Because people with HIV are at greater risk of mental health problems like depression or anxiety – which could stop them from taking their ARVs – access to treatment is imperative.
But this means medication must be accessible, and currently, only doctors can prescribe psychiatric medicines. And compounding the issue, most government clinics don’t have full-time doctors.
South Africa’s HIV plan has a solution, writes Linda Pretorius for Bhekisisa, which is to allow nurses to prescribe psychiatric drugs.
If lawmakers move fast enough, this should all happen by 2028. This would make antidepressants and drugs to manage anxiety far easier to obtain, especially for people with HIV, who are about five times more likely than those without the virus to have depression, and eight times more likely to experience anxiety.
At the moment, only doctors can prescribe mental health medication, but the country’s national five-year HIV plan, which ends in 2028, intends to change this.
Once the Health Minister publishes draft regulations to say who may give out what kind of drugs, it “could be a matter of months” for the new rules to come into effect, said Andy Gray, a senior lecturer in pharmacology at the University of KwaZulu-Natal and a member of the committee that advises the government on which medicines to buy.
The Health Department has not yet announced when it will start the process for changing the law, but the matter is urgent and relatively high on the department’s agenda, experts said, because adjusted legislation will help to slow down the spread of HIV.
Increased risk
Research has shown that there’s more chance of people with HIV experiencing psychological problems like depression or anxiety, to having suicidal thoughts.
These challenges have been linked to people with HIV taking their medicine less regularly, which means they could stay infectious.
Taking daily HIV drugs prevents the virus from multiplying, enabling the level of the virus to drop so much that it’s virtually impossible to transmit the infection through sex.
But South Africa’s public health system doesn’t have nearly enough doctors to staff clinics full-time (only about eight doctors for every 10 000 people, while the number sits at about 21 per 10 000 people in other upper middle-income countries).
Instead, nurses run such clinics, with doctors only doing shifts once or twice a week.
Allowing nurses to diagnose mental health conditions and prescribe treatment will mean patients won’t have to return for doctors’ appointments to get treated.
This would not be the first time such task-shifting would be written into the laws to help control the spread of HIV
When free ARVs were introduced to the public health system in 2004, only doctors were allowed to prescribe the meds.
Since 2010, however, nurses have been able to do this too – which is part of the reason why about 6.1m people with HIV are on treatment today (this is about 77% of people who know they have HIV).
And ARVs have become even more accessible: in August, trained pharmacists were given permission to prescribe them too.
Most mental health medicines are schedule 5 drugs, but at the moment nurses can hand out drugs only up to schedule 4, said Gray, so changing this rule will be the first step in jumpstarting the process for better access to mental health treatment.
A change in law won’t be enough, though. Nurses will have to get special training for dispensing psychiatric medicines, similar to what nurses who are allowed to hand out HIV drugs have to do.
Moreover, said Gray, these health workers would have to be guided by psychiatrists. “Mentoring is going to be really important, not only during the training, but as an ongoing referral mechanism for nurses who will be asked to take care of patients with mental conditions.”
So, what are the dangers of shifting some of the psychological care for people with HIV to nurses, and will it be as effective as when ARVs were put in nurses’ hands?
In Health Beat, Bhekisisa’s monthly TV show, Mia Malan spoke to Francois Venter – a doctor who has lived through HIV for the past two decades with his patients, and the director of Ezintsha at Wits University – to find out.
Mia Malan (MM): Does making medicine easier to access lead to patients taking it more consistently?
Francois Venter (FV): The transition from knowing your diagnosis to learning your status and then being able to collect your medicines is important. We’ve learned that getting your diagnosis fast, starting the treatment — usually on the same day in South Africa — and getting your medicines from somebody who knows what they’re doing, in the same place, near your home, facilitates people taking the tablets. We’ve now got millions of people successfully on therapy because of that.
MM: Tell us about before nurses were allowed to prescribe ARVs.
FV: When the state programme started on 1 April 2004, we started in hospital clinics, with doctors dispensing the pills to initiate the therapy. There was a big deal about adherence in many parts of the country – people often came back months after they were started on treatment. There was a big song and dance about beginning treatment: lots of blood tests, adherence visits. Then, when patients were ready after they’d been diagnosed and they’d come back a few times [for follow-up checks], they would get their drugs prescribed by a doctor. Then they had to come back several times as the drugs took hold, to finally get a couple of months’ therapy (three, or in some cases six months) at a time. It was a big process, and it took us a long time to get up to 100 000 patients. The big scale-up took place when we said: “Nurses can do this and counsellors could diagnose people.” We gained more confidence with the tests, we gained more confidence with the drugs. Nurses at primary healthcare clinics started to initiate the therapy and we realised it was [a] safe [approach]. Now we’re in an era where we’re saying even pharmacists must be able to prescribe these drugs. It’s a whole transition: saying the drugs are so safe and so good we should try to get their dispensing down to the lowest level (of medical staff) possible.
MM: Making the shift from having a very high level of health worker, like a doctor, prescribe ARVs to lower levels of staff, such as nurses and pharmacists, has helped us to make these drugs more accessible and to put more people on treatment. Will we see the same benefits with psychiatric drugs?
FV: I hope so. Mental health is grossly underdiagnosed and undertreated. We have therapies, we know how to diagnose [conditions]. We need to push these therapeutics into the hands of people who are able to, first, diagnose and, second, hand them out. We don’t have nearly enough doctors and nurses, and if we keep saying [prescribing these medicines is] going to be left in the hands of the highest tier of medical care, it means the people who need them aren’t going to get them. So we need the same approach to mental health as we have for HIV. That’s what HIV has taught us about a lot of chronic diseases: you need to devolve these therapeutics to the level at which people need them.
MM: If we make these medicines – antidepressants, anxiety drugs – more accessible, isn’t there a danger they can be abused?
FV: People are often concerned about this. You just need to be sensible and look at which strategy you’re dealing with. What are the dangers? All drugs have side effects. So, you need to consider the benefits to society and the harms. Then train the people who are handing them out [about the effects]. ARVs are a good example [of how to do this], and the same thing needs to be done with each group of mental health drugs. Some of them do need to be in the right hands, and perhaps that’s a group handled only by psychiatrists. Or there are some that might need to be handed out only by doctors. But there are many that can safely be handed out by lower tiers of medical staff, and from which people can get a lot of benefit.
See more from MedicalBrief archives:
Mental healthcare resources dire in some provinces, says Phaahla
Gauteng’s antidepressant stockouts impacting psychiatric patients — experts
Pharmacists can now prescribe HIV/TB meds, judge rules
Top HIV experts call for PrEP to be prescribed by all nurses and midwives
Doctors challenge law allowing pharmacists to give HIV meds without scripts