The Role of the Nurse in HIV Treatment and Care

Susan Yox, RN, EdD; Jason E. Farley, PhD, MPH, CRNP

Disclosures

August 09, 2012

Editor's Note:
At AIDS 2012: XIX International AIDS Conference in Washington, DC, Jason E. Farley, PhD, MPH, NP, spoke at the session Nurse Models of HIV Care and Treatment: Addressing Health Workforce Shortages for Long-Term Sustainability. Susan Yox, RN, EdD, of Medscape sat down with Dr. Farley the following day to discuss the role of and opportunities for nurses in HIV/AIDS care over the past 30 years and going forward.

Medscape: The history of HIV care may offer a great illustration of the role of nurses, packed into a 30-year timeframe, highlighting what nurses can do in care provision and expanded roles. Would you talk a little bit about the nurse's role in HIV testing, treatment, and care over the years?

Jason Farley, PhD, MPH, NP

Dr. Farley: Nursing has been directly involved in the HIV/AIDS pandemic since day 1. Before antiretroviral therapy was available, nurses mobilized in various cities to care for patients in hospital units and in their homes. They formed groups to come together to provide information and education to other nurses, and nurses were instrumental in making sure that in the beginning -- when care was all we had to give -- that it was provided.

Just like antiretroviral therapy has changed the face of AIDS and changed how HIV is viewed globally, nursing, as a result of this disease, has been changed. The way people view nursing globally has also changed.

I believe that the true spirit of care has never left the profession, but we have also taken on a new expanded role, and an expanded scope as frontline care providers -- those who are providing antiretroviral therapy. And nowhere is that more visible than in countries in sub-Saharan Africa. In my work in Africa, we are directly involved with training of nurses, which in turn expands access to care. This provides life-saving access to antiretroviral therapy in rural remote areas, where there are no physicians. In areas where there may be a physician, the physician provides oversight.

So, I think we've seen nurses go from providing essential supportive care to leading clinical treatment. Now, nurses are becoming the mainstay of antiretroviral treatment programs globally.

Medscape: That leads me to the next question about the role of task-shifting or task-sharing, encouraging professionals to practice at the full extent of their license. Would you talk a little bit about these concepts?

Dr. Farley: My perspective, and the perspective of the Association of Nurses in AIDS Care (ANAC), is that the term "task-shifting" was our original call to action, in terms of providing nurses with an expanded scope of practice. We now believe that the vernacular needs to change from "task-shifting" to "task-sharing."

In global HIV care, nurses are not looking to prescribe medications without having ongoing referral options, interdisciplinary communication, and support by collaborating physicians. A better term for this mode of practice is "task-sharing," where nurses can and do prescribe antiretroviral medications, but they do so in collaboration with, and with the support of, their physician colleagues.

In the United States, the terms "task-sharing" and "task-shifting" don't really apply, because since the 1960s the nurse practitioner and other advanced practice nurses have clearly demonstrated equivalent outcomes with those of physicians and physician assistants, in terms of treatment. Several studies of HIV care demonstrated equivalent treatment outcomes, as well as improved quality measures, when advanced practice nurses are involved in the patient's care.[1]

Medscape: At this International AIDS Society (IAS) meeting, we have certainly heard a lot about the role of the nurse-midwife in providing HIV care around the world. And here in Washington, DC, the decrease in mother-to-child transmission has been attributed in part to nurse-midwives. Would you comment on the role of nurse-midwives in HIV care?

Dr. Farley: Absolutely. In DC, it was noted by the mayor here at IAS that we've not had a single case of a child born with HIV since 2009. That was accomplished in part by the nurse-midwifery program in DC that tracks pregnant women with HIV and follows them to ensure that they have access to care and provides safe childbirthing practices.

Globally, the nurse and the midwife are oftentimes inextricably linked. People can be trained as both, so you are a nurse and a midwife together. When we talk about nursing and midwifery, we tend to separate the 2 in the United States, but globally it's oftentimes one and the same person.

In addition, in some countries, the term "midwife" is often used to describe a frontline care provider, particularly in Southeast Asia. For example, in Myanmar, they call the frontline care provider a midwife, even though this person may have very little to do with maternal child health and is more involved in such areas as immunizations. So our terms are not necessarily congruent. What is vitally important, though, is to realize that nurses represent 90% of the healthcare workforce worldwide.

Medscape: Tell me a little about your own professional background. How did become interested in infectious diseases and HIV as a nurse practitioner (NP)? I believe that these not common specialties for NPs. And how did you get involved doing research in South Africa?

Dr. Farley: My decision to go into HIV care started because I grew up in rural Alabama, and what I heard from my church, my peers, and from everyone there was that if you were in certain subgroups, such as injection-drug users or men who have sex with men, you acquired AIDS as a curse from God. That felt wrong to me in my heart of hearts, and I began to explore this in college.

I worked with a student organization called Students for the Education and Prevention of AIDS, on the University of Alabama campus. We brought together the faith community and a lot of different groups. We provided high-school outreach and education about HIV in rural Alabama, and volunteered to provide transport for patients to get to Birmingham to the HIV clinic. That galvanized me as a young adult.

When I moved into care and evaluation at a public health level, finishing a Masters in Public Health at the University of Alabama at Birmingham with infectious disease epidemiology as a specialty, I worked with HIV leaders Michael S. Saag and then Dr. Jim Raper, the lead NP there. That was when I realized the potential for what NPs could do. Susan Gaskins, DSN, ACRN, was another leader at the University of Alabama, and she taught my very first HIV course in nursing school in the early 1990s, before we had highly active antiretroviral therapy -- when it was all about providing quality nursing care.

Before getting involved in infectious diseases and HIV, I was a registered nurse and had worked in psychiatry/mental health. When I finished the NP program and got a job at Johns Hopkins in the Moore Clinic for HIV Care, I was surrounded by some of the world's leading experts in HIV. Being able to learn from these experts, such as John Bartlett, Joel Gallant, and others like them, has been phenomenal.

My particular interest is co-infections in patients with HIV. My research focuses on drug-resistant bacterial infections in patients with HIV. In South Africa, I study multidrug-resistant tuberculosis (MDR-TB). And in the United States, I recently received funding for a study evaluating methicillin-resistant Staphylococcus aureus in patients with HIV.

Medscape: I'm guessing those studies involve nursing interventions at some level?

Dr. Farley: Yes. In South Africa, there are 2 different ongoing studies. We just completed a pilot evaluation of a nurse case management model for patients with MDR-TB and HIV that is under evaluation for funding at the National Institutes of Health.

The second study is a nurse-initiation program for MDR-TB. We know that nurses can do and manage HIV treatment, and we know that nurses manage TB treatment. But drug-resistant TB has continually been the frontier of physicians only, and changing that to increase access to care is our focus. We're going back in August to expand nursing training, supplementing our efforts throughout the Ugu district of Kwa-Zulu Natal, South Africa.

Medscape: In your presentation, you mentioned that it is your belief that the IAS meeting does not emphasize nurses and the nursing role often or loudly enough. Here is an opportunity to talk to our readers about that concern.

Dr. Farley: Obviously, I have a perspective that nursing is exceptionally important at all levels in providing HIV care, both in the United States and internationally. What I find with conferences that are typically biomedically based is that they tend to ignore a variety of psychosocial issues. Meetings tend to ignore operational evaluation and implementation research as well. This conference is trying to do a little more in both areas. But I do believe that the meeting basically ignores the unique contributions and roles of nurses. We've had to work to get inclusion in a variety of activities.

The first example is that when the Washington D.C. Declaration to end the AIDS epidemic was published, it did not include nursing in any way. Signers were asked to indicate their profession, and nursing was not originally included. That oversight was exceptionally invigorating for ANAC members. We contacted organizers of the conference, and nurses have now been added, along with patients, advocates, social workers, and a variety of others, to the DC Declaration.

Why were nurses omitted? The response was, "Oh, we didn't think about that." My response to that is, "You can't have the discipline that provides the majority of HIV care in the world as an afterthought! That is no longer appropriate." So we sincerely thanked the organizers, such as Chris Beyrer, MD, MPH, from IAS, who assisted us in making that change. We also need to give special thanks to Ambassador Eric Goosby, MD, for his special recognition of nurses at this meeting. We believe that Ambassador Goosby is a true champion for nursing.

Medscape: Some readers may not be familiar with the nursing specialty organization you have mentioned, ANAC. Would you describe the organization?

Dr. Farley: The Association of Nurses in AIDS Care was founded 25 years ago to facilitate and support nursing care and research for HIV and AIDS. It has a variety of specialty committees. For example, a policy group looks at issues facing nursing in particular. One of our key policy position statements is about the criminalization of HIV.

Our members serve as experts on such panels as the US President's Emergency Plan for AIDS Relief (PEPFAR) and on committees for the Health Resources and Services Administration, for example. One of ANAC's key missions is to give nursing in AIDS care a voice and a seat at the table.

Medscape: Perhaps ANAC should be one of the coordinating partners of future IAS meetings?

Dr. Farley: That would be a dream come true for our organization. I'm a co-chair of our Global Specialty Committee, along with Pat Daoust and Emelia Iwu, and one of our main agenda items is more inclusion of nurses in IAS, with a focus on describing and evaluating the economic cost/benefit analysis of nursing and nursing care, particularly when nurses provide antiretroviral therapy. For example, what are those outcomes, and what do they look like when you galvanize and provide services through a nurse-run clinic, particularly in sub-Saharan Africa and other parts of the world? What proportion of the funds that are provided through PEPFAR and used to place patients on antiretrovirals are provided by nurses?

Medscape: I'd like to close by asking you to elaborate on your comment in an earlier session, where you said that it's "a great time to be a nurse."

Dr. Farley: Looking at a global perspective, I think many countries are seeing the barriers to comprehensive scope of practice fall. There is certainly a glass ceiling for nursing in terms of scope of practice, but we are seeing cracks in the glass ceiling globally. In South Africa, for example, the national strategic plan of the country calls for all primary care clinics in the country to be nurse-initiated MDR-TB and HIV treatment sites.

In the United States, patients are being treated, evaluated, and managed by NPs and nurses in AIDS clinics. Case management services and inpatient services are provided by dedicated nurses as well. And we're seeing patient outcomes improve. We're seeing decreased patient admissions. We're seeing a lot of patients increasing their access to antiretroviral therapy, because nurses are oftentimes more willing to work in rural areas in this country.

What we need now in the United States is to focus on places like those where I'm from, in Alabama, or Mississippi, or Georgia, where the epidemics seems to be concentrated in rural African American populations. We need practice barriers to come down, just like we need them to come down in sub-Saharan Africa, where NPs are often limited in their ability to practice because of scope of practice restrictions.

The reason I say it's a great time to be a nurse is partially because of the recent Institute of Medicine report, The Future of Nursing, which says that nurses are leading healthcare, that scope-of-practice barriers should be eliminated, and that nurses should practice to the fullest extent of their training and education and pursue advanced practice and education.

In terms of HIV management, I think it's a great time to be a nurse, because we are seeing the successes of what nurses can do in terms of increasing access to care, quality, and safety, all in a cost-effective manner.

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