Task-shifting of HIV care and ART initiation: Three year evaluation of a mixed-care

provider model for ART delivery

Megan McGuire1, Jihane Ben-Farhat1, Gaelle Pedrono2, Sylvie Goossens3, Annette Heinzelmann3, Owen Chikwaza4, Elisabeth Szumilin3, Mathilde

Berthelot3, Mar Pujades-Rodriguez5

1Epicentre, Nairobi, Kenya, 2 Médecins Sans Frontières , Chiradzulu, Malawi, 3 Médecins Sans Frontières ,

Paris, France, 4Ministry of Health, Chiradzulu, Malawi, 5Epicentre, Paris, France

Background and Objective

• Physician centered ART delivery models are not replicable in settings with high HIV prevalence and limited medical human resources

– Utilizing mixed level cadres of staff could facilitate scaling up of care

2010 monthly program activity: 14,000 HIV consultations, 700 program enrollments and 400 ART initiations

• We compared treatment outcomes of patients receiving ART and followed by different types of providers in a large HIV program in rural Malawi

Methods• Eligibility criteria for nurse care: ART naïve at therapy start, in

WHO stage 1 or 2, CD4 count >100 cells/μL, BMI >17 kg, on first line.

• Study population: Inclusion of 10,112 adults (>15 years) who started ART between Sept 2007- March 2010.

• Study definitions: ≥80% of visits by either nurse or clinical officer, <80% of visits in mixed group.

• Statistical analysis: Follow-up was right-censored at the earliest of the following dates: death, transfer out, last visit or

24 months of follow-up.

– Multivariable Poisson models to compare 2-year mortality and program attrition by type of provider

– Sensitivity analysis: patients with BMI>18.5 kg/m2, clinical stage 1 or 2 and CD4>100

Characteristics at ART start

CharacteristicsNurses

N=1901

COs

N=3386

Mixed

group

N=4825

Total

N=10112

Women (%) 1 263 (66.4) 1 905 (56.3) 3 276 (67.9) 6 444 (63.7)

Median age, years

[IQR]35 [29 – 43] 35 [30– 43] 34.9 [29– 43] 35.1 [29 – 43]

BMI, kg/m² (%)

<18.5293 (15.4) 1 197 (35.4) 1 250 (25.9) 2 740 (27.1)

Clinical stage (%)

Stage

1 or 2

Stage 3

or 4

1 414 (74.4)

363 (19.1)

1 167 (34.5)

1 997 (58.9)

2773 (57.5)

1 599 (33.1)

5 345 (52.9)

3 959 (39.2)

Median CD4 count,

[IQR] cells/μL195 [147 – 234]

147 [69 –

228]

182 [113 –

233]

178 [105 –

232]

Mortality and Attrition

0.12

0.15

0.170.19

0.23

0.30

0.34

0.00

0.10

0.20

0.05

0.15

0.25

0.30

0.35

0.40

Cum

ulat

ive p

roba

bility

of d

eath

0 6 12 18 24

Time since ART start (months)

Nurse Clinical officer Mixed

0.00

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.050.05

Cum

ulat

ive p

roba

bility

of a

ttritio

n0 6 12 18 24

Time since ART start (months)

Nurse Clinical officer Mixed

All patients aIRR (95% CI)

Less severe patients* aIRR (95% CI)

Mortality

Nurse 1 1

Mixed 0.72 (0.49-1.06) 0.84 (0.45-1.58)

Clinical Officer 5.04 (3.56-7.15) 5.80 (3.28-10.26)

Attrition

Nurse 1 1

Mixed 0.54 (0.45-0.65) 0.63 (0.47-0.86)

Clinical Officer 4.71 (4.02-5.51) 3.42 (2.60-4.48)

* BMI>18.5 and WHO stage 1 or 2 and CD4>100, N=3846

Nurse Clinical Officer Mixed Group

At 12 months 207 [118 – 317] 168 [81 – 278] 195 [112 – 301]

At 24 months 253 [164 – 377] 244 [150 – 387] 270 [166.5 – 403.5]

CD4 count gains since ART start by type of provider, cells/μL

Association between mortality or attrition by type of provider

Discussion• Mortality was similar in the nurse and mixed care groups

during the first 2 years of ART, but program retention was lower in the first group

• These results support the use of a mixed care approach with well trained and supervised nurses for the provision of HIV care

– Use of clear clinical criteria for inclusion and referral of patients is essential

– National policies need to be adapted to ensure continuation of ART scale-up, including ART initiation and follow-up, nurse deployment for HIV care as complementary workers is essential. Limitations: Observational study based on routine monitoring data; severe or

complicated patients primarily treated by or referred to CO’s. Nurses have additional responsibilities in HC. A competing risk analysis needs is to be done as a further sensitivity analysis.See poster presentation MOPE436 on six month appointments