care for all patients requiring antiretroviral treatment.

Study characteristics

We searched for studies up to March 2014. We found 10 studies, including four randomised controlled trials and 6 cohort studies collecting data from HIV care programmes. All the studies were conducted in Africa in adults who were followed up for up to one year.
We describe three types of care:

- Doctor versus nurse or clinical officer care for initiation and maintenance of antiretrovirals

- Doctor versus nurse or clinical officer care for maintenance of antiretroviral therapy

- Doctor versus community health workers for maintenance of antiretroviral therapy.

Key Results.

We found high quality evidence from trial data that when nurses initiated and provided follow-up HIV therapy, there was no difference in death and lower rates of losses to follow up at one year, (n = 2770). However, lower quality data from two cohort studies suggests that there may be an increased risk of death in the task shifting group, (n = 39 160) but no difference in patients lost to follow-up between groups,

We found moderate quality evidence from two trials that when doctors initiated therapy and nurses provided follow-up, that there was probably no difference in death or number of patients lost to follow up at one year (n = 4332). Lower quality evidence from the cohort study showed that death as well as the number of patients lost to follow-up at one year may be lower in the group treated by nurses.

Compared to doctor led care, we found moderate quality evidence from a single trial that when antiretroviral therapy was provided in the community, by trained field workers, there was probably no difference in death or losses to follow-up (n= 559).