Evaluation of a Nurse-Led Antiretroviral Treatment Program in a Rural South African Primary Health Care Clinic

South Africa claims one of the world’s largest burdens of HIV/AIDS infections. Shortages in human resources and infrastructure have resulted in delayed scale-up of HIV treatment programs. To address issues of physician shortages nurses in South Africa have been tasked with providing HIV treatment services in primary health care clinics. National implementation of nurse-initiated and -managed antiretroviral therapy began in 2010, with ongoing scale-up in the number of facilities providing this service.

This capstone project describes a nurse-led antiretroviral therapy program in a rural primary health care clinic in Limpopo Province, South Africa. Data from staff interviews, clinic observations, medical chart reviews, and a focus group, describe the clinic’s model for delivery of antiretroviral therapy services and evaluate program performance from January 2011 until April 2013. Major program challenges include clinic infrastructure, community stigmatization of HIV, integration of HIV and non-HIV services, and increased professional nurse workloads.

A total of 92 adults and adolescents new to the clinic’s program were started on treatment between January 1, 2011, and April 25, 2013. Overall mortality in patients starting treatment was 6.5% (6/92). Only 38 patients were enrolled in the ART program more than 12 months before chart reviews. At 12 months 68.4% (26/38) of these patients remained in care. CD4 positive T-lymphocyte counts and HIV viral load results were available for 57.7% and 69.2% of these patients, respectively. HIV viral load suppression (defined as an HIV viral load <400 copies/ml) was observed for 89.5% of those on treatment at 12 months. A statistically significant increase in mean CD4 positive T-lymphocyte count was observed at 12 months (147.6 cells/mm3 vs. 438.1 cells/mm3; p= .000008). Prescription of antibiotic prophylaxis within 2 months of starting antiretroviral therapy was 43.9% (26/82) in those with WHO stages 2-4 HIV disease.
This capstone project demonstrates that nurses can successfully manage HIV infection in the primary health care setting. Patients enrolled in nurse-led ART can achieve substantial improvements in immune function over a relatively short period. Greater attention should be directed at preventing opportunistic infections in HIV-infected patients managed in primary health care settings.