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Mind the gaps: ART and AIDS treatment in times of healthcare worker shortages

An estimated 70% of people living with HIV/AIDS (PLWHA) who need ART are still not receiving it. As the numbers of patients started on ART increase worldwide, the human resources for health (HRH) needed to manage and maintain care are lagging far behind. In countries where ARV drugs are now available, the acute shortage of health staff is one of the main reasons for failing to reach more patients. In contrast with public announcements from governments and international agencies, effective immediate measures on the ground are still missing.

Whereas the World Health Organization (WHO) minimum standard for the number of doctors per 100,000 people is 20, countries like Malawi, Mozambique, and Lesotho have ratios of 2, 3, and 5, respectively, based on 2006-2007 population and health data. Similarly, the WHO minimum standard for nurses per 100,000 people is 100, but the ratios in the same three countries are 56, 20, and 63, respectively.

Every day, MSF teams witness how the critical shortage of healthcare workers impacts the lives—and untimely deaths—of people with HIV/AIDS. We see patients forced to wait months to start treatment while their health deteriorates. For example, in two MSF-supported programs in Angonia and Mavalane districts in Mozambique, before important changes in patient flow and capacity, median waiting times for ART were 42 and 54 days, respectively, for patients enrolled in 2006. Rates of pre-ART loss to follow-up were 69% and 87%, respectively. Also, long waiting times for consultations increase the risk of patients interrupting treatment. Overwhelmed clinicians are thus under immense time pressures and do not have the time to perform thorough assessments of patients on treatment, which risks missing out on crucial signs of complications and/or health deterioration.

One primary strategy used by MSF and others is task shifting, combined with other measures to deliver care. Task shifting refers to a change in task allocation between different types of professional health workers (mostly lower cadres), or from professional to lay workers. It is a common practice for general health care both in developed and developing countries. In sub-Saharan Africa, especially rural areas, special cadres of non-physician health workers have been created to perform clinical tasks where physicians are scarce.

MSF regularly utilizes task shifting in its ART programs where physicians or other medical staff are in short supply. In a review of 19 MSF projects, task-shifting activities in HIV/AIDS care were assessed, looking at care setting, task division, staff qualifications, and workload management. The review showed that task shifting was mainly used in response to countrywide shortages of qualified health workers, particularly in southern African nations. Clinics in sub-Saharan Africa were either overloaded, centralized hospital-based ART programs, or ART care decentralized to health centers mainly in rural areas with extremely limited health staff. Clinical tasks were shifted to non-physician clinicians and nurses. Lay workers mainly performed tasks for HIV testing and counseling, adherence counseling, treatment literacy, and social and educational support. Lay workers were a valuable additional workforce within the health facilities, stepping in to perform registrations, simple patient assessments, and drug dispensing and explanations. Supervision was crucial to quality of care, requiring support from qualified staff.

An example of ART scale-up and rollout in the face of severe HRH shortages, albeit requiring additional financial and human resources, is MSF’s experience in Thyolo, Malawi. Thyolo district is a poor, rural region of Malawi, where MSF has one of its largest cohorts of patients on ART at well over 10,000, with about 450 new patients started on ART each month. Starting in 2005, the central hospital became overwhelmed by the increase in new patients. Patient time was severely constrained, and many patients had difficulties reaching the hospital for treatment, due to distance and cost of transport. Over the following years, ART initiation and follow-up were decentralized to 14 health centers (7 of which do initiations). Both within the ART clinic in the hospital and in the health centers, task shifting was implemented. Clinical officers, medical assistants, and nurses were trained and supported to handle ART initiation and follow-up. Additional workforce was summoned through nurses, lay workers, and community volunteers (often PLWHA) to administer testing, counseling, and psychosocial and nutritional support. In addition to the task shifting, extra clinical staff were recruited, treatments reorganized, and incentives provided.

In a 2007 analysis of the Thyolo program, 91% of patients (enrolled June 2006-December 2007) were still alive and on ARVs, illustrating the effectiveness of this decentralized, task-shifting treatment strategy, despite the relative difficulty and complexity of its implementation and costs. Further comparative analysis of retention and attrition rates (June 2006-June 2007) showed that of 4,074 patients followed up for a total of 1,803 person-years, >80% were still retained in care at both the hospital and health centers. Retention at the health centers was significantly higher than at the hospital level (adjusted hazard ratio: 1.2, P<0.001). Attrition rates (death, lost to follow-up, ART stoppage) were similar at approximately 15%. Similarly, in a MSF treatment program in Lusikisiki, South Africa (handed over in 2006), task shifting and health center-based care resulted in >80% of patients still alive and on ART after 1 year.

In MSF’s program in Lesotho, ministry of health (MOH) nurses at one district hospital and 14 rural health centers initiate and monitor patients on ART, and are supported by MSF mobile medical teams who visit each clinic weekly to provide clinical mentorship and other support. Facility-based lay counselors have become central to comprehensive patient management, performing a wide range of tasks including HIV testing and counseling, ART preparation, adherence support for both ART and TB treatment, scheduling of appointments, and identification and tracing of defaulters. At the most overloaded facilities, a simplified screening tool is being piloted where certain senior counselors can provide drug refills for stable adult patients (defined as non-pregnant adults on ART >12 months with no new opportunistic infections, ARV side effects, or adherence problems) and refer patients to nurses at the first sign of any complication. The essential tasks performed by lay counselors help to reduce the workload of nurses so that the nurses can continue to initiate new patients and focus on more complex clinical problems. In this program, 87% of ART patients analyzed were alive and remaining in care at 12 months.

In Tete province, Mozambique, the transfer of counseling tasks from nurses to lay workers allowed MSF to significantly increase the number of patients enrolled on ART. With lay counselors on the team, new ART initiations increased to an average of 16 per month (January-May), compared with 6 per month in the previous period. Adherence rates remained favorable at 8% loss to follow-up, with the lay counselors also tasked with tracing these patients.

The favorable capabilities of lower cadres of health workers are further exemplified by MSF’s largest ART program, in Chiradzulu, Malawi, where >12,000 patients are on treatment. MSF in collaboration with the MOH developed a task-shifting strategy transferring ART initiation from clinical officers to nurses and medical assistants in rural health centers. In a May-December 2007 analysis of >1,600 adult patients started on ART, 25% were initiated by nurses and medical assistants. Comparing patients followed by nurses/medical assistants or by clinical officers, 88% and 87%, respectively, were still active at >3 months. No significant difference was observed between outcomes of patients initiated by either group. These nurses and medical assistants trained in ART care thus appeared capable of treating and following up patients comparably with clinical officers in our setup with a simplified protocol.

Despite these local successes, task shifting is not a panacea and has its limits. Even when using qualified health staff more efficiently, MSF and others continue to hit the wall of the HRH shortage, especially as it pertains to significant ART scale-up. To effectively counter the HRH crisis, task shifting must be part of a larger strategy of retention and training of health care workers. Urgent mobilization at multiple policy levels is needed to sustain health workers in caring for their patients. Measures must be taken by donor, national, and international entities to retain skilled health care workforces and to attract new staff by increasing salaries and improving working and living conditions, as well as providing access to treatment and health care for the workers themselves.

International “brain drain” has also contributed to the HRH crisis, as workers leave poorer countries for better salaries and working conditions in richer countries. But such brain drain is also common within regions themselves. Countries like South Africa attract doctors and nurses from countries with lower remuneration, such as Democratic Republic of Congo, Lesotho, Malawi, Nigeria, and Zimbabwe. Codes of conduct and similar initiatives try to curb unethical international recruitment. Despite such pull factors, with necessary support and remuneration, more health staff may prefer to remain in their home countries.

In addition to salary and working conditions, illness and death among health staff add to continued loss. In Lesotho, Malawi, and Mozambique, death is the leading cause of health worker attrition, with a significant proportion being HIV-related. To keep health workers alive and active is a crucial challenge in countries with high HIV prevalence and staff loss. Paradoxically, health professionals face stigma and difficulty accessing HIV/AIDS treatment. Availability of confidential HIV testing, care, and treatment services for health workers is therefore of utmost importance. At the local level, several initiatives have been taken to improve access to care for HIV-infected staff. In Thyolo, Malawi, MSF supported the district health authorities in setting up a specialized clinic for staff and their immediate family members, as well as a staff support group. This initiative increased the number of health staff on ART from 31 to 58 over 2 years.

Although the scale and scope of the health worker crisis is now well acknowledged, effective interventions are still limited or slow to be implemented. Policymakers in national, donor, and international agencies have expressed their concern and pledged support. The Global Fund has adapted funding modalities to include health systems strengthening, with specific calls for proposals, in rounds 8 (July 2008) and 9 (October 2008), for measures to boost the health workforce by improving remuneration and increasing recruitment. Still to be seen are the actual scope and size of these proposed funding opportunities.

As these long-term solutions continue to be discussed, clinic staff, district health authorities, and nongovernmental organizations cope daily with the gaps but barely manage to keep clinics running. The main challenge is how to bring ART to patients in rural and difficult-to-access areas, where the demanding work and difficult living conditions make it problematic to attract and keep health care staff. Without short-term, emergency measures to boost and retain staff, the nurses and other health workers present in the field are likely to leave on short notice, ultimately causing health services to collapse and leaving too many HIV patients untreated.

Urgent and crucial steps to plug the gaps in health workforce include:

• Greater flexibilities in national work policies and scope of practice to allow task shifting to lower-qualified medical and non-medical workers
• Improved access to treatment for workers who themselves may become sick
• Training and recruiting additional qualified staff
• Increased salaries and benefits for national health workers in clinical care
• Improved work and living conditions for staff, particularly in rural areas
• Revision of multilateral and bilateral donor rules and practices allowing increased financial support to boost the public health workforce
• Lifting of salary and workforce spending limits by national and international finance bodies

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