Evolving roles of nurses in HIV care

Danielle Collins: Victorian AIDS Council, The Centre Clinic
Emily Wheeler: Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM)

Nurses have been involved in varying capacities in supporting people with human immunodeficiency virus (HIV) since the beginning of the HIV epidemic in the 1980s. As the epidemic has evolved from one of the greatest public health crises of the twentieth century along the chronic disease trajectory to a largely treatable and preventable chronic condition, so too has the nursing response.[1] [2] This section seeks to explore the evolving models of nursing care and roles within the HIV sector in Australia and internationally.

National context

Nurses, alongside doctors and allied health professionals, working at the forefront of HIV care in Australia in the early years of the epidemic, faced a highly politicised and stigmatising landscape given the nature of the illness and the already marginalised affected population.[3]  With no precedents, the HIV nursing models that emerged were shaped by the response the crisis demanded, creating a diverse range of nursing roles and a strong, flexible professional specialty. This challenging working environment has been attributed to the strong alliances formed between health professionals, creating the cohesive and resilient sector that still exists today.[4]

In this largely collegial working environment, nurses across all areas work collaboratively with HIV specialist general practitioners, infectious disease specialists, HIV specialist pharmacists, social workers and other allied health professionals to provide holistic, equitable HIV care. HIV specialist nurses work across a range of areas including:

  • Community and domiciliary nursing services such as Royal District Nursing Service (RDNS), Silver Chain, Sydney District Nursing Service
  • General practice and community health
  • Acute and subacute hospital in-patient and out-patient care; Hospital Admission Risk Programs
  • Youth, maternal and child health
  • Refugee health
  • Sexual health services
  • Clinical trial research.

Given the differing levels of complexity among patients, nursing roles vary considerably between settings. Nurses across the sector can experience differing levels of acuity for the same patient based on the setting from which they are providing care, whether it be seeing that patient at a routine GP follow-up appointment or undertaking a home visit through a community nursing program. A strength in the collegial working environment of the HIV sector is the ability for nurses across the spectrum of roles to support one another to ensure the best patient outcomes. This collegial approach can be conferred to other sectors not traditionally involved in HIV care who may now be involved in HIV prevention or diagnosis, given the expansion of HIV treatment and prophylaxis initiatives.

Principles

The principles underpinning nursing in this specialty sector have been translated into competency standards by the Australasian Sexual Health and HIV Nurses Association (ASHHNA).[5] Developed by referencing current national and international sexual health and HIV nursing competency standards, these standards account for differences in practice for both the registered nurse and advanced practice registered nurse and seek to clarify key areas under seven domains. The domains incorporate the Australian national guidelines for the advanced practice registered nurse.[6]

The domains in the ASHHNA Competency Standards are: 

  1. Effective communication
  2. Assessment, care planning and clinical management
  3. Health promotion and client education
  4. Research
  5. Legal and ethical nursing practice
  6. Collaborative care and partnerships
  7. Leadership and development of the specialty.[7]

The Competency Standards consider the differing roles among nurses within the sector from management to direct clinical care to research nursing, and are designed to guide best practice in the provision of these specialist clinical nursing services’ as well as provide guidance to nurses new to the sector.[8]

The values that guided the development of the competency standards were born out of the turbulent medical, social and political history of HIV and the complexities that faced those affected. A hybrid model of care was identified by combining a social and medical model approach, one that acknowledges the social determinants of health while also addressing disease specific requirements. This model is grounded in the principles of primary health care and champions social justice by seeking to provide advocacy, health promotion and accessible, equitable and holistic health care for all.

International context

There are vast differences between HIV nursing models nationally and internationally due to epidemiological variability, differences in health system infrastructure including the scope of nursing practice and access to resources worldwide.

Models of HIV nursing care are similar in resource rich settings to the models existing in Australia, as demonstrated by the translation of HIV and sexual health guidelines from the United Kingdom into an Australian context. These include similarities in access to care through hospital, outreach and collaborative care models and an emphasis on holistic HIV treatment and prevention. [9] [10] [11]  Nurse practitioners and nurse prescribers are well established in the HIV sector in Canada, the United States of America and the United Kingdom, unlike the Australian context. Barriers to the expansion of nurse practitioners specialising in HIV care in Australia include the restrictions to Schedule 100 medication prescribing which exclude nurse practitioners from the prescribing regulations as well as the wider debate in Australia as to the cost effectiveness of nurse practitioners. [12] [13]

Just as in a resource rich setting, resource poor settings typically work in collaborative care models, although the nuances between the models vary and appear largely driven by workforce shortages and a corresponding focus on task-shifting, and an economic imperative in resource poor settings. This, coupled with a high degree of patients lost to follow-up, co-infection with malaria or tuberculosis and limited access to HIV treatment and prevention strategies equate to a vastly different and challenging nursing environment. Task shifting, or the up-skilling of non-physician health-care workers, has been identified as an effective and economic way to manage the human resources crisis affecting HIV care in resource poor countries in sub-Saharan Africa.[14] [15]

This practice extends to up-skilling nurses to nurse practitioner-type roles, and community health workers to undertake some nursing duties in order to increase access to HIV treatment, care and prevention strategies.[16] With the current human resources crisis affecting health care in resource poor settings predicted to worsen, there may be a role to play for nurses in Australasia to work with and support nurses in resource poor settings to support the HIV treatment and prevention scale-up efforts already in place.[17] Uniting these differing models of health care is the underlying commitment to reduce the burden of HIV on those affected and continue to scale-up the response. Despite a vastly different landscape in HIV nursing in Australia today compared to when the sector developed 30 years ago, the same guiding philosophy and commitment to primary health-care principles exist among a sector that remains as bonded as ever.

As HIV in Australia is increasingly being managed as a chronic disease, nurses have a significant role in care delivery, comparable with chronic disease management care for other conditions. The role of nurses in leading chronic disease management approaches has been shown to be feasible and acceptable to both clients and fellow health professionals.[18] Nurses are the largest health profession in Australia and are effective in managing chronic diseases, including HIV. With increasing health-care costs demanding reform, there is a need to continue to support nurses to care for those affected by HIV and secure community-based nursing roles to prevent avoidable hospital admissions and improve patient outcomes.

HIV nursing organisations

Australian Sexual Health and HIV Nurses Association (ASHHNA) Inc.:
http://ashhna.org.au/

Australian and New Zealand Association of Nurses in AIDS Care (ANZANAC): an Australian Nursing and Midwifery Federation Special Interest Group (Victoria):
http://www.anmfvic.asn.au/interest-groups/australian-and-nz-association-of-nurses-in-aids-care-anzanac-sig/ 

1.
Crock E, Butwilowsky J. The HIV resource nurse at the Royal District Nursing Service (Melbourne): making a difference for people living with HIV/AIDS in the community. Australian Journal of Primary Health 2006; 12(2), pp. 83-89. 
2.
Hopwood M, Newman C, Persson A, Watts I, de Wit J., Reynolds R., . . . Kidd, M. Expert perspectives on the contribution of HIV general practice nursing to the ‘extraordinary story’of HIV medicine in Australia. Primary health care research & development. 2014; 15(02), 180-189. 
3.
Crock E, Butwilowsky J. The HIV resource nurse at the Royal District Nursing Service (Melbourne): making a difference for people living with HIV/AIDS in the community. Australian Journal of Primary Health 2006; 12(2), pp. 83-89. 
4.
Crock E, Butwilowsky J. The HIV resource nurse at the Royal District Nursing Service (Melbourne): making a difference for people living with HIV/AIDS in the community. Australian Journal of Primary Health 2006; 12(2), pp. 83-89. 
5.
Australasian Sexual Health and HIV Nurses Association (ASHHNA). ASHHNA Competency Standards for sexual and reproductive health and HIV nurses (2nd edition). Sydney: ASHHNA Inc.; 2011. 
7.
Hopwood M, Newman C, Persson A, Watts I, de Wit J., Reynolds R., . . . Kidd, M. Expert perspectives on the contribution of HIV general practice nursing to the ‘extraordinary story’of HIV medicine in Australia. Primary health care research & development. 2014; 15(02), 180-189. 
9.
Horrocks S, Anderson E, Salisbury C. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 2002; 324(7341), 819-823. 
10.
Remien RH, Bauman LJ, Mantell JE, Tsoi B, Lopez-Rios J, Chhabra R., . . . Teitelman N. Barriers and facilitators to engagement of vulnerable populations in HIV primary care in New York City. JAIDS Journal of Acquired Immune Deficiency Syndromes 2015; 69, S16-S24. 
11.
Samb B, Celletti F, Holloway J, Van Damme W, De Cock KM, Dybul M. Rapid expansion of the health workforce in response to the HIV epidemic. NEJM; 357(24): 2510-4. 
12.
The Pharmaceutical Benefits Scheme. Section 100-Highly Specialised Drugs Program.   Retrieved from http://www.pbs.gov.au/info/browse/section-100/s100-highly-specialised-drugs, 2015. 
13.
Van Der Weyden MB. Doctor displacement: a political agenda or a health care imperative. Med J Aust, 2008; 189(11/12), 608-609. 
14.
Callaghan M, Ford N, Schneider H. A systematic review of task-shifting for HIV treatment and care in Africa. Hum Resour Health 2010; 8, 8-16. 
15.
Lehmann, U., Van Damme, W., Barten, F., & Sanders, D. (2009). Task shifting: the answer to the human resources crisis in Africa? Human Resources for Health, 7(1), 49. 
16.
Byrne, M. W. (2015). Professional practice models for nurses in low-income countries: an integrative review. BMC nursing, 14(1), 44. 
17.
Byrne, M. W. (2015). Professional practice models for nurses in low-income countries: an integrative review. BMC nursing, 14(1), 44. 
18.
Elay DS, Patterson E, Young J, et al. Outcomes and opportunities: a nurse-led model of chronic disease management in Australian general practice. Australian Journal of Primary Health 2012; 19(2) 150-158.