Nursing Care for HIV - Nurse-Initiated Management of ART

Authors: Suzanne Jed, MSN, FNP-BC; Talitha Crowley, MCur, PGDip Primary Health Care, PGDip Nursing Ed, BCur
Editor In Chief: Stacie Stender, MSN, MSc ID, FNP (More Info)

Last Reviewed: September 10, 2017 (What's New)

Credit Information

inPractice® Africa’s Continuing Education Unit (CEU) provider, the South African Medical Association, does not offer CPD points for this individual module, but all participants who complete the module with a 70% pass rate will receive a participation certificate. To learn more on CPD credits and participation certificates, click here.

Introduction: Nurse-Initiated Management of Antiretroviral Therapy

  • Implementation of nurse-initiated management of antiretroviral therapy (NIMART) has improved access to antiretroviral therapy (ART)
  • Nurses have an essential role in the management and treatment of people living with HIV[Iwu 2014]
    • A recent randomised, controlled trial in South Africa reported on expanding primary care nurses’ roles to include ART initiation and represcription
      • These changes can be implemented safely
      • This will improve health outcomes and quality of care[Fairall 2012]
    • Another randomised noninferiority trial of 812 patients showed nurse-monitored ART is noninferior to doctor-monitored therapy[Sanne 2010]
    • More recently, patients who are stable on ART have been referred to decentralised care at community adherence clubs with care by nurses or community health workers[Campion 2015; Kredo 2013; Kredo 2014]
      • A study of one of these clubs in Cape Town demonstrated a 94% retention in care rate at 1 year with a 67% decrease in loss to follow-up when compared with similar clients of health centres[Grimsrud 2016]
      • A 2016 circular from the South Africa National Department of Health recommend decentralised care for those patients with stable chronic disease who have demonstrated good adherence to care and to their medicines (Management Guidelines)[ZA NDOH UTT 2017]
    • NIMART is acceptable among nurses, patients, and physicians
    • Nurses can develop confidence in their ability to deliver HIV care and treatment services successfully if they receive adequate training and support[Georgeu 2012]

Relationship Between the NIMART Nurse and the HIV-Positive Patient

  • Nurses initiating antiretroviral therapy (ART) can facilitate treatment success in several key ways

1. Encouraging testing. Late diagnosis can lead to unnecessary morbidity and mortality

  • Universal testing of all patients in clinical care and ART for all patients diagnosed with HIV infection is now recommended by the South Africa National Department of Health (Management Guidelines)[ZA NDOH UTT 2017]
  • World Health Organisation guidelines now have also recommended universal testing and rapid ART initiation (within 7 days, or on the same day as diagnosis in those ready to start) in all patients diagnosed with HIV infection (Management Guidelines)[WHO Rapid Init 2017]
  • These recommendations were based on a series of studies completed in patients with HIV infection
    • Several studies had shown that people living with HIV failed to seek care until they were already in the late stages of disease, with CD4+ cell counts < 200 cells/mm3[Bassett 2010; Katz 2011]
    • Early ART in HIV-infected adults with a CD4+ cell count between 200 and 350 cells/mm3 decreased mortality by 75% when compared with patients who initiated ART with CD4+ cell counts < 200 cells/mm3[Severe 2010]
    • Other cohort studies have also demonstrated a decrease in mortality in patients who started ART at higher CD4+ cell counts (> 350 cells/mm³ and > 500 cells/mm³) when compared with those who delayed ART to lower CD4+ cell count levels[Kitahata 2009; Sterne 2009; May 2007]
    • Two large, randomized clinical trials (START and TEMPRANO) demonstrated individual clinical benefit in those patients who start ART at CD4+ cell counts > 500 cells/mm3 rather than deferring to a lower CD4+ cell count or clinical indication[INSIGHT 2015; TEMPRANO 2015]
    • A meta-analysis of 4 randomized trials of same-day ART vs standard of care demonstrated increased numbers of persons starting ART, increased viral suppression, decreased loss to follow-up, and a trend toward decreased mortality and late return[Calmy 2017]
    • Finally, in the randomized clinical trial HPTN 052, risk of transmission of HIV was decreased in those with initiation of ART between 350-550 cells/ mm³ vs those who delayed ART to < 250 cells/mm³ or exhibited clinical symptoms[Cohen 2011]
    • Assisting patients in overcoming barriers to initiating treatment in earlier stages of infection, as currently recommended, is vital to their health and well-being

2. Encouraging patients to remain adherent to their regimens and to clinic appointments

  • Preventive care in addition to ART should include (Management Guidelines)[ZA NDOH HIV Tx 2015]
    • Appropriate patient histories and physical exams
    • Screening for tuberculosis, sexually transmitted infections, and opportunistic infections
    • Screening for noncommunicable diseases, such as diabetes
    • Routine CD4+ cell count testing and clinical staging
    • Provision of isoniazid preventive therapy and cotrimoxazole preventive therapy as recommended
    • Appropriate immunizations
    • For women, routine and regular gynaecologic care, including Pap smears, planning for conception or contraception
    • Counselling to avoid risk of transmission
    • Support for disclosure
  • Patients who are tested early but who opt not to receive ART at diagnosis may fail to return until in the late stages of disease
    • These patients should be encouraged to enroll in the Wellness Programme to facilitate follow-up and retention in care[ZA NDOH HIV Tx 2015]
    • Continuous counseling on the importance of early treatment and scheduled CD4+ cell count monitoring guidelines should continue

3. Once receiving treatment, it is important that patients stay in care and are not lost to follow-up

  • Routine follow-up helps to ensure
    • Continued effectiveness of treatment
    • Medication adherence
    • Prevention of resistance
    • Prevention or prudent management of adverse effects, drug–drug interactions, and toxicities
  • Routine healthcare maintenance should also be emphasized