As mentioned, the laundry list of tasks that could possibly be shifted are listed in a long annex in the guidelines, but many of these came from a list that Dr Ivers helped compile in Haiti.
There are about 8.5 million people living in Haiti but only 730 doctors and 1013 nurses working in the public sector. Partners in Health works in collaboration with the Ministry of Health and one of its focuses is the delivery of HIV at the primary health care/community level.
“Most of our staff are community health workers; we call them “accompagnateurs” in Creole or in French, meaning “the one who accompanies,” said Dr Ivers. “Accompagnateurs are community health workers from the area where we work, living in the communities where we work, neighbours of our patients and clients who bring medicines to people everyday.”
Incidentally, she added that there is something of a tradition of community health workers in Haiti. There are health agents called ‘Ajan fanm/Ajan sante’ dedicated to the care of women or trained to do vaccinations; there are counsellors drawn from the community and trained; many of the lab technicians are people from the community without a high degree of education, but who have been trained to assist in the labs. Similarly there are pharmacy technicians, x-ray technicians, social work assistants, data clerks and medical records clerks — many drawn from the community to provide services.
WHO commissioned Partners in Health to do a survey into task shifting, in which they asked many HIV service providers about the distribution of HIV care-related tasks and what tasks were usually exclusively performed by certain cadres. They came up with a list of about 140 HIV-related tasks, about 50% of them exclusively done by doctors, about 20% exclusively done by nurses and so on.
“Community health workers were not really featuring at all in the traditional model of HIV care,” she said. “However, when we surveyed our sites in Haiti, we found that our distribution of tasks had really shifted [so that most of the tasks were being] performed by doctors, nurses, community health workers and by other non-clinical staff.”
In fact, only 28% of the tasks were exclusive to doctors or nurses in Haiti.
However, the ART programme is nurse-centred in Haiti, and the tasks are shifted rationally by type, with the largest shift seen in the management of patients just prior to and after starting ART. Nurses are responsible for prescribing and managing patients. Only a few tasks are not done by nurses, including starting TB therapy in patients with HIV/TB coinfection or in smear-negative TB cases; the definitive management of some complicated side-effects and complicated opportunistic infections.
Community health workers handle much of the pre-ART care, and provide facilitated referrals if there are signs of opportunistic infections or side-effects of ART.
“Community health workers provided a support system in the community,” she said. “They referred patients who had side-effects from drugs, they supervised therapy of drugs, they were an advocate for patients coming to the clinic to say ‘My patient is not well.’ Their referrals are taken seriously, they consult with the physicians about their patients, they consult with the nurses formally about their patients; and in those referrals, in consultations, they are respected. They are advocates for their patients. They will come and tell us that the roof is leaking, this person has no food in the house and really far more beyond just delivering medications to the patient everyday.”
How did this affect care in the programme? Although the evidence doesn’t come from a randomised controlled study, it is easy to interpret. In over 3000 people on ART, some started as long as 10 years ago, only 2% have needed to change to second line treatment, and despite significant political instability.
“This is because the community health workers living in the community, they’re the neighbours, they still go to work everyday regardless of what was happening politically in the country," she said.
In addition, shifting tasks to nurses transformed clinics that were previously non-functional. Before task shifting, these clinics received on average only 10-50 visits per day. There were frequent stock-outs, no ART, absent staff, and HIV testing was only available at one stand-alone site that performed less than 40 tests per year.
Since introducing the nurse-led, community worker-supported model, each clinic receives an average of 200-300 visits per day. There are 50,000 voluntary HIV tests per year, over 8,500 people with HIV being followed and over 3,000 people on ART.
And as already mentioned above, patient satisfaction is very high.
Dr Ivers also stressed that the approach can be scaled up in other settings. Since 2005, Partners in Health began expanding this model to eastern Rwanda. In a short period that programme was able to enrol over 2500 people living with HIV on ART. They trained and hired over 800 villagers as community health workers and had nearly 100,000 visits in 2006, just one year after they started the programme.