Scaling up access to HIV pre-exposure prophylaxis (PrEP): should nurses do the job?

Summary

Task sharing has been one of the most important enabling policies supporting the global expansion of access to HIV testing and treatment. The WHO public health approach, which relies on delivery of antiretroviral therapy (ART) by nurses, has enabled a trebling of the number of people receiving ART during the past decade. WHO recognises that HIV pre-exposure prophylaxis (PrEP) can also be provided by nurses; however, many countries still do not have policies in place that support nurse provision of PrEP. In sub-Saharan Africa, most countries allow nurses to prescribe ART, but only a few countries have policies in place that allow nurses to prescribe PrEP. Nurse-led PrEP delivery is particularly low in the Asia-Pacific region, which has some of the world's fastest growing epidemics. Even in many high-income countries, PrEP scale-up has been limited because policies often require medical doctors or specialists to prescribe. Service providers in many countries are coming to realise that scaling up access to PrEP cannot be achieved by medical doctors alone, and nurse-led PrEP delivery can help to lay the groundwork for supporting uptake of other HIV prevention approaches that will become available in the future. Countries with policies that authorise nurses to prescribe ART could be early adopters and help to pave the way for wider adoption of nurse-led PrEP delivery.

Introduction

Task sharing has been one of the most important enabling policies supporting the global expansion of HIV testing and treatment access. Particularly in resource-limited settings, where the burden of new infections and disease is greatest and medical doctors are scarce, the expansion of HIV services has relied on key aspects of care being provided by nurses and community health workers. With 1·5 million new HIV infections in 2020,¹ there is a continuing need to implement evidence-based combination HIV prevention programmes, and pre-exposure prophylaxis (PrEP) is a key prevention strategy. Although PrEP is being scaled up globally, uptake must be accelerated to realise the potential of PrEP to interrupt HIV transmission and reduce new HIV infections. Increasing the scope of nurses via task sharing has the potential to support rapid expansion of access to PrEP.

Early in the HIV response, providing HIV treatment was the exclusive domain of specialist medical doctors in hospitals. However, it quickly became apparent that this model of care restricted access for the majority of people in need. Since 2006, WHO has promoted simplified care delivery as close as possible to people's homes, relying on nurses, community health workers, and peers. This public health approach was driven by necessity and guided by strong science, programme experience, and an understanding of the values and preferences of people living with HIV and care providers.² Over the past decade, the number of people receiving antiretroviral therapy (ART) has more than tripled—from 7·8 million in 2010 to 27·4 million in 2020.¹ Simplification of care—which gives preference to simple treatment regimens that require minimal laboratory monitoring and can be provided through integrated, decentralised services—has been central to achieving treatment coverage at scale.³ As well as allowing for improvements in coverage, simplification of care provisions has led to better outcomes both for the clients and the health system.^{4, 5, 6, 7}

WHO recognises that task sharing can be applied to support the expansion of PrEP services, with PrEP provided in full by suitably trained and qualified nurses, and advice and support for complex issues provided by medical doctors.⁸ Nurses trained in providing PrEP, particularly those experienced in sexual health or HIV, can provide PrEP drugs (via prescription where local regulations allow), give oversight to clinical services, assess PrEP suitability for initiation and follow-up, provide or order necessary testing, conduct counselling for PrEP, and provide complementary services such as contraception, hepatitis B and C services, and sexually transmitted infection screening, treatment, and referral.

A missed opportunity for PrEP expansion

Although nurses are allowed to provide ART in most countries, comparatively few countries have policies in place supporting nurse provision of PrEP. Since 2015, WHO has recommended offering tenofovir disoproxil fumarate-based oral PrEP to all people at substantial risk of HIV as part of combination HIV prevention, and these antiretroviral drugs are also the most commonly used ART backbone. In sub-Saharan Africa, the region with the greatest burden of HIV, most countries allow nurses to prescribe ART but only a few countries have policies in place that allow nurses to prescribe PrEP (figure). Nurse-led PrEP delivery, as reflected in national polices and guidance, is almost totally absent in the Asia-Pacific region, which has some of the world's fastest growing HIV epidemics.¹⁰ Although a role for nurses in providing some PrEP related services, including determining eligibility or conducting required testing, has been endorsed in some national PrEP policies within the region and is more widespread in practice, PrEP is typically prescribed by a medical doctor. Task sharing has instead emphasised the role of community health-care providers (often lay providers who are members of key populations) in countries such as Thailand and Vietnam.^{11, 12, 13}

Figure.

Policies allowing nurse prescribing and ART initiation in the WHO Africa region, 2018–20

This map depicts polices reported via the Global AIDS Monitoring system. Existence of a policy does not necessarily imply that the nurse prescribing is widely practised. Insufficient data were available from other regions to allow for global reporting. Reproduced from Global AIDS Monitoring.⁹ ART=antiretroviral therapy. PrEP=pre-exposure prophylaxis.

Countries with policies in place that allow nurses to provide ART could pave the way for adoption of nurse-led PrEP delivery. Tenofovir disoproxil fumarate and emtricitabine or lamivudine, the antiretroviral drugs used for both ART and PrEP, are well tolerated, there is no dose variation, and side-effects are mild. Although ART is comprised of three drugs, which increases the occurrence of side-effects compared with PrEP, current treatment is generally well tolerated, and prescription of ART by nurses has long been widely practised, even with older regimens that were associated with a higher frequency of side-effects and are no longer standard of care. In contrast to people receiving ART, people taking PrEP do not have HIV, are often young, and typically have few, if any, comorbidities. Furthermore, there are few contraindications to PrEP, and criteria for eligibility are well defined. HIV treatment is lifelong, whereas PrEP is taken during periods of HIV risk and can be started, stopped, and restarted in accordance with periods of risk and client preference.

Nurse-led PrEP provision

There has been considerable scale-up of PrEP services globally, although the number of people taking PrEP remains small relative to HIV epidemics in most countries.¹⁴ Even in many high-income countries, scale-up has been limited because policies often require medical doctors and specialists for prescribing¹⁵—studies from Canada and the USA have found that a large proportion of specialist doctors (eg, infectious diseases physicians) do not prescribe PrEP because of lack of knowledge about PrEP.^{16, 17} This is gradually changing as the evidence accumulates to show that nurse-led PrEP delivery is a viable strategy for PrEP delivery and can lead to rapid increases in PrEP service capacity without additional resources.¹⁸ In Australia, nurse-led PrEP delivery allowed for the rapid expansion of PrEP access to more than 8000 participants without additional resources.¹⁸ In Canada, nurse-led PrEP delivery at community health centres was found to support access and uptake of essential services.¹⁹ In South Africa, nurse-led PrEP delivery facilitated the rapid expansion of the PrEP programme to more than 2000 public health-care facilities.²⁰ In the USA, the proportion of nurse practitioners or physician assistants providing PrEP has increased from 18% in 2014 to 30% in 2019.²¹ A recent systematic review of studies from the USA concluded that nurses were 40% more likely than doctors to prescribe PrEP.²² Experience from task sharing of ART shows that clients often prefer receiving care closer to their homes,²³ and that this preference translates into improved retention in care and long-term clinical outcomes when care is decentralised.⁵ Task sharing can also improve the cost-effectiveness and efficiency of health systems.²⁴ Access to ART has been improved by task sharing because nurses are more abundant than medical doctors and are widely deployed within primary health centres and community health posts, including locations where there might be few or no medical doctors onsite. Similarly, task sharing has the potential to improve access to PrEP. Task sharing can facilitate decentralisation of care, by engaging other non-clinician providers such as retail pharmacists and physician assistants in PrEP delivery.²⁵ Decentralisation of PrEP across various services will be crucial to improving access for key populations who in many settings are unable to access traditional clinical services.²⁶

Currently, WHO recommends that oral PrEP be taken as either a daily dosing or an event-driven dosing (also called ED-PrEP or on-demand PrEP—ie, taken around the time of sex). WHO also recommends that PrEP can be delivered by a monthly PrEP vaginal ring, as an additional choice for women who do not want to or are not able to take oral PrEP. The monthly PrEP vaginal ring has received regulatory approval in a few countries—eg, South Africa and Zimbabwe—and it might receive approval in more countries in 2022.²⁷ Longer acting PrEP products are being developed, including cabotegravir, an injectable PrEP given every 2 months, which received regulatory approval from the US Food and Drug Administration in December, 2021²⁸ and will be considered for inclusion in WHO guidance in 2022. These long-acting products offer important additional choices for people who prefer not to or struggle to use existing PrEP methods effectively. Nurses provide almost all contraception services and are experienced in providing oral pills, long-acting injectables, and implantable or vaginal ring contraceptive products in many settings. If long-acting PrEP products are to have a place in HIV prevention, this expertise and experience could be built on, authorising nurses to deliver a range of HIV prevention options.²⁹ Nurse-led PrEP delivery would thereby strengthen service integration with contraceptive and other services.

Benefits of task sharing for PrEP provision

As well as benefiting clients, nurse-led PrEP delivery might provide greater job satisfaction for experienced nurses by allowing them to develop new skills and work to a fuller scope of practice. A qualitative study in Australia reported frustrations that nurse-led PrEP delivery was restricted after the trials phase because of existing restrictions on prescribing by nurses, despite the demonstrated competence of nurses during the trials.³⁰

Enabling policies are needed for nurse-led PrEP delivery, including changes to prescribing regulations and endorsement of the role of nurses in PrEP provision in national guidelines and policies.^{19, 31} Other key considerations to support sustained task sharing for nurse-led PrEP delivery include: training for both service providers and supervisors to maintain competence and confidence; adequate supplies of drugs and other commodities to support decentralisation; clear protocols and referral lines for clients in need of additional care; other supportive policies, regulations and curricula; addressing workloads and nurse staffing levels within the service; and remuneration reflecting changes in scope of practice.³²

Conclusions

20 years ago, there was consensus about the urgent need to scale up access to antiretroviral treatment, but the question was asked: who will do the job?³³ Today, we have a similar question for PrEP. There is an increasing push for differentiated PrEP service delivery to increase access and uptake, adapting services to the needs and preferences of people who could benefit from PrEP and optimising delivery of services in the most efficient and cost-effective ways. Service providers in many countries are coming to realise that the job of scaling up access to PrEP and providing differentiated services cannot be achieved by medical doctors alone. In addition to facilitating uptake of PrEP, a nurse-led approach—together with task sharing with other non-clinician providers—can help to lay the groundwork for supporting uptake of other HIV prevention approaches that will become available in the future. However, without changes in policy and practice to allow nurses to prescribe PrEP, this crucial prevention strategy is likely to remain inaccessible to those who need it most, exacerbating the inequities that already exist in HIV incidence and health outcomes.

Declaration of interests

We declare no competing interests.