At Malvern Clinic, a primary healthcare facility serving an impoverished suburb east of Johannesburg’s city centre, every seat was taken on a recent Monday morning.
“Today, I’m running like a headless chicken, we’re very short-staffed,” said Sihle Motha, a nurse, who sees an average 50 patients a day.
Since the clinic’s one doctor left several months ago and has not been replaced, Motha and the other nurses are doing “everything”, including preparing, initiating and managing patients on antiretroviral drugs (ARVs).
Malvern Clinic represents the likely future of HIV treatment in South Africa where there are simply too many people needing ARVs and not enough doctors in the public health sector to manage them all.
Faced with its own ambitious target of reaching 80 percent of those needing treatment by 2011, the South African government announced in April that ARVs would be made available at all of the country's 5,500 health facilities and that nurses would be trained to prescribe and manage patients on the life-prolonging drugs.
Experts generally welcomed the move but warned that nurses would have to be adequately prepared and supported to take on the additional responsibility.
Christopher Colvin of the School of Public Health and Family Medicine at the University of Cape Town and co-authors wrote in the South African Medical Journal that "the available evidence... points to NIM-ART [nurse initiation and management of ART] being a potentially effective, sustainable and acceptable approach, but one that also entails significant stresses and realignments in the health system".
He warned that "a too-rapid roll-out that does not build incrementally the capacity, confidence, co-ordination and support needed to implement NIM-ART at scale" could leave nurses to shoulder the burden of an expanded treatment programme without adequate training or support.
Eight months later, details on the implementation of nurse-initiated ART are still sketchy. As yet there is no national curriculum, only a list of core competencies and guidelines for when to refer complex cases to a doctor. The health department itself lacks the capacity to conduct the training, but NGOs such as the Foundation for Professional Development (FPD) have stepped in.
Gustaaf Wolvaardt, head of FPD, explained that his organization offered a five-day NIM-ART "crash course" to primary healthcare nurses who are used to prescribing drugs but lack a background in HIV. Longer courses are available for registered nurses and both include a substantial mentoring component. So far, FPD has trained about 400 nurses.
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Trainers are sourced from the Southern African HIV Clinicians Society and are the first port of call for nurses who have questions after completing the course. FPD also funds a toll-free hotline that allows nurses to direct treatment questions to pharmacists and doctors at the University of Cape Town and is partnering with the health department and the US President's Emergency Plan for AIDS Relief (PEPFAR) to deploy nurse mentors to provide on-site help.
"The critical thing is not to force them to start treatment if they’re not comfortable. If a person is not confidant, they develop a selective blind spot," said Wolvaardt.
Francois Venter, president of the HIV Clinicians Society, said the principles of managing HIV were not that different to managing a patient with diabetes, but that any clinician - doctor or nurse - needed some mentoring when they started treating people with chronic illnesses.
"They don’t need months of lecturing, they need either someone on site who can hold their hand or someone on the other end of a telephone," he said. "It's often just reassuring someone that they did the right thing."
Motha from Malvern had a background working with HIV/AIDS patients before she received three weeks of one-on-one NIM-ART training.
She has been managing ARV patients for over a year but, with the clinic's doctor no longer there, sometimes feels out of her depth.
"I think it's good [that nurses are initiating], but I think we need a doctor here at all times," she told IRIN/PlusNews.
She also felt that the standard five days of training was too short. "There’s quite a lot [to learn] about each and every one of those [ARV] drugs – the side-effects, how to deal with them and how to prevent [them].
"You have this person’s life in your hands - one mistake and then you fail that person and not just that person, the whole [health] department, because you end up having a lot of side-effects that cost us quite a lot in time and finances."
Natasha Davies, an NIM-ART trainer and mentor with the University of the Witwatersrand Institute for Sexual and Reproductive Health, HIV and Related Diseases, said the task of the nurses was made much harder by the fact that patients often present for treatment very late. "By the time they come they’re sick; if they came earlier, nurses would have no problem at all because there wouldn’t be so many complications."
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Davies also worried about the pressure to roll out nurse-initiated ART as rapidly as possible. "I think because the government very much wants to reach the NSP [National Strategic Plan] target on time, pressure is mounting to implement NIM-ART quickly. That pressure is being transferred from the highest levels down such that the healthcare workers on the ground are feeling it most," she said.
However, despite the additional workload and responsibility, the nurses at Malvern Clinic say they welcome the opportunity to help patients they previously had to refer elsewhere.
"Since we started prescribing ARVs, many people are coming here," said Nomkhosi Mosala, the clinic's manager.
"It's the best investment the government has made; it has strengthened our relationship with patients - they come back and thank us."