Expanding access to ART in South Africa: the role of nurse-initiated treatment.

The South African government’s recent policy decision to expand access to HIV care rapidly and ‘ensure that all the health institutions in the country are ready to receive and assist patients and not just a few accredited ARV centres’ represents a dramatic and welcome about turn on years of hesitation and confusion in the country’s response to the HIV epidemic. In the first 6 years of the antiretroviral therapy (ART) programme, approximately 900 000 people have been started on treatment. In the next 2 - 3 years, the government proposes to initiate treatment in another 1.2 million people. The medical and moral imperative for providing this life-saving treatment to all who need it does not need to be defended, but the limited capacity of the public health sector to achieve this scale of increase raises serious questions about the practicality of this objective. Along with raising the CD4 thresholds for access to treatment and scrapping the antiretroviral site accreditation process, nurse initiation and management of patients on ART (NIM-ART) is under discussion at the national level as a key strategy for expanding access. There are simply not enough doctors in the public sector to introduce and follow up this number of patients. The major load from this increase will therefore have to be shifted to nurses, themselves under severe pressure and in short supply.