In 2018, the USAID Health Finance and Governance (HFG) project supported the Ivoirian Ministry of Health and Public Hygiene (MHPH) to conduct an impact study on the implementation of nurse-initiated ART.  As a first step towards this intervention, the government of Cote d’Ivoire approved HIV task sharing for nurses and midwives in 2015 and mandated its inclusion in pre-service training to strengthen its efforts to meet the 90-90-90 UNAIDS objectives. In order to accelerate the number of nurses and midwives practicing task sharing, the MHPH trained a cohort of newly graduated nurses and midwives not yet placed in public health facilities in 2015-2016. Without this approach, the country might have had to wait as long as three years—the total number of years to earn a nursing or midwifery degree–for the first class of nurses and midwives to graduate with HIV care and treatment competencies. After the training period, the MHPH recruited and placed more than 200 of these nurses and midwives at public health facilities in eight health districts with a high HIV/AIDS prevalence: Korhogo, Bouake-North-West and South Bouake, Man, Daloa, San Pedro, Gagnoa, Issia and Bouafle.

The impact study sought to understand the extent to which the placed nurses and midwives were practicing task sharing, and capture information about these health workers’ satisfaction on the job and challenges encountered. The study took a representative sample of 80 nurses and midwives from across the eight health districts out of 218 known to be placed in units providing HIV/AIDS care and treatment as part of some or all of their services. Health Directors at each of the health districts were also interviewed on their knowledge and attitude toward implementation of task-sharing in their district. Fifty-one women and 29 men were interviewed, of which 41 were nurses and 39 midwives. Most of the nurses and midwives interviewed were posted at the primary care level (65%). The remaining participants practiced at secondary or tertiary referral hospitals (29% and 6% respectively). Investigators reached the study participants by phone and interviewed them according to a structured interviewed tool.

Key findings of the study include:

• A majority of nurses and midwives sampled reported practicing task sharing interventions, including prescribing first-line ART (78%) and renewing first-line ART prescriptions (59%).
• The proportion of nurses and midwives carrying out task sharing activities varied depending on the facility level. For example, 92% of respondents at the primary care level reported prescribing first-line ART compared to 52% at the secondary level and 40% at the tertiary level.
• After the placement of these nurses and midwives, the overall number of patients receiving HIV care and treatment services across the eight districts (including facilities in which the newly trained health workers were not placed) rose 63%, from 24,001 in 2015 to 39,104 in 2017. Trends in other HIV indicators varied widely during the same time period, from a 40% drop in number of patients testing positive to a 147% increase in the number of patients screened for TB symptoms. These variances may be explained by other national HIV program changes, such as a shift to index testing and new guidance to screen all HIV patients for TB.
• Most nurses and midwives surveyed expressed satisfaction with practicing task sharing interventions (86%), but many also noted difficulties (70%). The two most common obstacles cited were patient non-adherence to treatment and refusal of testing results.
• Health district managers responsible for supervising task-sharing activities were asked if they were aware of the trained nurses and midwives placed in their districts; 63% responded yes and 37% answered no. Of those who were aware, 62% thought that the training and placement of these nurses and midwives in their district had made HIV service delivery more efficient

The impact study suggests that Cote d’Ivoire’s initial efforts to implement HIV task sharing in high burden HIV districts have succeeded.  Because a significantly higher proportion of nurses and midwives were able to practice task sharing at the primary care level, the Ministry of Health may want to prioritize posting health workers with these competencies at primary care facilities to maximize the use of their full scope of practice. Further studies could also help shed light on why these health workers’ competencies are underutilized at higher levels of care.

Read the Impact Study: Evaluation de L’impact de la formation Pratiquesur les soins et Traitement des PVVIH au profit des Infirmiers et sages-femmes affectes en 2016 dans 8 districta sanitaires a forte morbidite LIEE au VIH/SIDA