Nurses and midwives take the lead in providing HIV services in Eastern and Southern Africa
"Nurse-initiated and managed antiretroviral therapy" (NIMART) is an innovative approach to making effective medications more accessible to people living with HIV (PLWH) in low-resource countries. A new study identifies challenges and opportunities to promoting nurse- and midwife-led HIV services in eastern and southern Africa, reports the July/August issue of The Journal of the Association of Nurses in AIDS Care (JANAC).
Improved training, supportive supervision, and formal mentorship programs are key steps toward establishing or strengthening NIMART care, suggests the new research by Rebecca E. MacKay, MPH, of Rollins School of Public Health at Emory University, Atlanta, and colleagues. They write, "Health facilities have important opportunities to advance NIMART practice through strengthening these aspects of in-service support."
Nurses/ Midwives Need Support and Education to Meet NIMART Goals
Eastern and southern Africa accounts for more than half of the PLWH globally—however, the region has also shown remarkable progress toward eliminating HIV. From 2010 to 2018, new HIV/AIDS cases declined by 28 percent in eastern and southern Africa, compared to a global decline of 16 percent.
Increasing access to effective antiretroviral therapy (ART) is a major part of the Fast-Track Strategy of the Joint United Nations Program on HIV/AIDS (UNAIDS), which aims to end the AIDS epidemic by 2030. Designed to make ART more accessible, NIMART is a "task-sharing" approach that enables nurses, midwives, and nurse-midwives—professionals who are far more available than physicians in sub-Saharan African—to provide advanced clinical services, including HIV testing and prescribing of ART for PLWH.
The study included a questionnaire completed by 200 nurses, midwives, and nurse-midwives at 30 healthcare facilities in 11 eastern and southern African countries. Up to 80 percent of nurses/midwives responded that they had "sufficient authority" to provide NIMART care. Sixty percent or more agreed that their pre-service education and in-service training had effectively prepared them to offer HIV treatment.
However, the nurses/midwives expressed more concerns about their level of supervision and mentorship. More than one-third of respondents felt they did not receive adequate supportive supervision or feedback on care provided. Nurses, midwives, and nurse-midwives providing pediatric HIV care tended to have less-positive responses than those providing prevention of mother-to-child transmission services for pregnant and breastfeeding women or HIV-exposed infants.
Interviews with 62 clinical supervisors at the same facilities identified several barriers to effective NIMART care: deficiencies in training, staff shortages, inadequate supplies or space, high workloads, and challenges in managing children with HIV. But the supervisors interpreted many of these barriers and challenges as potential opportunities for improving NIMART services: strengthening in-service training, increasing staffing, providing adequate supplies and space, and increasing capacity for pediatric services.
In a triangulation step, the issues identified in the nurse/midwife questionnaires and supervisor interviews were consistent with each other. "Although the nurses, midwives, and nurse midwives in the facilities assessed clearly had the authority to provide NIMART services, a substantial proportion did not feel that they were well prepared or well supported to deliver this care," Ms. MacKay and coauthors write.
The researchers believe their findings have implications for efforts to promote effective provision of NIMART care in southern and eastern Africa. Steps facilities can take to improve NIMART services include standardized in-service training, formal clinical mentorship programs in prevention, and specific protocols for ongoing supportive supervision. Ms. MacKay and colleagues conclude: "Taking advantage of these opportunities may be a critically important step toward meeting the Fast Track Strategy to the AIDS epidemic by 2030."