July 31, 2009

South African Study: Nurses Comparable to Doctors in Monitoring HIV Management

Nurses in South Africa perform just as well as doctors in terms of monitoring people living with HIV receiving antiretroviral (ARV) therapy, according to study results reported Wednesday, July 22, at the Fifth International AIDS Society (IAS) Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town. These results will likely be viewed favorably as plans continue to scale up ARV access in sub-Saharan Africa and other resource-poor areas, where there may be some reluctance to roll out expanded treatment initiatives in communities without licensed medical doctors to monitor patients.

The Comprehensive International Program for Research on AIDS in South Africa (CIPRA-SA) study, reported at IAS by Robin Wood, FCP, of the University of Cape Town, tested the hypothesis that nurse-monitored ARV treatment is not inferior to doctor-monitored treatment. CIPRA-SA was conducted at clinics in two poor South African townships: Masiphumele in Cape Town and Soweto in Johannesburg.

Wood’s team randomized 812 HIV-positive individuals—all with CD4 counts at or below 350 and no active opportunistic infection—to nurse- or doctor-monitored ARV therapy for at least 96 weeks. All patients were initially prescribed therapy by a medical doctor, consisting of generic- or brand-name nevirapine (Viramune) or efavirenz (Sustiva), along with stavudine (Zerit) and lamivudine (Epivir).

Both the doctors and nurses closely observed patients for overall health improvements and symptoms of serious side effects while on therapy, as well as viral load and CD4 testing. Similarly, both doctors and nurses received peer education and support in accordance with official South African HIV treatment guidelines. 

After 96 weeks of treatment, patients monitored by nurses did just as well on treatment compared with those monitored by doctors. Definitions and rates of treatment failure that occurred in the nurse and doctor groups, respectively, include: death (2.5 vs. 2.7 percent), inexplicably dropping out of the study (3.5 vs. 2.5 percent), poor viral load responses (10.9 vs. 9.6 percent), severe side effects preventing the continued use of therapy (16.8 vs. 16.2 percent) or missed clinic appointments (9.4 vs. 7.8 percent).

Even patients with advanced HIV disease in the study, defined as those with CD4s below 200 and viral loads above 100,000 copies, were just as likely to be successfully monitored by nurses, compared with doctors, while receiving ARV treatment.

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