The expansion of HIV services in sub-Saharan Africa (SSA) has been a signature achievement of global public health, facilitated by the ability of Ministries of Health and their partners to deliver complex chronic care in the context of weak health systems with critical workforce shortages [1–3]. The WHO estimates that SSA faces a shortfall of 4.2 million health workers, and that this will worsen to a gap of 6.1 million by 2030 (Fig. 1) .
In response to these shortages in human resources for health (HRH), key enablers of HIV program scale-up have included health workforce adaptations and innovations such as task shifting and the use of multidisciplinary teams . Over time, countries also implemented longer term HRH strategies, and global health donors made substantial investments in preservice education and in-service training . These initiatives were instrumental in enabling health systems to provide antiretroviral treatment (ART) to 19.5 million people living with HIV (PLHIV) by the end of 2017 .
Recognizing the fragility of existing primary health systems, and given the perceived urgency of HIV service delivery, most national HIV programs in SSA were designed as stand-alone initiatives. Moreover, despite similarities between the types of care required for HIV and chronic noncommunicable diseases (NCDs) [8–10], health workforce-related lessons learned from HIV programs are rarely translated or transferred to NCD programs , which have languished during the period of HIV scale-up, due to underinvestment and lack of prioritization [12,13].
In this article, we focus on HRH-related lessons from HIV scale-up, their implications for integrating NCD services into HIV programs, and ways to ensure that healthcare workers (HCW) have the knowledge, skills, resources, and enabling environment they need to provide PLHIV with screening, diagnostic, preventive, and treatment services for NCDs such as diabetes, cardiovascular disease, depression, and cervical cancer. In addition, we note that the development of a truly integrated chronic care platform has the potential to benefit both PLHIV and the general population, strengthening services, and reconceptualizing continuity care for all .
Health workforce lessons from HIV scale-up
There are four broad areas in which HRH lessons from HIV scale-up should inform efforts to integrate NCD services into HIV programs: the use of task shifting and multidisciplinary teams; consideration of work culture; the need for an enabling policy environment; and the importance of HCW capacity building.
Task shifting and multidisciplinary teams
Severe and chronic health workforce shortages required innovative strategies to ensure delivery of HIV services. Most countries in SSA prioritized a public health approach to HIV programing, centered on simplified evidence-based algorithms, streamlined monitoring, and HRH strategies such as task shifting and the use of multidisciplinary teams . More recently, differentiated service delivery models have emphasized the need for ongoing health system innovations, including the engagement of lay health workers [16,17].
Task shifting, defined by Fulton et al. as ‘delegating tasks to existing or new cadres with either less training or narrowly tailored training’, enables the transfer of clinical activities from physicians to nonphysician clinicians (e.g., nurses and clinical officers), community health workers, and laypeople such as peer educators and expert patients . Although not novel to the HIV response, the scaled-up use of this strategy enabled decentralization of HIV services beyond the urban hospitals in which physicians and other specialists were concentrated, markedly improving coverage of HIV prevention and treatment.
Nurse initiated and managed ART (NIMART) is an example of effective HIV task shifting . By changing scopes of practice and enabling nurses to prescribe and manage ART, countries increased the number of clinicians able to provide HIV treatment, while maintaining (or improving) the quality of care. Several studies have shown that nurse-led models have outcomes similar to or better than those achieved by physician-led teams [21–24]. Yet there are limitations to task sharing that should be noted. Task sharing is often adopted faster than policies and programs are able to adapt. At a minimum, HCW working beyond their scope of practice risk taking on new roles without adequate support, mentorship, or means of referral for complex or life-threatening situations. This risk can extend to professional discipline and allegations of malpractice. As task shifting can occur in an environment of great public health need but limited support, future efforts to scale-up task sharing need to address these challenges.
Recognizing the challenges specific to continuity care – including the need to support screening, diagnosis, adherence, retention, linkages, and sustained behavior change – many health systems have prioritized the use of multidisciplinary teams to deliver HIV care and treatment. These vary in function and membership – often including nurses, physicians, counselors, social workers, psychologists, peers, and/or lay workers [25,26]. Differentiated service delivery models for HIV service delivery – including facility-based adherence clubs (group visits), community ART distribution, and community-based ART refill groups – also leverage the benefits of task-shifting and multidisciplinary teams [27,28].
If NCD services are to be integrated into HIV programs, existing multidisciplinary HIV teams will need to add these activities to their portfolios. However, vertical programing and the lack of funding for NCD services have limited the ability of NCD programs to keep pace with the task shifting seen in HIV programs, despite growing evidence of its effectiveness [29–33]. This means that the diverse cadres used to deliver HIV services may not be familiar with NCD screening and management, and that close attention to their scopes of work, training, and supervision will be required.
Accessible, high-quality, chronic care is reliant on a people-centered work culture in which the values and practices of HCW are aligned [34,35]. As noted above, investment in HRH for HIV service expansion in SSA was initially driven by the imperative to rapidly train and deploy large numbers of HCW to deliver HIV services . This investment was a watershed for many countries, as such training newly emphasized continuity care for chronic disease versus curative and episodic services . The combination of substantive material inputs (infrastructure, equipment, drugs and supplies, health information systems), training, and more attentive supervision positively influenced espoused values, motivation, teamwork, and quality of HIV care in many settings [37–39].
However, several analyses demonstrate that in the course of investing in clinical competencies, comparatively little attention was paid to strengthening or reforming existing and deeply entrenched power relationships and social dynamics that continued to shape the decisions and work practices of frontline providers [40–43]. In Zambia, recent studies illustrate that perverse and prevalent work practices such as absenteeism and patient abuse in non-HIV departments at the primary level were unaffected by the much higher standards of care in the more recently established and well resourced HIV clinics, despite providers often shifting between departments . Other studies suggest that gains in the quality or coverage of HIV care came at the expense of other essential HRH functions in some settings [45,46]. The high quality of care achieved in many stand-alone HIV units did not translate or ‘trickle down’ into other areas of service.
An important lesson arising from the experience of HIV scale-up is the need to recognize how intervention strategies are interpreted and operationalized by the network of human actors within health systems. Although a selective or phased approach to training bestowed clear advantages on HCW who received early training, for example, it also led to some viewing themselves as de-facto specialists, unwilling to deliver other sorts of care and further challenging weak accountability mechanisms, whereas others felt overlooked and underappreciated, affecting motivation and service responsiveness .
A thoughtful approach to HIV/NCD integration requires consideration of how adding NCD services to HIV programs will be interpreted by HCW, whose perceptions will play a formative role in the way new roles and responsibilities are accepted by and embedded within routine work practices . Three priority areas to consider are the role of incentives and the need to minimize perceptions of ‘project-driven’ work overload; the structure and content of training opportunities, including the need for a mix of preservice and in-service trainings that incorporate and emphasize cross-clinic team building and accountability, not just technical capacity; and finally the structure of routine evaluation and leadership support for front-line managers to enable them to lead facilities with the rapidly changing responsibilities entailed in the provision of integrated HIV/NCD services.
Health workforce policies
Health workforce policies are important enablers of the approaches to HIV care and treatment described above. Whether adding new cadres, expanding scopes of practice, or task shifting, changes in professional scope of practice have significant implications for the certification, licensure, and legal protection of individual HCWs, and for the accreditation of educational institutions.
Regulatory authorities are legally mandated to clearly define who is qualified to perform certain duties, and to set and maintain practice standards. This is achieved through certification and licensing, establishing curricular standards, accreditation of preservice education programs and in-service training, and ensuring legal protection for HCWs. In practice, the capacity for regulatory reform in response to HIV in SSA was initially varied, with particular weaknesses in addressing scope of practice, licensure examinations, continuing professional development (CPD) systems, and accreditation renewal . Given this variation, strategies to strengthen the regulatory systems drew on a capability maturity model that mapped out context-specific incremental advancements toward appropriate regulatory reform . Lessons learned from these, and other similar strategies to strengthen regulatory systems to address HIV, are transferable to revision of existing policies and regulatory reforms needed to support the integration of NCD services into HIV programs.
At the national level, early engagement of relevant regulatory authorities may be required to support HIV/NCD integration, especially in which a change or expansion in scope of practice is anticipated. In contrast to NIMART, nurses and other clinicians in some SSA countries are currently not permitted to initiate or manage NCD medications, and special permissions may be necessary to alter their scope of practice . Adjustments to the scope of practice may also be necessary for peer educators and community health workers as they take on NCD care functions.
There are additional policy implications associated with changing HCW roles and potentially increasing workload for frontline providers. These include a revision of remuneration and incentive policies to align HCWs’ new level of responsibilities with cadres that have similar responsibilities, and attention to posting and transfer policies to make sure trained HCWs are appropriately posted to and retained in specific service areas at facilities in which they are able to practice to the full extent of their training.
Initial HIV training strategies in SSA were driven by the emergency nature of the HIV response. Rapidly changing clinical guidelines contributed to a large and variable array of short-term, in-service training initiatives, often designed and delivered by implementing partners and nongovernmental organizations in collaboration with ministries of health but not necessarily linked to preservice education or CPD programs, in which these existed. These training courses varied widely in content, approach, and duration, and were often provided off-site, removing scarce clinicians from their practice settings . Although coordination and efficiency suffered, the environment did foster innovation, enabling promising practices to emerge. Over time, more standardized, national training curricula were developed, and country ownership increased .
Lessons were also learned about whom to train. Early efforts focused on existing HCW, rather than investing in the creation of additional HCW through support for preservice education. This strategy was effective in the short term, but was not sustainable. In 2010, the United States President's Emergency Program for AIDS Relief addressed upstream capacity building needs by funding the Medical Education Partnership Initiative (MEPI) and the Nursing Education Partnership Initiative (NEPI) . MEPI partnered 13 African medical schools with US counterparts to strengthen education and research and increase HRH capacity. NEPI focused on improving the quality and quantity of nurses and midwives at 22 nursing schools across 10 countries in SSA (http://nepinetwork.org/).
Key lessons relevant to the integration of HIV and NCD services include the benefits of coordination between the higher education sector, which is responsible for HCW education institutions, and the health sector, which may have more up-to-date knowledge of the skills that HCW need upon graduation. The HIV experience also highlights the importance of competency-based training, structured supervision, streamlined evidence-based treatment algorithms, job aides and routine, structured assessment of provider competence . More recently, the use of mobile/Internet technology to connect more experienced clinicians with less experienced staff is also emerging as a practical way to educate, foster communities of practice and reduce costly off-site training (refer to example in Fig. 2) .
Although the experience of HIV scale-up provides important lessons for the integration of NCD services into HIV programs, many questions remain. Some are specific to the health workforce – such as identifying optimal training models – whereas others are broader but have important implications for HCW training, supervision, and management. Illustrative research questions are highlighted in Table 1.
Successful integration of NCD services into HIV programs will require HCW to refresh and expand their knowledge of NCD diagnosis and management and redefine their role as chronic care providers, rather than HIV specialists. It will also require a public health approach to NCD services that lends itself to ease of training and task shifting, expansion of multidisciplinary teams and referral patterns, diversification of peer educators to include patients with both HIV and NCDs, and integration of NCD-relevant information into paper-based and electronic medical records, monitoring and evaluation systems, laboratory services, and drug procurement and distribution systems.
At the policy level, HIV/NCD integration will need to be supported along the entire service delivery cascade, and the multidisciplinary teams now providing HIV services will need authorization to provide screening, diagnostic, and treatment services for NCDs. This will require changing scopes of practice for some cadres; nurses and medical officers will need to initiate and manage treatment for NCDs, nonlaboratorians will need to provide point-of-care testing for diabetes and high cholesterol, and nonpharmacists will need to dispense and distribute NCD medications. Careful attention to work culture will require expert management of HCW expectations and concerns regarding changes in workload, incentives, and supervision.
In-service training and preservice education will need to address the knowledge and skills needed to manage NCDS, and to emphasize the common competencies of chronic care – including screening, diagnosis, linkage to treatment, appropriate and safe prescribing, support for adherence to medications and retention in care, and ongoing monitoring, counseling and support for sustained behavior change. Developing standardized national curricula linked to licensure and CPD is a priority, as are on-the-job training, effective supervision, and the use of mobile technologies to link frontline HCW with more expert clinicians as needed.
The ultimate goal of HIV/NCD integration should not simply be to provide PLHIV with effective NCD services, but also to leverage the lessons of HIV scale-up to provide high-quality chronic care services to the general population. Integrating NCD prevention and treatment services into stand-alone HIV programs runs the risk of perpetuating a two-tiered system in which PLHIV receive better resourced health services than their HIV-negative peers. Ideally, countries will revisit their primary healthcare programs to design high-quality chronic care services for the general population, inclusive of both infectious and noncommunicable chronic diseases. In some countries, HIV programs may evolve into integrated chronic care programs. In others, the lessons from HIV may inform the development of robust parallel programs for NCDs. Each of these scenarios is dependent on a capacitated health workforce operating effectively within, and supported by the health system, capable of sustainably delivering accessible high-quality HIV and NCD care for all.
M.R. conceptualized and planned the article; all coauthors drafted sections, provided feedback, and reviewed and approved all drafts.
Source of support: this article as part of the Research to Guide Practice: Enhancing HIV/AIDS Platform to Address Non-Communicable Diseases in sub-Saharan Africa was supported by the US National Institutes of Health Fogarty International Center.
Conflicts of interest
There are no conflicts of interest.
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