The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review

Abstract

INTRODUCTION: Human resource shortages are a challenge to the rollout of antiretroviral therapy (ART) for HIV-infected patients, particularly in sub-Saharan Africa. Task-shifting has been recommended as an approach to reduce the impact of human resource shortages. We conducted a systematic review of randomized controlled trials and quasi-experimental studies to assess the effectiveness of task-shifting, and its impact on costs of ART provision. METHODS: We searched MEDLINE, EMBASE, PSYCINFO, Cochrane Library, Web of Knowledge and the Current Controlled Trials Register for articles published up to January 2011. We included studies evaluating any task-shifting model against any other intervention using any of the following outcomes: mortality (all causes); occurrence of new AIDS-defining illness; virological outcomes; CD4 cell count; adherence to ART medicines (e.g. self-report and pill counts); hospital admissions; clinic visits; toxicity or adverse events; quality of life indicators; costs and cost-effectiveness. We did not pool the results because of high levels of clinical heterogeneity. RESULTS: We identified six effectiveness studies including a total of 19 767 patients. Non-inferior patient outcomes were achieved with task-shifting from doctors to nurses, or from health care professionals to mid-level workers or lay health workers. However, most of the identified studies were underpowered to detect any difference. Three studies were identified on the cost implications of task-shifting. Task-shifting resulted in substantial cost and physician time savings. CONCLUSIONS: The reviewed evidence suggests that task-shifting from doctors to nurses, or from health care professionals to lay health workers can potentially reduce costs of ART provision without compromising health outcomes for patients. Task-shifting is therefore a potentially effective and cost-effective approach to addressing the human resource limitations to ART rollout. However, most of the studies conducted were relatively small and more evidence is needed for each task-shifting model as it is currently limited.