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Task Shifting HIV Care in Rural District Hospitals in Cameroon: Evidence of Comparable Antiretroviral Treatment-Related Outcomes Between Nurses and Physicians in the Stratall ANRS/ESTHER Trial

Boullé, Charlotte MSc*; Kouanfack, Charles MD, PhD; Laborde-Balen, Gabrièle MSc; Carrieri, Maria Patrizia PhD§,‖,¶; Dontsop, Marlise MD, MSc; Boyer, Sylvie PhD§,‖,¶; Aghokeng, Avelin Fobang PhD#; Spire, Bruno MD, PhD§,‖,¶; Koulla-Shiro, Sinata MD†,**; Delaporte, Eric MD, PhD*,††; Laurent, Christian PhD*for the Stratall ANRSESTHER Study Group

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 15th, 2013 - Volume 62 - Issue 5 - p 569–576
doi: 10.1097/QAI.0b013e318285f7b6
Epidemiology and Prevention

Background: Task shifting to nurses for antiretroviral therapy (ART) is promoted by the World Health Organization to compensate for the severe shortage of physicians in Africa. We assessed the effectiveness of task shifting from physicians to nurses in rural district hospitals in Cameroon.

Methods: We performed a cohort study using data from the Stratall trial, designed to assess monitoring strategies in 2006–2010. ART-naive patients were followed up for 24 months after treatment initiation. Clinical visits were performed by nurses or physicians. We assessed the associations between the consultant ratio (ie, the ratio of the number of nurse-led visits to the number of physician-led visits) and HIV virological success, CD4 recovery, mortality, and disease progression to death or to the World Health Organization clinical stage 4 in multivariate analyses.

Results: Of the 4141 clinical visits performed in 459 patients (70.6% female, median age 37 years), a quarter was task shifted to nurses. The consultant ratio was not significantly associated with virological success [odds ratio 1.00, 95% confidence interval (CI): 0.59 to 1.72, P = 0.990], CD4 recovery (coefficient −3.6, 95% CI: −35.6; 28.5, P = 0.827), mortality (time ratio 1.39, 95% CI: 0.27 to 7.06, P = 0.693), or disease progression (time ratio 1.60, 95% CI: 0.35 to 7.37, P = 0.543).

Conclusions: This study brings important evidence about the comparability of ART-related outcomes between HIV models of care based on physicians or nurses in resource-limited settings. Investing in nursing resources for the management of noncomplex patients should help reduce costs and patient waiting lists while freeing up physician time for the management of complex cases, for mentoring and supervision activities, and for other health interventions.

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*UMI 233, Institut de Recherche pour le Développement (IRD), University Montpellier 1, Montpellier, France;

Day Care Unit, Central Hospital, Yaoundé, Cameroon;

French Ministry of Foreign Affairs, Yaoundé, Cameroon;

§INSERM, UMR912 (SESSTIM), Marseille, France;

Aix Marseille Université, UMR_S912, IRD, Marseille, France;

ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Marseille, France;

#Virology Laboratory IMPM/CREMER/IRD (UMI 233), Yaoundé, Cameroon;

**University of Yaoundé 1, UMI 233, Yaoundé, Cameroon; and

††Department of Infectious and Tropical Diseases, University Hospital, Montpellier, France.

Correspondence to: Christian Laurent, PhD, Institut de Recherche pour le Développement (UMI 233), 911 Avenue Agropolis, BP 64501, 34394 Montpellier Cedex 5, France (e-mail:

The Stratall ANRS/ESTHER Study Group members are listed in the Appendix.

Supported by grants from the French National Agency for Research on AIDS and Viral Hepatitis (ANRS 12110) and Ensemble pour une Solidarité Thérapeutique Hospitalière En Réseau (ESTHER).

The authors have no conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received September 20, 2012

Accepted December 10, 2012

© 2013 Lippincott Williams & Wilkins, Inc.