Task-Shifting Can Be Part of the Answer to ART Access—If the Numbers of Lower Level Health Workers Expand Fast Enough

There has been a great deal of discussion at this week’s IAS Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa of four expensive directions for proposed expansion of access to antiretroviral treatment for AIDS patients in poor countries (ART):

1. ART as entitlement: Meeting commitments to treat those currently entitled by virtue of having been previously granted access to ART;
2. Expanding ART access: Doubling or tripling access to ART so as to provide it to those meeting existing treatment criteria;
3. Earlier ART initiation: Expanding treatment access to those with CD4 counts between 200 and 350. (The referenced journal article on South Africa is here.)
4. ART as HIV prevention: There has even been discussion of the possibility of expanding ART a great deal further, providing it immediately to people as soon as they become HIV infected in hopes of preventing transmission to others. (The original 2008 Lancet article is here and first author’s admirably clear and informative presentation of this idea at the IAS can be downloaded here.)

The financial crisis and the prospect of a slowing rate of increase of ART financing clearly threatens all four of these expensive ambitions. In the entitlement dimension, donors are allegedly slowing the rate at which they commit/obligate and disburse AIDS treatment funding which threatens existing patients as well as new enrollment. Virtually every plenary session at the IAS regretted failure to meet all existing need at the expanding access edge. At least one observer doubted the wisdom of pushing for earlier ART initiation when so many more desperately ill were still untreated. Regarding the “ART as prevention edge,” I saw little reference on-line to the skeptical views expressed by Geoff Garnett and Rebecca Baggaley or those of Ruark et al.Even if estimates of resources saved through earlier treatment are correct and these savings might eventually fund broader ART coverage over the longer term, earlier access and wider access are clearly in direct conflict in the short or even in the medium run. This is why conference organizers opened with an appeal for more – much more – AIDS resources.In contrast, the movement towards “task shifting” of treatment tasks from higher to lower level health care personnel and facilities holds out the hope of increasing the productivity of existing health care personnel and institutions, so that whatever resources are available could expand coverage in both dimensions – to more people and to earlier initiation for each person.The open question has been whether treatment quality would decline with task shifting and if so, by how much. One argument against shifting has been the perceived need for patients to be periodically tested by complex lab procedures, which could only be performed in higher level facilities and interpreted by higher level personnel. So the findings of the DART Trial reported in Cape town are relevant. In a presentation entitled “Cost effectiveness analysis of routine laboratory or clinically driven strategies - DART trial”, the DART Team made the case that the periodic laboratory testing that has been an argument for requiring ART patients to periodically visit higher level health facilities has only marginal health benefits despite its substantial costs. So this suggests that this lab-test constraint on task shifting could be relaxed at little health risk. Reducing the frequencies of these tests will itself release some financial resources. In fact, one of the DART researchers, James Hakim, claims that “a third more people could be successfully treated for HIV in Africa if expensive lab tests weren't used routinely”.But the question remains whether, at any given level of laboratory use, task shifting by itself would produce worse health outcomes. It has been known for decades that properly trained lower and intermediate level health care personnel can perform routine health maintenance tasks, such as well-child checkups, more reliably and thus with higher quality than physicians. The accepted explanation is that doctors’ training selects individuals who get rewards from solving challenging diagnostic puzzles and therefore get bored more easily with routine health maintenance and screening tasks, while lower level personnel can be trained to expect rewards from the individualized empathetic emotional support they provide during these otherwise routine health maintenance encounters. Some ongoing studies are testing this hypothesis in the context of ART maintenance. If the DART results on the small benefits of laboratory testing prove generalizable and if the tests of task shifting show either quality improvements or only small quality reductions, the way will be cleared towards this important approach to improving ART productivity, thereby freeing resources which could be used to expand access to ART.However, if we assume that lower-level personnel are already fully employed, we cannot shift more tasks onto them without an expansion of their numbers. Operations research such as work I contributed to in the 1970s can estimate how many additional hours of lower level personnel time are required to substitute for an hour of physician’s time in order to maintain quality. Such analysis must take into account that higher salaries for low level personnel can attract back workers who have left the field, but the longer run solution to the health worker crisis will require improving the incentives for work in the lower level health care professions, while offering avenues for training. Unfortunately there is no quick fix. The provisions to train and retain 140,000 new health workers in recipient countries contained in PEPFAR’s reauthorization (Sec 101.4.J) offer part of the solution as would a promise to gradually expand the number of US and EU visas available for well-trained foreign health workers. And I believe US creation of a Global Health Corps would also help.Look for a report on HIV/AIDS funding and health workforce development from CGD’s HIV/AIDS Monitor team in the near future.