Session:  Given human resource constraints, a Uganda cluster-randomized trial examined outcomes of persons randomized to care by either: 1) lay people trained to delivery home-based care; or 2) a traditional model of facility-based care.  Outcomes included clinical metrics and costs.  In the ‘intervention’ arm, lay persons (who were often college-degreed) were educated to travel to patients’ homes to conduct routine assessments, deliver medications, and refer patients to facilities as necessary.  Excellent clinical outcomes were equivalent as were total costs; however, out-of-pocket costs were reduced in the home-based arm.   This trial demonstrated that complex programs can be delivered near patients' homes and without frequent support from clinical staff.

Given human resource constraints and high unmet need for ART, a Lesotho program investigated a decentralized approach to care using task shifting of 1) routine patient management to nurses; and 2) special counseling for, and referral of, HIV/TB coinfected patients to specially trained counselors.  Through successful task sharing, it was demonstrated that a preferred, modified first-line regimen of TDF/3TC/EFV could be implemented, while simultaneously addressing the special renal and pregnancy considerations of the regimen.  The successful task-shifting approach used in this study also allowed for a change in HAART initiation to patient with CD4 < 350 and inclusion of a multi-drug PMTCT regimen.

Given human resource constraints, women in Malawi prefer and frequently utilize traditional birth attendants (TBAs) for childbirth.  The presentation described an attempt to improve PMTCT via TBAs.  TBAs were provided with training and registers/logs.  The program demonstrated that fewer than half of pregnant women identified as HIV positive by TBAs received NVP and less than a quarter of infants identified as HIV exposed by TBAs received NVP prophylaxis.  The findings support the government’s policy that women should not use TBAs but rather deliver in health facilities. 

A South African prospective cohort study described clinical outcomes among adult and pediatric patients referred to them for care and treatment.   This study found high retention in care for pediatric cases at three years (89.3%) and reasonably high retention for adults (74.1%).  Pediatric care can be successfully integrated with adult care.

Conclusion:  This session highlighted the ability of operations research to demonstrate effective and ineffective task shifting solutions to human resource shortages.