Faced with the ambitious target of reaching 85 percent of people in need of HIV treatment by the end of 2012, the Zimbabwean government has announced that nurses will be trained to prescribe and manage antiretroviral (ARV) drug treatment.
Experts welcomed the move but warned that nurses would have to be adequately prepared and supported to take on the additional duties. Previously, nurses were allowed only to administer the drugs after a doctor had prescribed them. Now, changes made in the job descriptions of nurses by the Nurses’ Council of Zimbabwe will see them prescribing the medication.
"Those nurses that have received training on the management of patients living with HIV and drug administering will be allowed to take up this responsibility. The government, with the support of its partners, began this training many years ago, and the training is actually still ongoing. I need to point out that it's not enough that a professional council allow nurses to administer drugs; this should be followed up with measures to capacitate nurses to do this work correctly," stressed Owen Mugurungi, head of HIV/AIDS and TB in the Ministry of Health and Child Welfare.
With doctors in short supply, many people living with HIV are forced to wait long periods before they can start taking ARVs. This is particularly problematic for those living in rural areas, where doctors often serve more than one health facility, and are likely to visit each facility only once or twice a month.
“It is cost-effective and can deliver effective community-based care to people living with HIV by expediting treatment roll-out and increasing access to treatment, as nurses have more daily contact with patients than doctors,” said Itai Rusike, executive director of the Community Working Group on Health.
In 2010, a South African study divided HIV patients into two groups - one received ARV therapy from doctors, the other from nurses. Both the nurses and doctors had been inexperienced in ARV management and received similar training from clinicians, who were on call for the duration of the study to answer questions. After 120 weeks, the patients managed by nurses were no more likely to have been lost to follow-up, to have failed treatment or to have died than those under a doctor’s care.
However, Rusike noted that adding to nurses’ responsibilities comes with its own challenges, including possible work overload and burnout and the need to increase payment for staff and training.
The government, facing inadequate resources and already struggling to pay civil servants’ salaries, recently froze the recruitment of nurses. Although the training of nurses will continue, this freeze has greatly affected service delivery at public health facilities.
Activists have also raised concerns about the supply of ARVs. “Our biggest challenge in Zimbabwe has been the erratic availability of ARVs or drug stock-out,” said Rusike. “This may also increase nurses’ frustrations, especially at the primary-care level, where there is poor drug distribution thereby affecting continuity for patients initiated on ART [antiretroviral therapy]. The resulting consequence can be drug resistance.”
“We have heard numerous stories of drug stock-outs in some provinces, of people on treatment sharing drugs as a result, and of even drugs expiring while some people are dying from lack of access to treatment. This is very disturbing, and it must be addressed,” warned Stanley Takaona of the Zimbabwe HIV/AIDS Activist Union.
An audit released in May by the comptroller and auditor-general's department revealed that ARV drugs had expired on the shelves of public health facilities.
But with a US$84 million grant by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the country will put in place a six-month ARV buffer stock to prevent treatment interruptions for the 480,000 patients currently receiving the medication. The funding will also cover the cost of ARVs for an additional 10,000 new patients to help Zimbabwe reach its 85 percent coverage goal by the end of the year.