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SAMJ: South African Medical Journal

On-line version ISSN 2078-5135
Print version ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.102 n.6 Pretoria Jun. 2012


2. Republic of South Africa. Department of Labour. Circular Instruction Regarding Compensation for Occupational Asthma. No. 176. Government Gazette 2003:24231(82):6-11.        [ Links ]

3. Myers JE, Garisch D, Cornell JE. Compensation for occupational diseases in the RSA. S Afr Med J 1987;71:302-306.        [ Links ]

4. White NW, Cheadle H, Dyer RB. Workmen's compensation and byssinosis in South Africa: a review of 32 cases. Am J Ind Med 1992;21:295-309.        [ Links ]

5. Ehrlich I. Workmen's compensation in South Africa - an overview. In: Coetzer GJ, Kinghorn J, van der Berg S, eds. Working Documents on the Post-Apartheid Economy. No. 5: Social Safety Nets. Stellenbosch: Stellenbosch Economic Project, 1992:1-9.        [ Links ]

6. Ehrlich RI, White N. Obstacles to submitting occupational disease claims (letter). S Afr Med J 1994;84:227-228.        [ Links ]

7. Ehrlich RI. Compensation for occupational disease: insult to injury. Occupational Health Southern Africa 1995;1:18-19.        [ Links ]

8. Goodman KC, Rees D, Arkles RS. Compensation for occupational lung disease in non-mining industry. S Afr Med J 1994;84:160-164.        [ Links ]

9. Onwuchekwe U, Ehrlich R, Jeebhay M, et al. Failure of the compensation system for occupational diseases and injuries. Occupational Health Southern Africa 2002;8:8-11.        [ Links ]

10. Jeebhay M, Omar F, Kisting S, Edwards D, Adams S. Outcome of workers' compensation claims submitted by the worker's clinic in Cape Town. Occupational Health Southern Africa 2002;8:4-7.        [ Links ]

11. Carman H, Fourie A. The problem of compensation for occupational skin disease in South Africa. Occupational Health Southern Africa 2010;16:12-21.        [ Links ]

12. Public Protector of South Africa. Report on a systematic investigation into allegations of poor service delivery by the Compensation Fund. Report No. 28 of 2009/10. Part 1; 2010. (accessed 21 June 2011).        [ Links ]

13. Public Protector of South Africa. Report on a systematic investigation into allegations of poor service delivery by the Compensation Fund. Report No. 28 of 2009/10. Part 2. 2010. (accessed 21 June 2011).        [ Links ]

14. Mkhwebane-Tshehla BJ. Response to complaint: failure of the Compensation Commissioner to perform statutory functions adequately. Occupational Health Southern Africa 2002;8:16-18.        [ Links ]

15. Supreme Court of Appeal of South Africa (Harms J). Mankayi v Anglogold Ashanti (126/2009)[2010] ZASCA 46.        [ Links ]

16. Republic of South Africa. Annual Report of the Compensation Fund for the year ending March 31 2010. Pretoria: Department of Labour, 2010.        [ Links ]

17. Loewenson R. Occupational disease in Southern Africa: causes and consequences of underreporting. Occupational Health Southern Africa 1998;4:8-22.        [ Links ]

18. Govender M, Ehrlich RI, Mohammed A. Notification of occupational diseases by general practitioners in the Western Cape. S Afr Med J 2000;90:1012-1014.        [ Links ]

19. Bateman C. A costly waiting game. S Afr Med J 2005;6:370-371.        [ Links ]

20. Gantsho M. COID Update. SAMA Insider 2008;June:13.        [ Links ]

21. Naidoo R, Jeebhay M. COID Update (letter). SAMA Insider 2008;September:6.        [ Links ]

22. SAMA (South African Medical Association). Retraction. SAMA Insider 2008;September:6.        [ Links ]

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Accepted 30 June 2011.



Corresponding author: R Ehrlich (





We regret that an error occurred on page 840 of the November 2011 SAMJ, in the guideline 'Recommendations for the management of adult chronic myeloid leukaemia in South Africa'. In the third line of the abstract, as the result of a typographical error, the chromosomal translocation was stated as being between the long arms of chromosomes 9 and 12, when in fact it is chromosomes 9 and 22. The online guideline was corrected on 23 November 2011.

The full reference is: V J Louw, L Dreosti, P Ruff, V Jogessar, D Moodley, N Novitzky, M Patel, A Schmidt, P Willem. Recommendations for the management of adult chronic myeloid leukaemia in South Africa. S Afr Med J 2011;101:840-846.




Nurse initiation and maintenance of patients on antiretroviral therapy: are nurses in primary care clinics initiating ART after attending NIMART training?



David CameronI; Amor GerberII; Melusi MbathaV; Judith MutyabuleIII; Helga SwartIV

IMB ChB, M Prax Med, M Phil, FCFP (SA). Department of Family Medicine, University of Pretoria; and Foundation for Professional Development, Pretoria
IIB Comm, DTE, SLP. Foundation for Professional Development, Pretoria
IIIBFST, B Cur. Foundation for Professional Development, Pretoria
IVHCM. Foundation for Professional Development, Pretoria
VBA (Hons) Psychol. University of South Africa, Pretoria




OBJECTIVES: To determine the percentage of nurses initiating new HIVpositive patients on therapy within 2 months of attending the Nurse Initiation and Maintenance of Antiretroviral Therapy (NIMART) course, and to identify possible barriers to nurse initiation.
METHODS: A brief telephonic interview using a structured questionnaire of a randomly selected sample (126/1 736) of primary care nurses who had attended the NIMART course facilitated by the Foundation for Professional Development (FPD) between October 2010 and 31 March 2011 at primary care clinics in 7 provinces. Outcome measures were the number of nurses initiating ART within 2 months of attending the FPD-facilitated NIMART course.
RESULTS: Of the nurses surveyed, 62% (79/126) had started initiating new adult patients on ART, but only 7% (9/126) were initiating ART in children. The main barrier to initiation was allocation to other tasks in the clinic as a result of staff shortages.
CONCLUSIONS: Despite numerous challenges, many primary care nurses working in the 7 provinces surveyed have taken on the responsibility of sharing the task of initiating HIV-positive patients on ART. The barriers preventing more nurses initiating ART include the shortage of primary care nurses and the lack of sufficient consulting rooms. Expanding clinical mentoring and further training in clinical skills and pharmacology would assist in reaching the target of initiating a further 1.2 million HIV-positve patients on ART by 2012.



Despite the remarkable achievement of the scale-up of antiretroviral therapy (ART) in South Africa over the past 7 years (about 1 million people on ART), the estimated number of people (1.2 million) requiring treatment in the next 2 years exceeds the capacity of the healthcare system if treatment continues to be initiated only by doctors.1-3

In South Africa, there are 69 doctors and 388 nurses per 100 000 population.3 Task-shifting from doctors to nurses for initiating and maintaining ART is a logical strategy to meet the need of increased access.2,4,5 Nurse initiation and maintenance of antiretroviral therapy (NIMART) improves access, is cost effective, is not inferior to doctor managed ART, and achieves similar outcomes of viral suppression, adherence, toxicity and death.4,6 Further motivation to rapidly improve access is evidence showing that more than 80% of deaths during the first year after diagnosis of HIV infection occurred before these patients could be started on ART.7

Because of the need to scale-up access to ART, President Zuma announced on World AIDS Day, 1 December 2009, that any citizen would be able to access counselling, testing and treatment at any health centre.8 This meant increasing the number of sites providing ART from 496 to 4 333.9 The Acting Director-General of Health, Dr K Chetty, authorised professional nurses who had the necessary training and supervision to initiate HIV-infected patients on ART from 1 April 2010. The Foundation for Professional Development (FPD) developed a 5-day NIMART training course that included a revision of basic HIV and opportunistic infections in adults and children, the appropriate investigations, and diagnosis and treatment of HIV, TB and STIs. The theory was reinforced by case study discussions and role-play exercises using the approach of the Integrated Management of Childhood Infections (IMCI) and Practical Approach to Lung Health and HIV/AIDS (Palsa Plus).

Large-scale training of nurses in 7 provinces began in October 2010; by the end of March 2011, 1 736 nurses had attended one of the 39 NIMART courses facilitated by FPD faculty. All participants received a study manual containing all the lecture notes and a file containing the national guidelines on the management of HIV, TB, INH prophylactic therapy (IPT), prevention of mother-to-child transmission (PMTCT) and sexually transmitted infections. The Hlabisa Casebook, a pocket guide of drug interactions and a service directory of health resources in each province were also supplied. Each nurse received a laminated card with the telephone number of the HIV helpline (0800212506). This free service gives the caller access to advice from a clinical pharmacist in the Department of Pharmacology at the University of Cape Town. Nurses were also encouraged to contact the FPD faculty member facilitating the course, if they had clinical questions.

A 60-question multiple choice open book test, with a pass mark of 70%, was administered on the last day of the course. Those who did not pass were given 2 opportunities to rewrite similar tests with different sets of questions. In addition to assessing knowledge, a key aim of the test was to encourage participants to become familiar with the course material.

Following the course, each nurse was encouraged to work in a facility where they could receive weekly mentoring until they were confident to work more independently. Mentoring was available in many sites from the local HIV doctor or a nurse mentor working for one of the PEPFAR-funded partners.



To determine the percentage of nurses initiating new HIV-positive patients on therapy within 2 months of attending the Nurse Initiation and Maintenance of Antiretroviral Therapy (NIMART) course, and to identify possible barriers to nurse initiation.



For quality assurance, a brief telephonic interview using a structured questionnaire was conducted at the end of May 2011 with a randomly selected sample of 126 (7%) of the 1 736 participants of the FPD-facilitated NIMART courses. The number selected from each province was roughly in proportion to the number of nurses from that province attending the NIMART courses (Table I). Verbal consent was obtained at the beginning of the interview, and those who agreed to participate were assured of the confidentiality of their responses that were recorded against a number on the data sheet. About 25% of the nurses initially selected declined to participate. Most said they were too busy at the time. The next participant listed was then contacted. In addition to the questions listed below, participants were asked about the month when they started initiating ART.




The answers were recorded on an Excel spreadsheet, and are summarised in Table II.

At the end of the 5-day course, 60% of the participants were able to achieve at least 70% in the open book exam (Table III).




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