Task Shifting - Global Recommendations and Guidelines - unaids

Recommendations on the organization of clinical care services
traditionally the responsibility of medical doctors Annex a . It follows, therefore, that extending the
scope of practice of nurses to allow them to deliver a wider range of HIV services could increase
access to services amid a shortage of more specialist health-care workers.
A number of studies have observed a successful expansion of the role of nurses in a wide range
of health services, including for HIV, in both resource-constrained and non-resource-constrained
settings 5-8 216 .
One of the earliest examples is from Botswana, where the quest to increase access to
antiretroviral therapy using the medical doctor-led model of treatment and care that has evolved
in industrialized countries was to prove impossible due to a shortage of medical doctors. Two
nurse-centred antiretroviral therapy delivery pilot projects started in 2004 and have shown
reduced waiting lists (indicating increased access to treatment), reduced congestion at
centralized antiretroviral therapy centres, reduced unnecessary travel by service users and the
localized provision of support for adherence and education 217 . In Uganda many health centres
are run by nurses or midwives without either a medical doctor or non-physician clinician on site.
The WHO-Commissioned Study on Task Shifting observed models of HIV care delivery that used
a nurse-centred approach in combination with a significant community-based component. These
models were achieving rapid scale-up in access to HIV services in, Ethiopia, Haiti, Malawi,
Rwanda and Uganda.
There are particularly convincing data on the safety and quality of outcomes for service users in
both Haiti and Rwanda Annex a . The HIV treatment programmes that were using a task shifting
approach showed low rates of abandonment; low rates of failure of first-line antiretroviral therapy;
low rates of switch to second-line therapy; and rates of mortality at 12 months that were
comparable to published studies from similar settings. Furthermore, people living with HIV
reported high levels of satisfaction with their health care.
Qualitative interviews and focus groups with staff members in sites where task shifting was
occurring found that nurses and doctors agreed with the usefulness of task shifting and reported
that they were willing both to take on more complicated tasks, and to shift more tasks to other
cadres in the setting of appropriate training and mentorship Annex a .
Advantages:
• Nurses are more numerous than medical doctors and non-physician clinicians in many of the
countries that face shortages of human resources for health.
• Extending the scope of practice of nurses and midwives can increase access to services in
the absence of medical doctors and non-physician clinicians.
• Expanding the role of nurses and midwives can help to ease bottlenecks and brings services
closer to service users.
Uncertainties:
• To achieve the best outcomes, a nurse-centred service delivery model requires regular
supportive supervision and immediate opportunities for referral to a medical doctor or nonphysician
clinician.
Selected examples of experience/additional resources:
The WHO-Commissioned Study on Task Shifting documents numerous examples of HIV service
delivery where nurses are undertaking tasks formally considered the responsibility of medical
doctors or non-physician clinicians Annex a .
In Ethiopia and Malawi the scope of practice of nurses has been formally extended to include the
prescription of antiretroviral therapy in public sector health services.
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