Research

Using nurses to identify HAART eligible patients in the Republic of Mozambique: results of a time series analysis

Sarah O Gimbel-Sherr^1,2 , Mark A Micek^2,3 , Kenneth H Gimbel-Sherr^1,2 , Thomas Koepsell¹ , James P Hughes⁴ , Katherine K Thomas⁴ , James Pfeiffer^2,3 and Stephen S Gloyd^1,2,3

¹  Department of Epidemiology, Box 357236, School of Public Health and Community Medicine, University of Washington. Seattle, WA 98195, USA

²  Health Alliance International, 1107 NE 45th St, Ste 427, Seattle, WA 98105, USA

³  Department of Health Services, Box 357660, School of Public Health and Community Medicine, University of Washington, Seattle, WA 98195, USA

⁴  Department of Biostatistics, Box 357232, University of Washington, Seattle, WA 98195, USA

author email corresponding author email

Human Resources for Health 2007, 5:7doi:10.1186/1478-4491-5-7

Published:	28 February 2007

Abstract

Background

The most pressing challenge to achieving universal access to highly active anti-retroviral therapy (HAART) in sub-Saharan Africa is the shortage of trained personnel to handle the increased service requirements of rapid roll-out. Overcoming the human resource challenge requires developing innovative models of care provision that improve efficiency of service delivery and rationalize use of limited resources.

Methods

We conducted a time-series intervention trial in two HIV clinics in central Mozambique to discern whether expanding the role of basic-level nurses to stage HIV-positive patients using CD4 counts and WHO-defined criteria would lead to more rapid information on patient status (including identification of HAART eligible patients), increased efficiency in the use of higher-level clinical staff, and increased capacity to start HAART-eligible patients on treatment.

Results

Overall, 1,880 of the HAART-eligible patients were considered in the study of whom 48.5% started HAART, with a median time of 71 days from their initial blood draw. After adjusting for time, expanding the role of nurses to stage patients was associated with more rational use of higher-level clinical staff at one site (Beira OR 1.9, 95% CI 1.1–3.3; Chimoio OR 0.2, 95% CI 0.1–0.5). In multivariate analyses, the rate of starting HAART in patients with CD4 counts of less than 200/mm³ increased over time (HR = 1.07, 95% CI 1.02–1.13), as did the total number of new patients initiating HAART (β = 7.3, 95% CI 1.3–13.3). However, the intervention was not independently associated with either of these outcomes in multivariate analyses (HR = 0.9, 95% CI 0.7–1.2) for starting HAART in patients with CD4 counts of less than 200/mm³; (β = -5.2, p = 0.75) for the total number of new patients initiating HAART per month. No effect of the intervention was found in these outcomes when stratifying by site.

Conclusion

The CD4 nurse intervention, when implemented correctly, was associated with a more rational use of higher-level clinical providers, which may improve overall clinic flow and efficient use of the limited supply of human resources. However, this intervention did not lead to an increase in the number of patients starting HAART or a reduction in the time to HAART initiation. Study month appears to play an important role in all outcomes, suggesting that general improvements in clinic efficiency may have overshadowed the effect of the intervention. The lack of observed effect in these outcomes may be due to additional health systems bottlenecks that delay the initiation of treatment in HAART-eligible patients.