Task shifting of antiretroviral treatment from doctors to primary-care nurses in South Africa (STRETCH): a pragmatic, parallel, cluster-randomised trial

The effectiveness of task shifting of antiretroviral therapy (ART) from doctors to other health workers needs to be evaluated. This paper assesses the effects of task shifting in terms of ART on mortality, viral suppression, and other health outcomes, focusing particularly on South Africa.

The paper reviews quality indicators of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) programme, which provides educational outreach training of nurses to initiate and re-prescribe ART for AIDS patients, and to de-centralise AIDS-related healthcare.

The authors reveal that:

• the results support task shifting of ART from doctors to nurses and other health workers, which seems essential for ART expansion in South Africa and elsewhere in Africa
• they show practical problems with large-scale implementation of ART in Africa
• the expansion of primary-care nurses’ roles to include ART initiation and re-prescription can be done safely, and improve health outcomes and quality of care, but might not reduce time to ART or mortality.

Concerning the STRETCH programme, the document finds that:

• STRETCH is an effective and feasible method of rapidly expanding ART provision in South Africa and other countries where shortages of doctors restrict access to ART
• problems need to be tackled, including the reduction in nurses’ ability to initiate ART promptly due to difficulties with funding and facilitations, and the initial hesitation of nurses to initiate ART when the option of referrals to doctors exists
• the suitability of STRETCH approach in countries where access to physicians is even more restricted than in South Africa or is non-existent should be assessed in a separate trial.