Features

Transforming HIV care across sub-Saharan Africa

Nurses lead the effort to meet ambitious goals
Nimart nurses

Ambitious targets are in place to beat AIDS by 2030. Nurses in Africa are leading the effort to improve the detection and treatment of HIV and meet the '90-90-90' goal, reports Jacqui Thornton

For six years, professional nurse Lynette Kosgei was single-handedly running the Asayi dispensary health clinic in Siaya County, Kenya, which provides general care to more than 5,000 farmers and their families.

Alongside other kinds of health treatments, the single mother of two was only able to offer basic HIV treatment to pregnant women and their newborns, such as antibiotics to prevent pneumonia and single dose anti viral nivaparine.

All of her other HIV patients had to travel long distances at high personal cost to receive anti-retroviral treatment (ART) in higher level facilities.

Lynette Kosgei, NIMART nurse Photo: International Aids Society/ICAP

Even when she began offering HIV tests, and a roving clinician visited

...

Ambitious targets are in place to beat AIDS by 2030. Nurses in Africa are leading the effort to improve the detection and treatment of HIV and meet the '90-90-90' goal, reports Jacqui Thornton

For six years, professional nurse Lynette Kosgei was single-handedly running the Asayi dispensary health clinic in Siaya County, Kenya, which provides general care to more than 5,000 farmers and their families.

Alongside other kinds of health treatments, the single mother of two was only able to offer basic HIV treatment to pregnant women and their newborns, such as antibiotics to prevent pneumonia and single dose anti viral nivaparine.

All of her other HIV patients had to travel long distances at high personal cost to receive anti-retroviral treatment (ART) in higher level facilities.

Lynette Kosgei
Lynette Kosgei, NIMART nurse
Photo: International Aids Society/ICAP

Even when she began offering HIV tests, and a roving clinician visited every week to prescribe ART to those with a CD4 count of less than 350, there were still delays and low take-up. ‘Clients would wait for a long time, leading to defaulting, stigma and discrimination,’ says Ms Kosegi.

But in 2014, she became a pioneer in NIMART – nurse-initiated and managed ART – which is transforming HIV care across sub-Saharan Africa.

In partnership with the International Center for AIDS Care and Treatment Programs (ICAP) at Columbia University in New York City, she was trained how to prescribe ART and manage patients, and how to be a trainer.

Ms Kosegi has now trained seven nurses in NIMART, one of whom works with her at Asayi. Since she has been able to prescribe ART, none of the babies born to HIV-positive mothers in her care have had the virus.

'Dynamite in small packages'

Her success has been so impressive that she was asked to present her findings at the prestigious International AIDS Society’s conference in Durban, South Africa, in July.

Susan Michaels-Strasser, ICAP’s senior implementation director had gone to see Ms Kosegi in Kenya and been 'really touched by her'. 'She reminded me of why I went into nursing. Providing these services single-handedly, then with just one other nurse, is pretty remarkable.’

At the conference, the chief nursing officer of Lesotho Makholu Lebaka put it succinctly when she said: ‘Lynette is an example that dynamite comes in small packages.’

A shy, slight woman, uncomfortable with being put in the spotlight, Ms Kosegi said she was 'humbled' by the positive comments she received at the conference.

UN targets

Her achievements are part of a much wider movement introducing NIMART in sub-Saharan Africa, which is being seen as particularly important in the light of new targets introduced in 2014 by UNAIDS – the Joint United Nations Programme on HIV and AIDS.

It wants all countries to reach for the goal of 90-90-90 – for 90% of all people living with HIV to know their status, 90% of those to be on treatment and 90% of those to have an undetectable viral load.

If these figures could be achieved by 2020, the global AIDS epidemic would be all but over by 2030, UNAIDS says.

This challenge will need to be tackled in different ways around the world. The UK, for example, has excellent access to treatment and adherence to treatment, but it is believed that 76% of those with HIV do not know they have it.

In Africa, access to treatment and effective treatment is far harder, and nurse-led treatment in the community is seen as crucial to achieving the targets.

President of the Association of Nurses in Aids Care Jason Farley says nurses are 'the absolute centrepiece of responses to HIV, whether as prescribers of ART or adherence nurses, keeping people engaged in their care for the rest of their lives’.

Rolling out NIMART

South Africa has high rates of HIV – 6.4 million out of 52 million are living with the virus, with a 29% prevalence in pregnant women compared with 12.2% in the general population.

The NIMART model has been successfully rolled out since 2010, with 23,000 nurses NIMART trained to work in primary care settings. This is out of a total of 25,000 professional nurses, and 276,000 enrolled nurses and auxiliaries.

Nimart nurses. Photo: International Aids Society/ICAP

It started with a massive testing programme – 18 million people in 18 months. In 2009, before NIMART, only 510,317 people were on ART. By 2012, the number had increased to 2.17 million.

South Africa’s health minister Aaron Motsoaledi says: ‘It’s been extremely successful and the outcome of patients is the same as if the initiator was a doctor. Nurses are going to become even more central in the future.’

Steps for the future

Penny Msimango, from the KwaZulu-Natal province department of health, says nurses now need to develop their roles.

Penny Msimango, Department for Health, KwaZulu-Natal province.
Photo: Jacqui Thornton
  • HIV needs to be integrated into general nursing so when a patient appears with a skin rash or a minor injury they are offered a test and counselling. Patients need to understand why it is important to know their HIV status.
  • There needs to be a move towards ‘universal test and treat’, so all nurses in the community can initiate and follow up treatment, making it less stigmatised. Nurses play a vital role in educating patients in why they need to stay connected with health services, especially with those who do not feel unwell.
  • To ensure the effectiveness of treatment, nurses should be able to monitor ARVs and analyse blood tests. If they are not effective, they need to work out why and report back to other healthcare professionals to suggest interventions or alternatives. This means increasing clinical governance and learning protocols, reviewing patients' audits, knowing how to implement quality improvement to reduce morbidity and mortality, and looking at pharmacovigilance – what drugs are being used, are they second line, third line.

NIMART is being used in Kenya, Zimbabwe and other countries, but now needs to be rolled out in other African countries where access to diagnosis and treatment is available in the capital cities, but less so in other areas.

In Kenya, Ms Kosegi is keen to press on with achieving 90-90-90. ‘I’m passionate about my expertise and the challenge of being there for the patient. That is what is making me struggle to achieve the 90-90-90. I want to come up with factors that will motivate other nurses.’

In Durban, she did just that.

Global Nurses Call to Action

The Association of Nurses in Aids Care (ANAC) has demanded greater investment in nursing to fulfil the 90-90-90 targets, supported by ICAP, the Internatial Council of Nurses, UNAIDS and others.

ANAC aims to attract 10,000 signatures. Its call to action is asking for policy changes to support nurse-led care, support for inter-professional collaboration, equity in decision making, and greater investments in nursing.

ANAC chief nursing officer Carole Treston says: ‘We are mobilising nurses across the world to sign our petition to get a critical mass.

‘Chief nurses can then go to their department of health and say we need more resources, and here’s the evidence. It can be used in high level contract negotiations, or by individual nurses saying we need one more nurse in this department.

‘It calls for policy and legal changes so that if nurses are not allowed to prescribe medication such as ART on their own, that can be changed.’

Erica Ehrhardt and Carole Treston, Association of Nurses in Aids Care.
Photo: Jacqui Thornton

ICN analyst Erica Ehrhardt admits that a number of barriers exist for countries to reach the targets, but healthcare providers should think positively.

‘When a nurse sees a patient in a clinic, the targets become 100-100-100. She or he should aim to test 100% of patients at risk, put 100% of positive patients on treatment, and ensure 100% that they remain virally suppressed.’

To sign the call to action go to www.nursesinaidscare.org/signthecall

Jacqui Thornton is a freelance writer

Want to read more?

Subscribe for unlimited access

Enjoy 1 month's access for £1 and get:

  • Full access to nursing standard.com and the Nursing Standard app
  • Monthly digital edition
  • RCNi Portfolio and interactive CPD quizzes
  • RCNi Learning with 200+ evidence-based modules
  • 10 articles a month from any other RCNi journal

This article is not available as part of an institutional subscription. Why is this?

Jobs