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PEPFAR Implementation: Progress and Promise
One aspect of retention that is not emphasized in PEPFAR’s workforce strategy is the need to protect health workers from exposure to HIV and to identify and treat those who are exposed or infected. Postexposure prophylaxis is established policy in many countries but does not appear to be used frequently. There are few specific counseling and testing campaigns for health workers, some of whom express concern about being tested because of the lack of privacy. All of the relevant policies are currently present in PEPFAR’s prevention and treatment strategy but are not consolidated in a manner that would enable the development of an effective approach for health workers. This important issue requires greater emphasis since in some countries, as many as 25 percent of all workers may be presumed to be infected, and losses to HIV are increasingly frequent.
Improvements in efficiency through task shifting A mainstay of PEPFAR policy, also endorsed by WHO, is task shifting from scarce workers to those who are more generally available (Gilks et al., 2006). The term is somewhat confusing in that it covers everything from the full delegation of responsibility for treatment to clinical officers and/or nurses to the training of lay counselors to offer counseling and testing and of community workers to support adherence. One approach is WHO’s integrated management of adult, adolescent, and childhood illness, which promotes the shifting of responsibility for follow-up of stable patients to clinical teams at primary care facilities (WHO, 2004b). These teams are expected to be able to treat nonsevere opportunistic infections, manage ART, undertake simple clinical decision making, and promote prevention of transmission in areas where the HIV burden is high (Gilks et al., 2006). In many settings, such responsibilities can be assumed without changes in existing standards for the practice of nurses or clinical officers.
Another, more radical approach has been demonstrated in Zambia and Malawi (Harries et al., 2006; Stringer et al., 2006), where specially trained clinical officers and nurses are responsible for the complete management of ART. Other areas in which adaptation of practice rules and shifting of tasks are needed include requirements that only pharmacists or pharmacy technicians may dispense ARVs.
Recently, the Ministry of Health in Mozambique removed the requirement that only physicians may prescribe ARVs, so that prescribing may be done by other health professionals with appropriate, targeted training. Similarly, Kenya and Ethiopia now allow clinical officers to prescribe ARVs. Rwanda has adopted a pilot program that allows nurses to prescribe ARVs and now permits trained nurses to provide follow-up to patients on ART. In Uganda, lay people, many of them people living with HIV/AIDS, have been trained to provide basic nursing care; supply refills of medications