Nursing Care for HIV - Nursing Management

Authors: Winnifred Moleko, MED (PHC), PDM (HIV), AHM; Sheena Jacob, MSN, MPH
Editors In Chief: Ian M. Sanne, MBBCH, FCP(SA); Stacie Stender, MSN, MSc ID, FNP (More Info)

Last Reviewed: July 8, 2016 (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

Universal access to HIV treatment services can be accomplished by comprehensively strengthening clinical healthcare systems. The South Africa National Department of Health developed National Core Standards for Health Establishments to guide healthcare systems in providing effective healthcare delivery in South Africa, including HIV and TB related services.[NCS 2011] The National Core Standards provide national benchmarks of quality to assist healthcare providers and facilities managers in identifying gaps and improving HIV programmes at healthcare facilities.[NCS 2011] These standards apply to healthcare facilities at all levels, and need to be integrated into the work of all providers, including nurses who are involved in the management of HIV-infected patients. In 2013, the National Health Amendment Act made provision for the establishment of the new independent Office of Health Standards Compliance. This office is mandated to protect and promote the health and safety of health service users through monitoring service performance, enforcing compliance with prescribed standards, and ensuring the investigation and resolution of complaints.

The decentralisation of antiretroviral therapy (ART) management from a predominantly hospital-led service to a service offered through primary levels of care has underlined the importance of effective referrals within South Africa’s district health system. Currently, hospitals have a responsibility to those primary healthcare clinics (PHCs) and community health centres (CHCs) that have referred people living with HIV requiring complex care to them. The development of a strong, clearly understood referral network that allows for the seamless transfer of patients and their medical records between facilities is critical not only to the efficiency of an integrated healthcare system but also to optimise patient outcomes. An intensive national training programme targeting hospital management and district teams across all provinces was conducted from February 2011 to August 2012. The training aimed to orient and secure buy-in and commitment from senior leadership, highlighting the importance of skills development in assessment and remedial action. A focus on teamwork encouraged staff to apply the quality improvement to achieve favourable outcomes for quality of care. 

Comprehensive care of people living with HIV requires a carefully coordinated, patient-centred system in which each facility ensures clients transferred to another level of care receive appropriate, quality care. The overarching aim is to retain people living with HIV (PLHIV) within the healthcare system at the level of specialisation and care that they require. Nurses, as frontline healthcare workers and case managers, play an important role in ensuring continuity of care across facility types within and beyond a given catchment area.

The nurse’s role in management of PLHIV is rapidly evolving. Nurses who have received specialised training have taken the lead in HIV care and are increasingly able to demonstrate higher levels of competencies. This enables nurses to manage a wide array of clinical situations with more independent decision making complementary to the healthcare team to meet the needs of clients. Decentralisation of ART initiation by professional nurses was shown to increase ART uptake and reduce workload at referral facilities, enabling the “higher levels of care” to concentrate on complicated cases.[Nyasulu 2012] Clinical mentorship programmes have helped to increase competence to allow transfer of care from medical officers to nursing staff.[Green 2014]

The public healthcare system in South Africa has established a hierarchy of care that begins at the primary healthcare centre (PHC) level. (Table 1). PHCs are typically run by nurses, with clinical support provided by visiting doctors. The types of services provided include comprehensive preventive, curative, and rehabilitative care. Family planning, chronic illness care, immunisation, mother and child care, and sexually transmitted infection treatment are examples of the types of care provided. Persons needing more specialised diagnostics, care, or treatment, as well as inpatient services can be referred to secondary healthcare facilities (ie, district hospitals). The hospital system in South Africa is divided into three levels: district hospitals (level 1), regional hospitals (level 2), and tertiary hospitals (level 3). Specialised hospitals providing singular specialised care (eg, psychiatric, paediatrics, tuberculosis) are also available.

Table 1. Organisation of the Healthcare System in South Africa

Facility Type

Definition

Care provided

PHC

Point of entry into South African healthcare system; suitable for ambulatory care

  • Clinic

Facility providing a range of PHC services; typically only open 8 hrs/day; 5 days/wk

An essential drug list for PHC has been established that includes medications and supplies that all clinics must keep on hand

  • Primary care, including family planning, antenatal and postnatal care, child health, immunization, TB treatment, HIV care and treatment, and care for acute illnesses 
  • CHC

Facility providing a range of PHC services; and includes up to 30 beds allowing patient observation for up to 48 hrs (but not admission as inpatients)

  • Typically provides 24-hr maternity and emergency services
  • Minor procedures, but not operations (ie, general anaesthesia) can be performed

Hospital services

Facilities providing inpatient and outpatient care, including outpatient departments, specialty clinics, and emergency services

  • District (level 1) hospital

Open 24 hrs/day, 7 days/wk; depending on the size will have no fewer than 50-200 beds, 24-hr emergency service, and operating facilities

Typically staffed with general practitioners and clinical nurse practitioners rather than specialists

  • Offers services that include inpatient and ambulatory services as well as emergency health services
  • Care according to the following clinical disciplines should be provided by generalised staff: family medicine and primary healthcare, internal medicine, obstetrics and gynaecology, psychiatry, rehabilitation, surgery, paediatric health services, and geriatrics
  • Regional/secondary (level 2) hospital

Facilities providing care that requires the intervention of specialists and general practitioners; open 24 hrs/day

The hospitals serve as a platform for training of healthcare workers and research

  • Any hospital that provides a single specialist service is classified as a specialised level 2 hospital; to be classified as a general level 2, the hospital must provide and be staffed permanently in at least 5 of the following 8 basic specialties: surgery, medicine, orthopaedic surgery, paediatrics, obstetrics and gynaecology, psychiatry, diagnostic radiology, and anaesthetics
  • Tertiary (level 3) hospital

Facilities providing specialist and subspecialist care

Specialised and general level 3 hospitals differ according the number and type of specialty care provided

The hospital serves as a platform of training of healthcare workers and research

    • Provincial tertiary (tertiary 1)

Receives patients from, and provides subspecialist support to, regional hospitals

Care provided is primarily that which requires expertise of clinicians working as subspecialists or in rarer specialties

    • National referral (tertiary 2)

Tertiary 1 hospital that also provides a defined range (package) of other specialised services (more advanced specialties)

    • Central referral (tertiary 3)

Facilities providing additional package of subspecialties (hepatology, liver transplantation) including very highly specialised national referral units allowing multispecialty clinical services and research; currently 10 central hospitals in South Africa

Includes multidisciplinary teams, more advanced technology, and high-cost/low-volume services with sustained care of high quality

They also serve as highly specialised referral units for the other hospitals

  • Specialised

Facilities providing care in a single specialised area (eg, psychiatric or tuberculosis) and used for training of healthcare workers and research

This chapter delineates the essentials of nursing management for HIV services that are consistent with the quality of care outlined in the National Core Standards.[OHSC; NCS 2011] The National Core Standards include 7 domains that apply across all levels of healthcare services:

  • Patient rights
  • Patient safety, clinical governance, and care
  • Clinical support services
  • Public health
  • Leadership and corporate governance
  • Operational management
  • Facilities and infrastructure

These domains help to define safe, quality care for South African health establishments. These standards include a subset of 6 priorities that have been identified as specifically important in providing quality healthcare services as listed below and reflected in the following figure (Figure 1):

  • Values and attitudes
  • Waiting times
  • Cleanliness
  • Patient safety
  • Infection prevention and control
  • Availability of medicines and supplies

Figure 1. The 7 domains and the 6 priorities of the National Core Standards.[NCS 2011]

The 7 domains provide nurses with a framework to understand the healthcare system to provide quality, comprehensive, integrated HIV and ART services at the various levels of care. The remainder of this chapter describes the key nursing functions that are specific to HIV service delivery related to each domain of the National Core Standards.

In addition, the 2015 South Africa National Department of Health HIV Treatment Guidelines outline the following guiding principles for delivery of HIV care (Management Guidelines)[ZA NDOH HIV Tx 2015]:

  • Increasing effectiveness and efficiency of programmes
  • Managing HIV as a chronic health condition
  • Strengthening integration of services
  • Promoting human rights and health equity
  • Promoting a family approach to HIV care

Each of these principles involves the nurse to ensure that these are met. 

For more information on the role of the nurse in the clinical management of HIV, including nurse-prescribing as delineated by the Nurse-Initiated Management of Antiretroviral Treatment plan, click here.

Case Vignette 1