HIV and AIDS

In low-income countries with a generalised HIV epidemic, HIV and AIDS has considerably exacerbated existing human resource problems. It has placed a double burden on an already overstretched and poorly functioning health workforce. Workloads have increased through the growing demand for services such as counseling and testing, diagnosis and prevention and treatment of opportunistic infections, while the supply of health workers has decreased as they themselves have become infected, fallen sick and died. Direct costs to health sector have been in the form of lost productivity due to absenteeism resulting from illness, attending others' funerals and caring for sick relatives, and death.

Human capital and the HIV epidemic in Sub-Saharan Africa outlines how the HIV epidemic not only reduces the stock of those with higher level professional and managerial training and experiences, but also reduces capacity to maintain the flow of those with needed skills and training. Training and educational institutions are themselves losing staff due to HIV and AIDS, reducing their capacity to meet growing demands.

Hospital beds are now dominated by patients with HIV and AIDS related illnesses, such as pneumonia and TB, which are complex to treat and generally require longer hospital stays than other illnesses. Nurses have had to work longer hours due to the growing demand for services but also to cover for staff shortages resulting from the epidemic. Overall, the AIDS epidemic has weakened staff morale and motivation. Health workers have felt a sense of professional inadequacy in the face of such high mortality, and the perception of occupational risk of infection has remained high.

HIV/AIDS, equity and health sector personnel in Southern Africa  identifies how increased stress and fear amongst health workers as a result of HIV and AIDS have been important push factors in their leaving the public health sector and migrating overseas. Health worker attrition related to HIV and AIDS has worsened the existing rural urban bias in the distribution of human resources within the sector. The human resource gap is projected to get worse as the disease progresses and a higher number of staff contract HIV.

The recent global movement towards incorporation of antiretroviral treatment (ART) into a comprehensive HIV approach to prevention, treatment and care (see Treating 3 million by 2005: making it happen, the WHO strategy) poses new human resource challenges. Estimating health workforce needs for antiretroviral therapy in resource-limited settings argues that availability of trained health workers will be the single biggest obstacle to scaling up ART, and estimates that between 20,000 and 100,000 doctors, nurses and pharmacists would be needed to meet the WHO target.

Human capacity-building plan for scaling up HIV/AIDS treatment outlines a strategic plan for WHO to support the development, strengthening and sustaining of the workforce necessary to radically scale up and maintain antiretroviral treatment. Scaling up HIV/AIDS care outlines the staffing requirements of different systems of ART delivery and points to existing solutions to the human resources issues that are involved.

Treatment within a continuum of care will require new clinical and management skills, including provision of palliative care, laboratory monitoring and the ability to ensure treatment adherence to prevent development of drug resistance. Demand for ART will be cumulative since it is required for life. Provision of antiretroviral therapy in resource-limited settings: a review of experience up to August 2003(Attawell and Mundy, HSRC 2003) identifies human resource shortages as a major constraint to ART scale up affecting the capacity to absorb new resources and provide quality ART, and meet cumulative demand for chronic care.

To help mitigate the HR problem related to prevention, treatment and care, WHO in A public health approach to antiretroviral therapy: overcoming constraintsrecommend reducing the reliance on qualified health staff by devolving responsibilities to other less qualified health care workers, such as clinical officers, pharmacy technicians and lay counselors. They also stress the importance of involving communities, particularly in provision of psychosocial support and adherence counseling, and in the selection of who receives ART. Expert patients and AIDS care considers how people with HIV themselves could play a greater role in ART provision.

As is the case for treatment of other sexually transmitted infections (STIs), it is likely that private providers will provide a substantial proportion of ART treatment. Antiretroviral treatment in developing countries: the peril of neglecting private providers (R. Brugha in BMJ vol 326 2003) outlines some of the poor ART practices already taking place within the private sector, such as provision of incorrect doses and the indiscriminate switching of different therapies. An equally worrying finding was the belief by some private patients of ART to be a cure for HIV. Clearly, an urgent HR challenge is the improvement of government stewardship of ART provision in the private sector.

Poorly planned HIV and AIDS treatment and care scale up could have a detrimental impact on health systems, by diverting scarce human resources away from other essential health services. Viewed in a positive way, the prospect of substantial new resources for ART can be seen as an opportunity for strengthening health systems broadly and human resources specifically. For this to happen, HR planning for ART needs to be integrated into sector wide HR plans, which in turn need to be part of national level multi-sectoral poverty reduction planning processes. ART resources could then be used to address systemic HR problems, such as low pay and retention, and geographical imbalances.