AIDSImpact.com:: - Santa Fe, USA 2011

Abstract #166 - The impact of task-shifting to nurses on psychosocial outcomes among HIV-infected patients initiating antiretroviral therapy in rural district hospitals in Cameroon (STRATALL, ANRS 12-110/ESTHER)
Authors: Presenting Author: PhD Sylvie Boyer - INSERM
Additional Authors: Dr. Charles Kouanfack, Ms. Jerôme Blanche, Dr. Marie Suzan, Prof. Eric Delaporte, Dr. Patrizia Carrieri, Prof. Jean-Paul Moatti, Dr. Christian Laurent, Dr. Bruno Spire,
Aim: The scaling-up of ART in resource-limited settings is being hampered by human resource shortages. While task-shifting of follow-up consultations from physicians to nurses has been found to be a worthwhile strategy in achieving favorable treatment outcomes, its effect on psychosocial outcomes has been hitherto insufficiently explored. This study aims to investigate how psychosocial outcomes are influenced by task-shifting to nurses using longitudinal data from the STRATALL trial in Cameroon.
Method / Issue: STRATALL is a 24-months, randomized, open-label trial which have enrolled, from 2006-2008, 459 HIV-infected ART-naive adults in 9 rural district hospitals in Cameroon. The trial was designed to compare the effectiveness of a clinical monitoring versus a clinical plus laboratory monitoring (viral load+CD4). In the clinical group, partial task-shifting to nurses was also implemented. Besides clinical data, psychosocial and behavioral data were collected through face-to-face questionnaires administered at enrolment (M0) and at follow-up visits (M1, M3, M6, M12, M18, M24). Generalized Estimating Equations (GEEs) regression models were used to assess the impact of task-shifting to nurses on the following psychosocial outcomes: the number of self-reported disease symptoms (assessed using the HIV-symptoms index developed by Justice and al.), depression (assessed using the CESD scale), adherence to ART (assessed using a previously validated scale), and self-reported quality of life (HRQL) (assessed using the WHO-OQL which enables the computation of four sub-scores related to physical health, mental health, social relationships and environment). Each model was adjusted for gender, age, time of the follow-up visits, measure of outcomes at baseline, time since HIV diagnosis, clinical stage of the disease, treatment switching, CD4 cells count and finally, occurrence of adverse events.
Results / Comments: Analyses were conducted for the population having available data at baseline and at least at one follow-up visit (n=393-408 depending on the outcomes). Seventy-one percent of patients were females with a median[IQR] age of 36[30-44] years and median[IQR] CD4 cells count of 188[88-347] cells/µl at enrolment. Most of the psychosocial outcomes improved between enrolment and M24: respective medians[IQR] were 11[7;15] versus 3[1;6] for the number of self-reported symptoms; 22[16;29] versus 12[7;21] for the depression score; 38[19-56] versus 69[50;81] for physical health; 50[31;56] versus 56[44-69] for mental health and 38[25-50] versus 44[31-56] for the HRQL environment dimension. However, the HRQL social dimension remained stable between M0 and M24 (median[IQR]=44[25-56] versus 44[25-69], respectively) while the proportion of highly adherent patients decreased between M1 and M24 (69.8% versus 58.7%, respectively). Over the whole follow-up, 839 (33.5%) visits were task-shifted to nurses. After multiple adjustment, patients whose visits were task-shifted to nurses were found to have improved physical and mental health (coefficients[95%CI]=4.24[2.00-6.48] and 3.26[1.12-5.40], respectively), less self-reported symptoms (IRR[95%CI]=0.89[0.81-0.99] and a lower depression score (coefficient[95%CI]=-1.07[-1.89;-0.25]. However, no significant association was found between task shifting to nurses and adherence or with the social and environmental dimensions of HRQL.
Discussion: This study confirms the positive impact of ART on psychosocial outcomes. It also provides evidence that task-shifting to nurses may be mobilized to sustain these favorable outcomes when human resources for healthcare are limited.
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