Abstract:
This PhD research project was conducted in Tshwane district of Gauteng province, South Africa. This project was subdivided into four different papers.
First abstract
The aim of this study was to understand potential benefits and barriers to delivering HIV care at the community level in Tshwane district and develop recommendations for improvement. Seven focus group discussions were conducted with 58 participants. While home-based human immunodeficiency virus (HIV) care was seen as a support strategy which could motivate patients to take their medication, the unpredictability of patients’ responses to HIV test results, incorrect addresses (driven by the need for identity documents), fear of stigma through association with ward-based primary health care outreach teams (WBPHCOTs), especially those in uniform, little or no preparation of patients for home-based care, and lack of confidentiality and trust were raised as potential barriers.
Second abstract
The aim of this study was to assess the acceptability of community-based HIV services offered by community health workers (CHWs). A survey was conducted in 10 clinics across Tshwane district, Gauteng, South Africa. CHWs conducted interviewer-administered standardised questionnaires with 674 adult participants. Overall, 95.5% of participants thought that home-based HIV care is a good initiative and rated screening for illnesses and referral to health facilities highly. Although the vast majority (>94%) were willing to disclose their status to health professionals in clinics, women were more willing to do so. However, only 53.6% of participants were willing to disclose their HIV status to a CHW from the same neighbourhood and 28.8% would find it problematic if CHWs visited them at home with branded cars.
Third abstract
This 2 x 2 factorial cohort study assessed the effect of two interventions - WBPHCOTs and an adherence game - on 12-month retention in care and virological suppression in participants newly initiated on ART. Clinics were randomized into four comparator arms: WBPHCOT; Game; WBPHCOT-Game in combination; and Control (standard of care). A total of 467 participants were included in the analysis: WBPHCOT (n=72); Games (n=126); WBPHCOT-Games (n=85); and Control (n=184). After 12 months, 340 participants (86.2%) remained in care. The Games group had the highest retention compared to the Control group (96.8% vs 77.8%; relative risk [RR] 1.25; 95% CI 1.13–1.38; p=0.01). While retention was better in the WBPHCOT-containing interventions than in the Control group, the differences were not statistically significant. Younger participants (<35 years) were significantly less likely to remain in care (71% vs 89%; RR 0.80; 95% CI 0.69 – 0.93; p=<0.001). The overall virological suppression rate was 75.3% and was similar across the four arms.
Fourth abstract
Following the reporting requirements of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, an aggregative narrative synthesis approach was used to summarize the results of qualitative studies published between 1 January 2000 and 6 November 2020. In total, 17 studies met the selection criteria and were included in the analysis. They reported on a range of roles played by CHWs in HIV care, including 1) Education: home visits; health education and promotion; 2) HIV-specific care: HIV testing services; screening for opportunistic infections and acute illness; medication delivery; tracing persons who had defaulted from care; and 3) Support: treatment support; referral; home-based care; and psychosocial support. Many different barriers to community-based HIV care were reported and centred on the following themes: 1) Stigma and non-disclosure: stigma; non-disclosure of HV status; concerns about confidentiality; 2) Inadequate support: lack of resources, inadequate training, lack of support, poor communication, inadequate funding, and inadequate monitoring; and 3) Health care system challenges: patient preference for more frequent visits, and poor integration. Most articles also provided a set of recommendations to mitigate these barriers, most notably: Professionalizing CHW programmes; intensifying health campaigns; strengthening CHW supervision, providing CHWs with the necessary equipment, and improving CHW attitudes.
Conclusion
The 2 x 2 factorial cohort study was the first to demonstrate that a physical adherence game improved the retention of people living with HIV (PLWHIV) newly initiated on ART and hence has the potential to improve treatment outcomes. In addition, home-based HIV care was largely accepted as an important and positive intervention. To successfully implement effective home-based HIV care in South Africa, it is important to address perceived barriers to such care and involve all stakeholders, from decision makers to CHWs and PLWHIV.
