Erratum: 'I am afraid the news is not good' - Breaking bad news in the time of COVID: Experiences from a field hospital.

No abstract available.

South African adolescents' lived experiences of acquired hearing loss following multidrug-resistant tuberculosis treatment.

Objective: The impact of acquiring hearing loss might be exacerbated during adolescence, as this normal transition from childhood to adulthood is characterised by identity construction and social intensity. This study aimed to describe the lived experiences of South African adolescents with acquired hearing loss following aminoglycoside treatment for multidrug resistant tuberculosis. Design: The study adopted a descriptive phenomenological design and in-depth, semi-structured interviews were conducted in English, isiZulu and Afrikaans. The data was managed and analysed according to a modified version of Hycner's framework. Study sample: Six participants aged 16-24 years with bilateral, mild to profound hearing loss acquired from aminoglycoside treatment were recruited from two South African provinces. Results: Three themes emerged which created a triple burden for participants. They endured socio-economic hardship encompassing limited economic and emotional support. Participants battled the consequences of life-threatening MDR-TB including illness, hospitalisation, stigma, and other challenges. Finally, participants were left with life-changing hearing loss. Conclusion: The findings indicate the necessity of holistic management of adolescents with aminoglycoside-related acquired hearing loss and serves as motivation to improve ototoxic monitoring practices and patient uptake of monitoring services and calls for the cessation, or at least cautious use, of aminoglycosides.

'I am afraid the news is not good' - Breaking bad news in the time of COVID: Experiences from a field hospital.

BACKGROUND:  The COVID-19 Pandemic had profound effects on healthcare systems around the world. In South Africa, field hospitals, such as the Mitchell's Plain Field Hospital, managed many COVID patients and deaths, largely without family presence. Communicating with families, preparing them for death and breaking bad news was a challenge for all staff. AIM:  This study explores the experiences of healthcare professionals working in a COVID-19 field hospital, specifically around having to break the news of death remotely. SETTING:  A150-bed Mitchells Plain Field Hospital (MPFH) in Cape Town. METHODS:  A qualitative exploratory design was utilised using a semi-structured interview guide. RESULTS:  Four themes were identified: teamwork, breaking the news of death, communication and lessons learnt. The thread linking the themes was the importance of teamwork, the unpredictability of disease progression in breaking bad news and barriers to effective communication. Key lessons learnt included effective management and leadership. Many families had no access to digital technology and linguo-cultural barriers existed. CONCLUSION:  We found that in the Mitchell's Plain Field Hospital, communication challenges were exacerbated by the unpredictability of the illness and the impact of restrictions on families visiting in preparing them for bad news. We identified a need for training using different modalities, the importance of a multidisciplinary team approach and for palliative care guidelines to inform practice.Contribution: Breaking the news of death to the family is never easy for healthcare workers. This article unpacks some of the experiences in dealing with an extraordinary number of deaths by a newly formed team in the COVID era.

Reflections of volunteer counselors working remotely during the COVID-19 pandemic-Implications for policy and practice.

PURPOSE: We reflect on our experience of running a remote volunteer counseling service, known as the Counseling Collective, to support patients and their families during the second wave of the COVID-19 pandemic in Cape Town, South Africa, and the learning and implications for practice and policy regarding the effective utilization of volunteers during a crisis or disaster context. BACKGROUND: The Beta SARS-Co-2 variant dominated the second COVID-19 wave which gained momentum in December 2020, as public sector health teams prepared to deescalate services over the South African summer season. The ferocity with which the wave hit the city soon made it clear that volunteers would be needed to assist with counseling services as the Beta variant caused serious disease, resulting in a significant upswing in hospitalisations and deaths. METHODS: Four counselors and a colleague with oversight responsibilities of the volunteers reflected on the service we provided. This was done with the benefit of hindsight a year after the activities of the Counseling Collective were wrapped up. LESSONS LEARNED: Virtual volunteers are a largely untapped resource in the South African health care system. Much is to be gained by using this underutilized resource to deliver patient-centred services, especially in times of crisis. CONCLUSION: Networks of retired and self-employed health professionals, particularly nurses,-skilled volunteers-are a valuable resource and can be deployed for critical work using their versatile skillsets, in public health emergencies. Telephonic consultations are a useful modality for providing quality care and need to be built into the business of health services. Skills to conduct such consultations and for the provision of palliative care services need to be mainstreamed into the skillsets of health professionals. POLICY AND CLINICAL RELEVANCE: Public health disaster plans should include a blueprint for the rapid recruitment and deployment of volunteer counselors to assist permanent staff in providing crucial patient-centred care.

Experiences of Mothers Living With HIV in a South African Prevention of Mother-to-Child Transmission of HIV Programme: A Qualitative Descriptive Study.

ABSTRACT: More than 90% of all HIV infections in children result from mother to child transmission. Elimination of mother-child transmission is a global priority and vital for the improvement of child survival in high-burden, limited resource settings. Retention in HIV care is vital to reduce transmission risk. This qualitative study explored the experiences and adherence challenges of mothers living with HIV of the Prevention of Mother-to-Child Transmission of HIV (PMTCT) programme in Khayelitsha, Cape Town, South Africa. Interviews were conducted with purposively selected participants enrolled in a PMTCT programme at a primary care facility. Thematic analysis generated six themes. Findings demonstrate the complexity of living as a woman with HIV in a socioeconomically disadvantaged and marginalized periurban community. For each woman, there is a set of concerns relating to person, home, community, and clinic which may affect her understanding, acceptance of, and adherence to the PMTCT programme.

Sexual and reproductive health knowledge of postgraduate students at the University of Cape Town, in South Africa.

BACKGROUND: Globally and in South Africa, university students' knowledge of sexual and reproductive health (SRH) is low. This study was conducted in response to the dearth of information about the sexual and reproductive health knowledge of postgraduate students. Research conducted to explore the SRH knowledge of undergraduate students suggests that the level of SRH knowledge among undergraduate students is low. The aim of this study was to determine the SRH knowledge of postgraduate students with regards to contraceptives, sexually transmitted illnesses (STI), human immunodeficiency virus (HIV), Pap smear and clinical breast examination at University of Cape Town (UCT), in South Africa. METHOD: A cross sectional survey design was utilized, using an adapted and pretested online questionnaire. The aim of this study was to determine the SRH knowledge of postgraduate students at the UCT. Minor adjustments were made to the questionnaire to suit the South African context. Selected aspects of SRH were included in the current study: knowledge and use of contraceptives, Pap smear, clinical breast examination, STIs and HIV. These variables were considered to be general enough to be answerable by male and female respondents and are the most important considerations in reproductive health care in South Africa, as there is a high prevalence of STIs, HIV and cervical and breast cancers. All postgraduate students enrolled in the first semester of 2017 (9444) were invited to anonymously complete the online survey. Data was exported to the Statistical Package for Social Sciences (SPSS) version 23.0 and analysed using descriptive statistics such as mean, standard deviation, frequencies and percentages. RESULTS: Four hundred and six (406) students completed the online survey, of whom 293 were female and 107 males. The age range of respondents was between 18 and 57 years, with the median age for both male and female respondents being 24 years. Six survey responses were excluded from the statistical analysis because of incomplete data. Post graduate students from the African continent comprised 90.75% of the respondents. Most respondents were white (51.50%) from both Africa and abroad. The results indicated that respondents knew about sexually transmitted infections, and human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). Female respondents were more aware of breast examination, and the role of Papanicolaou smear (Pap smear) in SRH. Almost half of the respondents in this study (49%) stated that they had no need for more information about contraceptives. Lecturers were identified as one of the top five sources of information, which suggests that the university environment provides students with important SRH-related information. CONCLUSION: Most postgraduate students had knowledge of sexual and reproductive health with regards to contraception, Pap smear, clinical breast examination, STIs, HIV and AIDS. Further research should focus on the relationship between SRH knowledge and usage among this population. As university lecturers were identified as an important source of information across faculties, the University should consider the incorporation of SRH education in the broader curriculum and as an integral component of student health services.

Approximately 44% of pregnancies worldwide are unplanned, with 25.1 million reported unsafe abortions, 95% of which occur in low- and middle-income countries. Youth, including university students, are particularly vulnerable to poor sexual and reproductive health (SRH) knowledge. In South Africa, university students possess low levels of SRH knowledge yet engage in high-risk sexual behaviours. The study explored postgraduate students' knowledge of contraceptives, sexually transmitted illnesses, human immunodeficiency virus, Pap smear and clinical breast examination at the University of Cape Town in South Africa. A cross-sectional study using an online questionnaire was conducted. Descriptive statistics and multiple linear regression analysis were performed. Of the 403 respondents, 65.8% reported sexual engagement. Overall, students were knowledgeable about selected aspects of SRH and obtained their information from university academic lecturers and health professionals. In conclusion, universities have a key role in the provision of SRH information. Such information should be incorporated into the curricula and other activities, to promote healthy lifestyle choices.

Adolescent paediatric transplant patients' experiences of transition to adult services.

Background: Transition of adolescents from paediatric to adult health services is an important aspect of caring for young people with chronic diseases. Successful transition of adolescents living with a transplant is critical for long-term survival into adulthood. This qualitative study explored the lived experience of adolescents in a South African setting following their planned and supported transition process. Aim: To explore the lived experience of transition for adolescents who had received a renal or liver transplant as a child, from paediatric to adult transplant services in the public health sector. Setting: Cape Town, South Africa. Method: Six purposively sampled adolescents, who had participated in a planned transition from a tertiary level children's hospital to the affiliated adult hospital, were interviewed in the setting and language of their choice. The transcribed interviews were analysed using an interpretative phenomenological analysis (IPA) approach. Results: Five themes emerged: living with uncertainty in a changing world; being known, not knowing, and knowing; ambivalent relationships; the journey of loss; and being heard. Pre-transition planning, support groups, and consistency of clinicians within an accepting environment facilitated the adolescents' individuation and acceptance of self-care responsibility. Conclusion: Carefully planned, collaborative preparation and implementation of a facilitated psycho-supportive intervention for transition can facilitate adolescent cooperation and adherence, minimise the risk of psychological and medical sequelae, and support the adolescent in adapting to living with a transplant as an adult. Contribution: This study offers insight into the importance of planned and supported transitional care of adolescents living with an organ transplant.

Rwandan nursing students' knowledge, attitudes and application of evidence-based practice.

BACKGROUND: Evidence-based practice (EBP) plays a key role in improving health outcomes of a country's population; however, the teaching of EBP is often theoretical and inconsistent, resulting in negative attitudes and limited application. OBJECTIVES: The aim of this study was to determine the knowledge, attitudes and application of EBP by nursing students at a school of nursing in Rwanda. METHOD: A total of 82 third- and fourth-year nursing students completed the survey. Univariate statistical analyses were performed to explore the distribution of data. Chi-square tests were utilised to examine the relation between knowledge, attitudes and application of EBP with the year of study. RESULTS: Most students reported being knowledgeable of the steps of EBP, with a range of 84% - 92%. However, 50% reported negative attitudes and only 12% reported daily searches for evidence. The main reported barriers to the application of EBP were lack of knowledge, lack of time and lack of examples or role models. CONCLUSION: Knowledge about EBP does not necessarily positively influence student attitudes. Evidence-based practice should be integrated into the theoretical and practical component of the nursing curriculum to promote the effective application of EBP by nursing students.

Understanding how young people become motivated to take their human immunodeficiency virus medication (antiretroviral therapy) and how the need for adherence is communicated.

BACKGROUND: Antiretroviral therapy (ART), the only effective treatment for human immunodeficiency virus (HIV), requires excellent long-term compliance. Poor levels of adherence to ART, especially amongst adolescents and young adults in South Africa, have been reported. AIM: This study aimed to explore how young people become motivated to take their HIV medication (ART) and how the need for adherence is communicated. SETTING: The study was conducted in a peri-urban township in the Western Cape, South Africa. METHODS: A qualitative grounded theory approach was employed. Eighty young people were purposively recruited. Participant observation, focus groups and semi-structured interviews were utilised to explore how effective ART adherence messages are in motivating adherence amongst young people and how they would like ART adherence to be communicated to them. All interviews and focus groups were transcribed and analysed by using cross-comparison analysis. Measures to ensure trustworthiness were established and ethical considerations were adhered to. RESULTS: Young people's adherence motivation was an outcome of reconnecting to one or more trusted significant other(s) from within their belonging group, who accepted and supported them, which in turn affirmed their prior belonging identities of son, daughter, other family member or close friend. This facilitated reconnection to their present and future hopes, which in turn increased their motivation to live and to adhere to treatment. CONCLUSION: The findings highlight the need for the development of more effective communication strategies, which facilitate and support young people's reconnection to trusted members of their belonging groups, and also help belonging group members to accept, affirm and support adherence.

Effects of a psychosocial intervention on the quality of life of primary caregivers of women with breast cancer.

PURPOSE: Breast cancer is the leading form of cancer among women in Nigeria. The care of such patients has shifted from hospital-based care to home and community care, with the resultant increase in responsibility and burden on caregivers. The study aimed to implement and evaluate the effectiveness of a psychosocial intervention programme on the quality of life (QOL) and caregiver burden of the primary caregivers of women with breast cancer. METHOD: This was a quasi-experimental study with 108 primary caregivers (54 in both intervention and control groups). The intervention comprised six 90-min educational sessions, held weekly. Topics included information about breast cancer, the emotional aspect of caring, adjustment to the role of caregiver and communication strategies. The intervention group received the psychosocial intervention programme in addition to routine care, and the control group received routine care. Primary outcome (caregiver burden) and caregiver QOL were measured using the Zarit Burden Interview (ZBI) and Caregiver Quality of Life Index-Cancer (CQOLC) at baseline, week six and week 12. RESULTS: The psychosocial intervention reduced caregiver burden at both T1 and T2 (p = 0.000, p = 0.018 respectively) and improved the caregiver QOL (p = 0.000, p = 0.020 respectively) in the intervention group compared to the control group. CONCLUSION: The psychosocial intervention programme had a positive effect on caregiver burden and QOL. Issues such as sustainability of such programmes and advocacy relating to caregiver burden need further research.

Conflict, Complicity, and Challenges: Reflections on the South African Truth and Reconciliation Commission Health Sector Hearing.

PURPOSE: This article describes the work of the South African Truth and Reconciliation Commission (TRC) in examining the role of the health sector in human rights violations in the protracted conflicts during apartheid. ORGANIZING CONSTRUCT: The enabling legislation contained in the Promotion of National Healing and Reconciliation Act of 1995 allowed for in-depth examination of violations and complicity in human rights abuses. We provide an overview of the process of the public hearings, soliciting submissions, examining evidence of abuse, personal testimony of conflict in situations of dual accountability, and ultimately the recommendations made by the TRC. The article also outlines the responses of various health professional training institutions to the TRC's recommendations, the implementation of university health and human rights courses, and some current challenges post-TRC. CONCLUSIONS: The health sector hearings of the TRC provided a window into the structural unequal access, racial discrimination, prejudice, and abuse in the health services under the apartheid regime. Examination of past violations perpetrated by an abusive regime and by those such as health workers operating in such a system is imperative to ensure that these abuses are not repeated in the future. CLINICAL RELEVANCE: In delivering comprehensive, compassionate, and ethical care, healthcare professionals have accountability to respect and promote the human rights of their patients. Training in human rights and its relationship to health should be incorporated into all health professional programs.

e-PC101: an electronic clinical decision support tool developed in South Africa for primary care in low-income and middle-income countries.

Health technology is increasingly recognised as a feasible method of addressing health needs in low and middle-income countries (LMICs). Primary Care 101, now known as PACK (Practical Approach to Care Kit), is a printed, algorithmic, checklist-based, comprehensive clinical decision support tool. It assists clinicians with delivering evidence-based medicine for common primary care presentations and conditions. These assessment and treatment guides have been adopted widely in primary care clinics across South Africa. This paper focuses on the process of designing, developing, and implementing a digital version of the clinical decision support tool for use on a tablet computer. Lessons learnt throughout its development and pilot implementation could apply to the creation of electronic health interventions and the digitisation of clinical tools in LMICs.

Mental health leadership and patient access to care: a public-private initiative in South Africa.

BACKGROUND: Mental health leadership is a critical component of patient access to care. More specifically, the ability of mental health professionals to articulate the needs of patients, formulate strategies and engage meaningfully at the appropriate level in pursuit of resources. This is not a skill set routinely taught to mental health professionals. METHODS: A public-private mental health leadership initiative, emanating from a patient access to care programme, was developed with the aim of building leadership capacity within the South African public mental health sector. The express aim was to equip health care professionals with the requisite skills to more effectively advocate for their patients. The initiative involved participants from various sites within South Africa. Inclusion was based on the proposal of an ongoing "project", i.e. a clinician-initiated service development with a multidisciplinary focus. The projects were varied in nature but all involved identification of and a plan for addressing an aspect of the participants' daily professional work which negatively impacted on patient care due to unmet needs. Six such projects were included and involved 15 participants, comprising personnel from psychiatry, psychology, occupational therapy and nursing. Each project group was formally mentored as part of the initiative, with mentors being senior professionals with expertise in psychiatry, public health and nursing. The programme design thus provided a unique practical dimension in which skills and learnings were applied to the projects with numerous and diverse outcomes. RESULTS: Benefits were noted by participants but extended beyond the individuals to the health institutions in which they worked and the patients that they served. Participants acquired both the skills and the confidence which enabled them to sustain the changes that they themselves had initiated in their institutions. The initiative gave impetus to the inclusion of public mental health as part of the curriculum for specialist training. CONCLUSIONS: Despite the significant adverse social and economic costs of mental illness, psychiatric and related services receive a low level of priority within the health care system. Ensuring that mental health receives the recognition and the resources it deserves requires that mental health care professionals become effective advocates through mental health leadership.

A life uncertain - My baby's vulnerability: Mothers' lived experience of connection with their preterm infants in a Botswana neonatal intensive care unit.

BACKGROUND: Preterm and low-birth weight infants are often separated from their mothers when admitted to neonatal units for stabilisation of body temperature and technological support. OBJECTIVES: The aim of the study was to explore and describe the lived experiences of mothers regarding care of their hospitalised preterm infants in a neonatal unit in a public hospital in Gaborone, Botswana. METHOD: This study utilised a qualitative exploratory and descriptive phenomenological study design. Mothers of hospitalised preterm infants were purposefully selected, with whom there was extensive engagement. Two in-depth interviews were conducted with each participant (P). RESULTS: Mothers were shocked by the sudden birth of a preterm infant and found the neonatal environment intimidating. This increased their fear and anxiety and delayed development of a relationship with their infants. Support from staff, other mothers in the neonatal unit and family members enabled the mothers to overcome their fear and to develop an emotional connection with their infants. CONCLUSION: On-going supportive communication with the mothers by healthcare professionals promotes their confidence and competence in caring for their preterm infants, which in turn promotes mother-infant attachment.

Trends in task shifting in HIV treatment in Africa: Effectiveness, challenges and acceptability to the health professions.

BACKGROUND: Task shifting has been suggested to meet the demand for initiating and managing more patients on antiretroviral therapy. Although the idea of task shifting is not new, it acquires new relevance in the context of current healthcare delivery. AIM: To appraise current trends in task shifting related to HIV treatment programmes in order to evaluate evidence related to the effectiveness of this strategy in addressing human resource constraints and improving patient outcomes, challenges identified in practice and the acceptability of this strategy to the health professions. METHOD: Electronic databases were searched for studies published in English between January 2009 and December 2014. Keywords such as 'task shifting', 'HIV treatment', 'human resources' and 'health professions' were used. RESULTS: Evidence suggests that task shifting is an effective strategy for addressing human resource constraints in healthcare systems in many countries and provides a cost-effective approach without compromising patient outcomes. Challenges include inadequate supervision support and mentoring, absent regulatory frameworks, a lack of general health system strengthening and the need for monitoring and evaluation. The strategy generally seems to be accepted by the health professions although several arguments against task shifting as a long-term approach have been raised. CONCLUSION: Task shifting occurs in many settings other than HIV treatment programmes and is viewed as a key strategy for governing human resources for healthcare. It may be an opportune time to review current task shifting recommendations to include a wider range of programmes and incorporate initiatives to address current challenges.

Trends in task shifting in HIV treatment in Africa: effectiveness, challenges and acceptability to the health professions

Background: Task shifting has been suggested to meet the demand for initiating and managing more patients on antiretroviral therapy. Although the idea of task shifting is not new; it acquires new relevance in the context of current healthcare delivery.Aim: To appraise current trends in task shifting related to HIV treatment programmes in order to evaluate evidence related to the effectiveness of this strategy in addressing human resource constraints and improving patient outcomes; challenges identified in practice and the acceptability of this strategy to the health professions. Method: Electronic databases were searched for studies published in eng between January 2009 and December 2014. Keywords such as 'task shifting'; 'HIV treatment'; 'human resources' and 'health professions' were used.Results: Evidence suggests that task shifting is an effective strategy for addressing human resource constraints in healthcare systems in many countries and provides a cost-effective approach without compromising patient outcomes. Challenges include inadequate supervision support and mentoring; absent regulatory frameworks; a lack of general health system strengthening and the need for monitoring and evaluation. The strategy generally seems to be accepted by the health professions although several arguments against task shifting as a long-term approach have been raised.Conclusion: Task shifting occurs in many settings other than HIV treatment programmes and is viewed as a key strategy for governing human resources for healthcare. It may be an opportune time to review current task shifting recommendations to include a wider range of programmes and incorporate initiatives to address current challenges

The perceived benefit of the disability grant for persons living with HIV in an informal settlement community in the Western Cape, South Africa.

For persons living with HIV (PLWH) in limited socioeconomic circumstances in South Africa, social grants for disability have contributed significantly to alleviate poverty, yet there is a risk that recipients may lose these grants once they are clinically stable on antiretroviral therapy (ART). Our qualitative research explored perceptions and experiences of PLWH on ART concerning the social grant for disability and its contribution to health. Three focus groups were conducted with 15 purposively selected participants who attended a primary care clinic in the Western Cape. A thematic data analysis approach revealed two themes: (a) disability grants as a means of survival and (b) disability grants and ART adherence. The disability grant was considered an essential source of income and, for some, the sole means of survival. Participants valued their health more than the income, however, and, despite the risk of losing the grant, remained adherent to ART.

Pre-registration nursing students' perceptions and experiences of violence in a nursing education institution in South Africa.

Violence is a growing problem worldwide in the field of health care and within the nursing profession. A study comprising a survey and focus groups with nursing students, and interviews with nurse educators was conducted to examine nursing students' perceptions and experiences of violence at a nursing education institution in the Western Cape, South Africa. A self-administered questionnaire was distributed to all nursing students. Two hundred and twenty three (n = 223) respondents completed the questionnaire. Focus groups were conducted with purposively sampled student participants and semi-structured interviews with nurse educators. The findings indicated that the nature of the violent incidents experienced by students on campus, especially in the residences, ranged from verbal abuse to violation of students' property and personal space, and could be attributed primarily to substance abuse. Violence among student nurses could negatively affect learning. In a profession in which nurses are exposed to violence in the workplace, it is important that violence in the learning environment is actively prevented and respect of individual rights, tolerance and co-operation are promoted.

Lived experiences of male intimate partners of female rape victims in Cape Town, South Africa.

BACKGROUND: Sexual violence in South Africa is a major public health and social problem. Sexual assault or rape is a traumatic event which disrupts not only the life of the female rape victim, but also that of her male intimate partner (MIP), irrespective of whether he witnessed or was informed of the incident. OBJECTIVES: The study aimed to explore the lived experiences of MIPs of female rape victims and the meaning of these experiences in the six months following the partner's rape. METHOD: We conducted a longitudinal hermeneutic phenomenological study. Nine purposively sampled adult MIPs were interviewed over a period of six months. The participants were in an intimate relationship with a female rape victim prior to and immediately after the rape; their partners had been treated at a specialised centre for victims of rape and sexual assault. Four interviews were conducted with each of the nine intimate partners of female rape victims: (1) within 14 days of, (2) a month after, (3) three months after, and (4) six months after the rape. RESULTS: Two major themes emerged: being-in-the-world as a secondary victim of rape, and living in multiple worlds, those of their female partners, family, friends, society, employers or colleagues, professionals and the justice system. The participant's familiar world became strange and even threatening, and his relationship with his partner became uncertain. CONCLUSION: Early supportive intervention for intimate partners of female rape victims is required to prevent on-going emotional trauma and alleviate the effects of chronic post-traumatic stress disorder and suffering at intra- and interpersonal levels.

Task shifting and integration of HIV care into primary care in South Africa: the development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention.

BACKGROUND: Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial. METHODS: DEVELOPING THE INTERVENTION: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services. RESULTS: COMPONENTS OF THE INTERVENTION: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process. DISCUSSION: Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout.The STRETCH trial is registered with Current Control Trials ISRCTN46836853.