In 2008, the World Health Organisation International Conference on Task Shifting recommended that countries should consider a task-shifting approach where access to HIV and other health services are constrained by health worker shortages [Article Reference]. In addition, strategies are needed that will empower health workers with skills to deliver a comprehensive quality health service to those infected with HIV. South Africa has the world’s highest HIV/AIDS burden, as well as a shortage of skilled health workers. Its national guidelines recommend that antiretroviral treatment (ART) be provided by doctors, although primary care is mainly provided by nurses.
STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) was developed to support the integration and decentralisation of HIV services, including re-prescription and antiretroviral treatment initiation in selected adults by nurses. Based on PALSA PLUS, it was implemented in selected primary care facilities in the Free State province.
STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) is a complex health systems intervention to support the integration and decentralisation of HIV services, including antiretroviral treatment initiation in selected adults by nurses. It was based on PALSA PLUS but also includes clinical algorithms to triage ARV patients for nurse- or doctor-managed care.
STRETCH includes systematic reorganisation of HIV services to facilitate their decentralisation and integration with primary care services. It redefines the roles of clinical staff for pre-ART HIV care, monitoring of stable ART patients and ART re-prescription and initiation in selected adults. This frees doctors to manage complex cases.
STRETCH aims to provide high quality HIV and ARV care while expanding ARV treatment access. At the same time this intervention can consolidate care for most clients to the clinic/assessment site to reduce traveling between facilities and to avoid fragmented care. STRETCH is not just nurse-initiated ART, nurses doing doctor’s work, excluding doctors or a quick fix, but provides a sustainable model of care and support health workers working together to avoid burn-out.
STRETCH was evaluated by means of a pragmatic cluster randomised controlled trial using 31 primary care clinics in the Free State. The two primary outcomes were mortality among patients waiting for antiretroviral treatment (to evaluate effect on treatment access) and viral load suppression rates among those receiving treatment (to evaluate effect on quality of care).
The STRETCH trial provided valuable recommendations for high quality HIV and ART care and the expansion of ART access at the level of primary health care [Article Reference]. It showed that with the relevant training nurses can safely prescribe ART.
Funding was been made available for the STRETCH trial from Irish Aid, the Canadian International Development Agency and the British Medical Research Council.
Since 2008 this intervention was also piloted as a health program in the Western Cape province in South Africa and and has now merged into the NIMART programme of the Department of Health of the Western Cape.
It is recommended that STRETCH be introduced in 3 phases:
- Site preparation including decentralisation of HIV care according to provincial policy
- Consolidation of decentralisation of HIV care and ARV monitoring to PHC services
- Initiation and management of ARV treatment by nurses who have received the necessary training and clinical mentorship.
The STRETCH toolkit is a “guideline” for managers on how to implement STRETCH.