Antiretroviral treatment roll-out in a resource-constrained setting: capitalizing on nursing resources in Botswana

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Abstract
As programmes to deliver antiretroviral therapy (ART) are implemented in resource-constrained settings, the problem becomes not how these programmes are going to be financed but who will be responsible for delivering and sustaining them. Physician-led models of HIV treatment and care that have evolved in industrialized countries are not replicable in settings with a high prevalence of HIV infection and limited access to medical staff. Therefore, models of care need to make better use of available human resources. Using Botswana as an example, we discuss how nurses are underutilized in long-term clinical management of patients requiring ART. We argue that for ART-delivery programmes to be sustainable, nurses will need to provide a level of clinical care for patients receiving this therapy, including prescribing ART and managing common adverse effects. Practicalities involved in scaling up nurse-led models of ART delivery include overcoming political and professional barriers, identifying educational requirements, agreeing on the limitations of nursing practice, developing clear referral pathways between medical and nursing personnel, and developing mechanisms to monitor and supervise practice. Operational research is required to demonstrate that such models are safe, effective and sustainable.