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Nurse-led antiretroviral treatment for HIV infected children: A comparative study from Lilongwe, Malawi

Aim We compared prescriptions of antiretroviral treatment (ART) between nurses and clinicians in order to inform policy in paediatric ART management. Methods Caregivers of children on 1st line ART provided information about visit dates, pill counts and dosage first to a nurse and then to a clinician during routine clinic visits at an urban public sector clinic. Nurses and clinicians independently calculated the new dosage based on body weight, adherence and next appointment. Only clinicians had access to an electronic data system that made the calculations for them, based on information of prior visits, actual and expected pill consumption, and standard drug supplies. Bland Altman graphs, plotting the mean against the mean differences of paired nurse clinician assessments, were used to assess agreement between cadres for each visit. Results A total of 704 matched nurse and clinician reviews among 367 children were analysed. Children's median age at ART initiation was eight years and their mean time on ART was 2.1 years. Eight nurses and 18 clinicians were involved in the study; two nurses and five clinicians managed 100 visits or more. Overall, there was good agreement in the responses of nurses and clinicians with narrow ranges of 95% limits of agreement and little deviation of means from zero, indicating that responses were not skewed towards one cadre. Mean (95% CI) differences between nurses and clinicians were −0.005 (– 0.02 to 0.01) and −0.009 (−0.02 to 0.01) for morning and evening ART dosages respectively. The 95% limits of agreement for adherence calculations were 24% above and below the mean difference of 0.003 with corresponding 95% CI from −0.9 to 0.9. Next appointment calculations between nurses and clinicians differed more widely (mean difference of 0.96 days, 95% CI −0.59 to 2.5). Conclusion Nurses' ART prescription practices for children on 1st line ART and calculations of their adherence and next appointments are similar to clinicians that used an automated electronic system. Our findings support the decision of Malawi's health officials to utilise nurses to manage paediatric patients on ART.