Open Access Open Badges Research

Implementing nurse-initiated and managed antiretroviral treatment (NIMART) in South Africa: a qualitative process evaluation of the STRETCH trial

Daniella Georgeu1*, Christopher J Colvin2, Simon Lewin34, Lara Fairall15, Max O Bachmann6, Kerry Uebel17, Merrick Zwarenstein158, Beverly Draper1 and Eric D Bateman15

Author Affiliations

1 Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, George Street, Mowbray, 7700, Cape Town, South Africa

2 Centre for Infectious Disease Epidemiology and Research (CIDER), School of Public Health and Family Medicine, Falmouth Building, Faculty of Health Sciences, University of Cape Town, Observatory, 7925, Cape Town, South Africa

3 Norwegian Knowledge Centre for the Health Services, Pilestredet Park 7, 0176, Oslo, Norway

4 Health Systems Research Unit, Medical Research Council, Francie van Zijl Drive, Tygerberg, 7505, South Africa

5 Department of Medicine, Faculty of Health Sciences, University of Cape Town, Old Main Building, Groote Schuur Hospital, Observatory, 7925, Cape Town, South Africa

6 Norwich Medical School, University of East Anglia, Earlhan Road, Norwich, NR4 7TJ, United Kingdom

7 Department of Internal Medicine, Faculty of Health Sciences, University of the Free State, Nelson Mandela Drive, Bloemfontein, 9301, South Africa

8 Sunnybrook Research Institute and Department of Health Policy, Management and Evaluation, Health Sciences Building, University of Toronto, College Street, Toronto, M5T 3M6, Canada

For all author emails, please log on.

Implementation Science 2012, 7:66  doi:10.1186/1748-5908-7-66

Published: 16 July 2012



Task-shifting is promoted widely as a mechanism for expanding antiretroviral treatment (ART) access. However, the evidence for nurse-initiated and managed ART (NIMART) in Africa is limited, and little is known about the key barriers and enablers to implementing NIMART programmes on a large scale. The STRETCH (Streamlining Tasks and Roles to Expand Treatment and Care for HIV) programme was a complex educational and organisational intervention implemented in the Free State Province of South Africa to enable nurses providing primary HIV/AIDS care to expand their roles and include aspects of care and treatment usually provided by physicians. STRETCH used a phased implementation approach and ART treatment guidelines tailored specifically to nurses. The effects of STRETCH on pre-ART mortality, ART provision, and the quality of HIV/ART care were evaluated through a randomised controlled trial. This study was conducted alongside the trial to develop a contextualised understanding of factors affecting the implementation of the programme.


This study was a qualitative process evaluation using in-depth interviews and focus group discussions with patients, health workers, health managers, and other key informants as well as observation in clinics. Research questions focused on perceptions of STRETCH, changes in health provider roles, attitudes and patient relationships, and impact of the implementation context on trial outcomes. Data were analysed collaboratively by the research team using thematic analysis.


NIMART appears to be highly acceptable among nurses, patients, and physicians. Managers and nurses expressed confidence in their ability to deliver ART successfully. This confidence developed slowly and unevenly, through a phased and well-supported approach that guided nurses through training, re-prescription, and initiation. The research also shows that NIMART changes the working and referral relationships between health staff, demands significant training and support, and faces workload and capacity constraints, and logistical and infrastructural challenges.


Large-scale NIMART appears to be feasible and acceptable in the primary level public sector health services in South Africa. Successful implementation requires a comprehensive approach with: an incremental and well supported approach to implementation; clinical guidelines tailored to nurses; and significant health services reorganisation to accommodate the knock-on effects of shifts in practice.

Trial registration


Antiretroviral treatment; NIMART; South Africa; Primary healthcare; Nurse training; Process evaluation; PALSA PLUS