Ethics of Task Shifting: Exploring the Role of Community Health Workers in HIV Care in Tanzania

In high HIV prevalence settings, the delivery of HIV prevention, treatment and care services has created an enormous strain on health systems currently struggling to cope with critical shortages of health personnel. In attempts to address this dilemma, task shifting has taken place across sub-Saharan Africa to improve access to testing and treatment, decrease service costs, improve outreach, and ultimately combat the spread of HIV. Within this, task shifting can take many forms. For example, nurses can provide treatments that were previously the responsibility of medical doctors; likewise, lay counsellors can offer voluntary HIV testing, which nurses and practitioners formerly conducted. Within the provision of HIV care delivery, Community Health Workers (CHWs) have played a critical role, as they are individuals who receive basic training to conduct specific services that overburdened staff would otherwise struggle to carry out. However, widespread usage of CHWs within HIV care has not been immune to ethical challenges. For instance, CHWs have often been expected to carry out emotionally- and physically-demanding tasks with inadequate training, supervision and even compensation. Moreover, CHWs have been poorly integrated into formal health systems, which has not only impacted the quality of their work, but has further perpetuated power asymmetries between them and other health worker cadres. By using Tanzania as a case study, the objective of this paper is to examine ethical challenges and propose strategies to potentially resolve them, which emerge within HIV care delivery programs that involve CHWs. In this study, I evaluate these challenges through the lens of Ethical Principlism and more specifically, by focusing on the following ethical principles: respect, justice, beneficence, critical reflection, and confidentiality. As discussed, prioritizing these principles can help to ensure that CHWs receive fair and standardized forms of remuneration, are provided with adequate resources to conduct their work, and have increased power and decision-making within HIV programs. These outcomes can ultimately enable CHWs to help combat the spread of HIV through a means that does not exploit or take their critical role within service delivery for granted.