Our study shows that nurses’ ART prescription practices for children on first line split adult or paediatric FDC, calculations of patient adherence and next appointment date setting are similar to those practices among clinical officers supported by an automated electronic system. The formulas and dosage charts provided to both nurses and clinical officers appear user-friendly and arithmetic skills of involved nurses are sufficient. Interestingly, the time required to visit each cadre was similar. Our findings highlight several aspects of paediatric ART management that have clinical and programmatic implications.
First, nurses correctly calculate – with pen and paper – medication adherence since the last visit using pill counts. Paediatric ART in FDC tablet formulation is more practical than syrups [11
], and allow nurses to transfer the skills learned in adult pill count measurements to paediatric care. Though incorporating fractions of tablets and differing doses based on body weight from remaining supplies of prior and current visits make calculations difficult, our study shows that nurses, using this information and following a formula, can correctly calculate adherence based on pill counts. The process of conducting an accurate pill count and carefully calculating adherence in the presence of child and caregiver may, in itself, reinforce and promote adherence. However, it is unknown why differences between nurses’ and clinical officers’ calculations increase in regions of lower adherence.
Second, nurses were able to choose the correct formulation and prescribe the correct dosage for AM and PM dosing. Despite using FDC tablets, the regimens used in the study were still complex: in some weight bands AM and PM dosages differed for split adult tablets and two different paediatric formulations were in use. Although only a small proportion of visits required changes in regimens or dosing bands our finding of correct AM and PM dosing is important – errors during these critical events may result in over- or under-dosing, potentially with severe consequences for the child. If regimens and dosages remain unchecked, errors are carried forward. Nurses are often “the last line of defence” to administer prescribed medications correctly [5
]; in the context of a public health sector ART clinic in Malawi and other countries in sub-Saharan Africa, they are often the only ones providing care. However, our study also highlights a limitation of task shifting: the study was interrupted for three weeks during which 233 paediatric visits at MPC were managed only by clinical officers because the two available nurses were required to conduct routine reviews for stable adult patients. Although there is some risk that continued task shifting to nurses may stretch human resources or exceed nurse capacity resulting in lower quality of services [32
], our findings show that paediatric ART can be prescribed safely by nurses in these settings and adds further support to nurse-led, high quality care.
Third, based on standard 1- or 2-month supplies according to weight bands, nurses were able to calculate next appointment dates correctly. Knowing when patients are expected to return has three major implications for clinic organization and patient management. First, it allows daily planning and staffing of the clinic due to a foreseeable workload. This is particularly important when the demand for services outweighs the capacity of providers. At the same time, patients are re-assured that they receive services that day, reducing anxiety, transportation and time costs. Second, it facilitates identification of patients that miss appointments, helping launch tracing efforts at an early stage of lost to follow up (LTFU). Early tracing helps to identify true outcomes and return patients back to care [26
]. This, in turn, improves the quality of routine monitoring and evaluation of the entire programme by reducing LTFU and presenting realistic outcomes [26
]. Lastly, calculating appointments correctly enables nurses to adjust appointments between child and caregiver, should he/she also be on ART. Synchronized appointments of the family members may have a positive effect on adherence by reducing the number of clinic visits per family and improving patient satisfaction especially in health facilities where adults and children are frequently seen in the same queue. Care provided to the family unit may also reduce stigma and have other positive effects, for example allowing a discussion of family planning, HIV counselling and testing or control of STDs [33
Lastly, the dramatic differences in workload between individuals of the same cadre and between cadres merit attention as the division of labour may affect the quality of care, including the fundamental paediatric management skills assessed in this study. From the results of the study, it appears that a few nurses and clinical officers completed a disproportionate amount of the patient assessments and reviews. Several factors likely contributed to this finding. First, some clinical officers work at Lighthouse on a rotation, contributing only few study reviews. Second, staff have other responsibilities, by choice or by requirement, outside of patient care. Clinical officers often have management responsibilities including clinic coordination, mentoring duties, and supervision, both within and outside the clinic. In addition to providing care for the vast majority of stable adult patients, nurses also rotate to manage the pharmacy and provide counselling sessions. The differences in work load revealed by these findings require further elucidation and follow-up to better distribute the burden among all staff members.
Our study has a number of limitations. First, as Lighthouse Trust provides services only to HIV-infected individuals, the study nurses already routinely managed adult patients and were used to both pill-count measurement and calculation of next appointments. However, many factors are the same between Lighthouse and other clinics. Dosage guidelines, 1- or 2-month supplies of pills, and formulas for measurement of adherence are standardized in the national ART guidelines, and all staff, nationwide, undergoes standard National ART training based on these guidelines; therefore, our results may be reproducible in other facilities in Malawi. Second, as discussed above, relatively few nurses and clinical officers managed the majority of visits, which may reflect preferences for paediatric management by a few better-qualified, more motivated nurses and clinical officers and result in higher than average care quality. Moreover, some caregivers and children may prefer a specific nurse or clinical officer, accepting a longer waiting time or re-arranging their place in the patient queue to be seen by their preferred provider. However, in post hoc analysis limited to the five nurses and five clinical officers that contributed 50 or more visits (results not shown), the findings were similar to our original analysis. Third, we only examined FDC tablet formulations. Results are likely to be different if different formulations (e.g. tablets and syrups) are used or combinations of different tablets containing single drugs or dual formulations, as it is the case for alternative first- or second-line regimens, where complexity is higher. Lastly, the design did not allow comparison of patients’ clinical or virological outcomes, and we did not assess or compare the clinical skills of nurses and clinical officers, two aspects that would add to the discussion of service quality. However, we believe that the aspects of paediatric patient management included in our study are demonstrative of quality care and suggest that paediatric patient outcomes would be favourable whether managed by nurses or clinical officers.