Swaziland has yet to act on a 2006 World Health Organization (WHO) recommendation to alleviate health worker shortages through task-shifting and according to the Ministry of Health, the failure to do so is compromising scale-up of the antiretroviral (ARV) programme.
Dr Velephi Okello, National Coordinator of HIV Care and Treatment, told the recent annual meeting of the Rural Doctors Association of Southern Africa (RuDASA), which was held in Swaziland, that the lack of a policy allowing healthcare tasks to be shifted from doctors to nurses, and from nurses to community health workers, was hampering the expansion of ARV treatment and prevention of mother-to-child HIV transmission (PMTCT) services.
"If we want to sustain the provision of ARVs, we have to ensure that the rural clinics have capacity to initiate and monitor," Okello told IRIN/PlusNews. Other obstacles include the poor integration of HIV services into the health system, and shortages of HIV testing kits and drugs.
Task-shifting has helped several countries in the region that are experiencing severe health worker shortages to make more effective use of scarce doctors and nurses; Malawi, Zambia and South Africa now allow lay counsellors to carry out HIV testing, freeing nurses to perform other tasks.
An estimated 26 percent of Swazis between the ages of 15 to 49 are living with HIV - the world's highest HIV prevalence - but Okello said only about 40 percent of HIV-positive pregnant women were receiving PMTCT services.
She noted that access to ARVs would have to be drastically scaled up to reach the estimated 90,000 HIV-positive Swazis eligible for treatment since the threshold for starting treatment was raised from a CD4 count (which measures immune system strength) of 200 to 350, in accordance with the latest WHO guidelines.
Nurses can manage HIV care, but a doctor is required to initiate ARV treatment; with just 200 doctors for a population of 1.1 million, Health Minister Benedict Xaba said allowing nurses to initiate ARVs would be vital to meeting the increased need, but that the lack of a formal policy had so far prevented such a move.
Task-shifting may also be important in meeting ambitious targets to reduce HIV transmission by performing male circumcision (MC). About 15,000 adults have been circumcised since a national campaign began in 2008, a long way from the goal of circumcising 80 percent of men aged 15 to 24 by 2012.
National MC coordinator Ayanda Nqeketo said the US President's Emergency Plan for AIDS Relief (PEPFAR) had provided funding to expand the campaign, but it would take 25 percent of Swaziland's doctors to implement.
Xaba said the government would like to introduce task-shifting as a retention strategy to lighten the workload, and to improve the working conditions of health workers, but the concept remained controversial.
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"[There] is a big debate between the [professional] health workers and the community health workers, where some people are saying that these [less trained health workers] are taking our jobs," he told IRIN/PlusNews. "There's also the issue of the quality of healthcare, where some people will say that they don't trust the community health workers to do the work."
Derek von Wissell, director of the National Emergency Response Council on HIV/AIDS (NERCHA), said they were also looking at improving health workers' salaries to plug the flow of trained healthcare professionals from the country.
The government recently signed a memorandum of understanding with neighbouring South Africa that it would restrict the hiring of Swazi health professionals.