HIV This Week

Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, Dybul M. Rapid expansion of the health workforce in response to the HIV epidemic. N Engl J Med. 2007; 357(24):2510-4.

The World Health Organization (WHO) estimates that there is now a global deficit of more than 4 million trained health workers. The shortages in health workers are critical in 57 countries, mostly in sub-Saharan Africa and parts of Asia. The situation is further exacerbated by the direct effect of the human immunodeficiency virus (HIV) on health workers in resource-constrained countries in which the disease is epidemic. Poor working conditions and low pay conspire with the risks of occupational transmission and the stress of working in communities devastated by the HIV epidemic to drive up rates of attrition. In countries with the highest rate of HIV, leading causes of attrition are the morbidity and mortality caused by HIV itself. In Botswana, 17% of the health workers died from diseases related to AIDS from 1999 to 2005. The “Treat, Train, Retrain” global effort aims to prevent HIV among health workers and to treat those who are infected, to expand the workforce by training new people and by making more efficient use of the current pool of human resources for health, and to retain skilled staff. Possibly the most challenging imperative to expand the health workforce is the need for “task shifting”, the process of delegation in which tasks are moved, where appropriate, from more to less specialized health workers. Reorganizing the force in this way allows more efficient use of available human resources and quickly expands the overall human resource pool. Although such programs are in their early days, there is evidence of success. In South Africa, care models that shift many medical tasks to nurses were found to be feasible, acceptable to patients, and potentially more affordable. After 6 months of follow-up, outcomes such as virologic suppression, adherence, and retention of patients at sites with doctors were similar to those at sites without doctors where there was adequate supervision. The process of delegation can further extended from health professionals to community members. Adopting new models for the delivery of health services requires political and financial commitment. Governments, as well as international and bilateral agencies, will need to recognize and allow systems that train and deploy nonphysicians, including community-level workers and patients living with HIV in health care delivery. Although research is needed in these areas, sufficient data are already available to support a prompt scale-up of HIV prevention, care, and treatment through task shifting to save as many lives as quickly as possible.

Editors’ note: Although the term “task shifting” is new, the experience of task substitution has been documented since the 1970s in a variety of settings, often as a measure to enhance quality and reduce cost rather than as an emerging response to scarcity. Task shifting works best when standardized protocols, appropriate training, ongoing supervisory support, and a meaningful career pathway support it.