The size of the HIV disease burden in South Africa has required expanded access to treatment. The 2009 call by political leaders to intensify efforts in the fight against HIV/AIDS has meant greater drive towards prevention, scale up of services for testing and care of HIV positive patients including antiretroviral treatment.

Models of doctor led ART delivery are not replicable in countries with a high HIV burden and limited human resources for health, proving to be a major obstacle to implementing policies for HIV treatment. Scale up of provision of antiretroviral treatment therefore requires task shifting to nurse-managed care in primary care settings.

Studies in South Africa and other African countries have shown that nurses are able to safely manage ART provision. Results from the STRETCH trial in the Free State province involving over 15,000 patients have shown that nurses can safely prescribe ART. In addition, lower mortality was found among intervention patients with baseline CD4 levels >200 cells per µL as well as improved health outcomes and quality of care.

However, nurses who prescribe ART need effective training. Nurses working in facilities in the STRETCH intervention received at least four educational outreach training sessions covering ART prescribing and side-effects using the PALSA PLUS guidelines which included algorithms for starting and monitoring patients on ART, and identifying those requiring referral to a doctor.

From 1 April 2010, nurses in the public sector started initiating antiretroviral treatment (ART). The National Department of Health recommended that provinces follow the Integrated Common Programme to train nurses for NIMART in order to bridge the gap between knowledge and practice. The Department has supported the Knowledge Translation Unit to introduce rapid and effective training to all nurse practitioners and other health care providers in primary health care clinics in South Africa using the methodology of PALSA PLUS. Legal provision for nurses to prescribe ART has been provided using Section 56(6) of the Nursing Act of 2005. This clause provides for emergency situations and NIMART was regarded as an emergency.

Once a nurse practitioner has received basic HIV training and has gone through PALSA PLUS and the IMCI ART training, mentoring is still required to authorize that the nurse is confident and confident to prescribe ART. This mentoring takes place at facility level to equip health care providers with clinical knowledge, skills and attitudes to provide quality care. Once all requirements have been met during this process, the clinical mentor will sign off the nurse practitioner as competent. The regulations for clinical mentorship are contained in the Clinical Mentorship Manual for Integrated Services, January 2011, issued by the National Department of Health
http://www.doh.gov.za/docs/policy/2011/clinicalmentorship.pdf

The PALSA PLUS programme trains nurses to provide all HIV/AIDS care for adults, including ART where indicated. It is therefore safe to say that NIMART training is included in PALSA PLUS training. PALSA PLUS is now a national training requirement for any nurse prior to authorization to prescribe NIMART (see diagram below). Paediatric NIMART training is included in PALSA PLUS training, using the ART section of the IMCI guideline.