The Achilles' heel of prevention to mother-to-child transmission

16 Pages·2017·1.38 MB·English

SAHARA-J: Journal of Social Aspects of HIV/AIDS
An Open Access Journal
ISSN: 1729-0376 (Print) 1813-4424 (Online) Journal homepage: http://www.tandfonline.com/loi/rsah20
The Achilles’ heel of prevention to mother-to-child
transmission of HIV: Protocol implementation,
uptake, and sustainability
Violeta J. Rodriguez, Richard P. LaCabe, C. Kyle Privette, K. Marie Douglass,
Karl Peltzer, Gladys Matseke, Audrey Mathebula, Shandir Ramlagan,
Sibusiso Sifunda, Guillermo “Willy” Prado, Viviana Horigian, Stephen M.
Weiss & Deborah L. Jones
To cite this article: Violeta J. Rodriguez, Richard P. LaCabe, C. Kyle Privette, K. Marie Douglass,
Karl Peltzer, Gladys Matseke, Audrey Mathebula, Shandir Ramlagan, Sibusiso Sifunda, Guillermo
“Willy” Prado, Viviana Horigian, Stephen M. Weiss & Deborah L. Jones (2017) The Achilles’
heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake,
and sustainability, SAHARA-J: Journal of Social Aspects of HIV/AIDS, 14:1, 38-52, DOI:
10.1080/17290376.2017.1375425
To link to this article: http://dx.doi.org/10.1080/17290376.2017.1375425
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Original Article
The Achilles’ heel of prevention to mother-to-child transmission of HIV:
Protocol implementation, uptake, and sustainability
VioletaJ.Rodriguez a, RichardP.LaCabeb, C.KylePrivettec, K.MarieDouglassd, KarlPeltzer e†,
Gladys Matseke f, Audrey Mathebulag, Shandir Ramlagan h, Sibusiso Sifunda i†,
Guillermo “Willy” Prado j‡, Viviana Horigian k‡, Stephen M. Weiss l§, Deborah L. Jones m§∗
aMSEd is aSenior Research Associate at the Department ofPsychiatryand Behavioral Sciences, University of Miami
Miller School of Medicine, Miami, FL, USA
bBA, is aVolunteer Research Assistant at the DepartmentofPsychiatryand Behavioral Sciences, University ofMiami
Miller School of Medicine, Miami, FL, USA
cisaseniorundergraduatestudentintheDepartmentofBiologyandResearchAssistantinthe,DepartmentofPsychiatry
and Behavioral Sciences, University ofMiami Miller Schoolof Medicine, Miami, FL, USA
dBS,isathird-yearmedicalstudentattheUniversityofMiamiMillerSchoolofMedicine,Miami,FL,USAandpursuing
joint Doctor of Medicine andMaster ofPublic Healthdegrees
ePhD,is adistinguished research fellow inthe HIV/AIDS/STIsandTB(HAST)Research Programme,Human Sciences
ResearchCouncil, Pretoria,South Africa
fMPH, is aSenior Researcher/PHD research trainee in the HIV/AIDS/STIs andTB (HAST) Research Programme,
7
1 Human Sciences Research Council, Pretoria,South Africa
0
2 gBA(Hons), isa Project Supervisor in the HIV/AIDS/STIs andTB (HAST) Research Programme,Human Sciences
r
be ResearchCouncil, Pretoria,South Africa
m
e hMDevSt,isaResearchSpecialistintheHIV/AIDS/STIsandTB(HAST)ResearchProgramme,HumanSciencesResearch
ept Council, Pretoria, South Africa
9 S iPhD,MPH,isChiefResearchSpecialistattheHIV/AIDS/STIsandTB(HAST)ResearchProgramme,HumanSciences
1
9 ResearchCouncil, Pretoria,South Africa
3:4 jPhD, isthe Dean ofthe Graduate School, the Leonard M. Miller Professor ofPublic Health Sciences, Miami, FL, USA
at 0 kMD,isAssociateProfessorattheDepartmentofPublicHealthSciences,UniversityofMiami,MillerSchoolofMedicine,
] Miami, FL, USA
6
4 lMD, is aProfessor at the Department ofPsychiatryand Behavioral Sciences, University of Miami Miller Schoolof
8.
7 Medicine, Miami, FL, USA
5.
5 misaProfessorattheDepartmentofPsychiatryandBehavioralSciences,UniversityofMiamiMillerSchoolofMedicine,
2
5. Miami, FL, USA, ∗Email: [email protected]; [email protected]
6
1
[
y
b
d
e
d Abstract
a
o
nl TheJointUnitedNationsProgrammeonHIVandAIDSproposedtoreducetheverticaltransmissionofHIVfrom(cid:3)72,200to(cid:3)8300
w
o newly infected children by 2015 in South Africa (SA). However, cultural, infrastructural, and socio-economic barriers hinder the
D
implementation of the prevention of mother-to-child transmission (PMTCT) protocol, and research on potential solutions to
address these barriers in rural areas is particularly limited. This study sought to identify challenges and solutions to the
implementation,uptake,andsustainabilityofthePMTCTprotocolinruralSA.Forty-eightqualitativeinterviews,12focusgroups
discussions(n¼75),andonetwo-dayworkshop(n¼32participants)wereconductedwithdistrictdirectors,clinicleaders,staff,
and patients from 12 rural clinics. The delivery and uptake of the PMTCT protocol was evaluated using the Consolidated
Framework for Implementation Research (CFIR); 15 themes associated with challenges and solutions emerged. Intervention
characteristics themes included PMTCT training and HIV serostatus disclosure. Outer-setting themes included facility space,
healthrecordmanagement,andstaffshortage;inner-settingthemesincludedsupplyuseandavailability,staff–patientrelationship,
∗ProfessorinPsychologyatFreeStateUniversity,Bloemfontein,SouthAfrica;DepartmentofPsychology,UniversityofLimpopo,Turfloop,SouthAfrica;
ProfessorattheASEANInstituteforHealthDevelopment,MahidolUniversity,Salaya,Thailand.
†HonoraryProfessorattheCentreforGlobalHealthResearch,WalterSisuluUniversity,Mthatha,SouthAfrica.
‡DirectoroftheDivisionofPreventionScienceandCommunityHealthattheUniversityofMiamiMillerSchoolofMedicine,Miami,FL,USA
‡DirectorofPublicHealthEducation,DirectoroftheAmericasInitiativeforPublicHealthInnovation,andExecutiveDirectoroftheFloridaNodeAlli-
anceoftheNationalDrugAbuseTreatmentClinicalTrialsNetwork(CTN)housedattheUniversityofMiami,CoralGables,FL,USA
§AProfessor(Honorary)attheDepartmentofPsychiatry,SchoolofMedicine,UniversityofZambia,Lusaka,Zambia
§AnAssociateProfessor(Honorary)attheDepartmentofPsychiatry,SchoolofMedicine,UniversityofZambia,Lusaka,Zambia
#2017TheAuthor(s).PublishedbyInformaUKLimited,tradingasTaylor&FrancisGroup
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/4.0/),
whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
38 Journalof Social Aspects ofHIV/AIDS VOL. 14 NO.1 2017
Article Original
andtransportationandscheduling.Themesrelatedtocharacteristicsofindividualsincludedstaffrelationships,initialantenatalcare
visit,adherence,andcultureandstigma.Implementationprocessthemesincludedpatienteducation,testresultsdelivery,andmale
involvement. Significant gaps in care were identified in rural areas. Information obtained from participants using the CFIR
framework provided valuable insights into solutions to barriers to PMTCT implementation. Continuously assessing and
correctingPMTCTprotocolimplementation,uptakeandsustainabilityappearmeritedtomaximizeHIVprevention.
Keywords:implementationscience,PMTCT,HIV,SouthAfrica
Re´sume´
LeprogrammeconjointdesNationsUniessurleVIHetleSIDAavaitpropose´dere´duireleschiffresdetransmissionverticale
du VIH de 72.000 a` 8.300 chez de nouveaux enfants infecte´s en Afrique du Sud tout au long 2015. Cependant, les obstacles
culturels, des infrastructures, et socioe´conomiques ont empeˆche´ la mise en route du protocole de pre´vention de la
transmission me`re-enfant (PTME). D’autre part, la recherche de solutions possibles pour e´viter ces obstacles dans des
milieux ruraux est spe´cialement limite´e. Cette e´tude est oriente´e a` l’identification des difficulte´s et des solutions pour la
mise en route, adaptation et soutenabilite´ du protocole PTME dans des re´gions rurales d’Afrique du Sud. Dans ce but,
7 l’e´tude a compris 45 interviews qualitatives, 12 group de discussion (n ¼ 75) et un workshop de deux journe´es (n ¼ 32
01 participants) de´veloppe´s avec la participation des directeurs de district, des cliniciens responsables, personnel d’aide et des
2
r patients de 12 cliniques rurales. La livraison et l’acceptation du protocole PTME ont e´te´ e´value´es en accord avec le CFIR
e
b (Consolidated Framework for Implementation Research) : 15 sujets associe´s aux difficulte´s et aux solutions sont apparus.
m
e La re´ve´lation de l’entrainement dans le protocole PTME et du status se´rique VIH sont des sujets caracte´ristiques de
pt
e l’intervention. La disponibilite´ d’espace, le traitement et controˆle des histoires cliniques et la limitation de moyens
S
9 humains peuvent eˆtre conside´re´s comme des aspects moins directs, tandis que l’usage et la disponibilite´ de ressources
1
9 mate´rielles, les relations entre le personnel qualifie´ et le patient, le transport et son horaire sont des aspects de controˆle
4
3: plus directs. Les aspects qui sont d’avantage en rapport avec les caracte´ristiques individuelles de chaque patient incluent
0
at les relations avec le personnel qualifie´, la visite initiale de soin pre´natale, l’adhe´sion au protocole, la culture et les stigmas.
] L’e´ducation du patient, la livraison des re´sultats des tests et le compromis masculin sont les aspects le plus importants
6
4
8. pour la mise en marche du processus. Quelques lacunes dans l’application des soins ont e´te´ identifie´es dans des re´gions
5.7 rurales. Ne´anmoins, l’information obtenue des participants qui ont utilise´ the sche´ma CFIR a fourni des donne´es tre`s
25 pre´cieuses pour trouver des solutions aux proble`mes de la mise en route du protocole PTME. Dans le but d’ame´liorer au
65. maximum la pre´vention du VIH, il est tre`s important de suivre de tre`s pre`s le protocole PTME pour appliquer les
1
[ corrections, adaptation et soutenabilite´ ne´cessaires
y
b
d Motscle´s:implementationresearch,VIHetleSIDA,pre´ventiondelatransmissionm`ere-enfant(PMTE),AfriqueduSud
e
d
a
o
nl
w
o
D
Without treatment, global rates of mother-to-child transmission PMTCT coverage (Peltzer et al., 2011), and a 52% decline in
(MTCT)ofHIVrangedfrom20%to45%(DeCocketal.,2000), new HIV infections (UNAIDS, 2013). However, rural SA
though these rates were substantially reduced by Prevention of regions continue to report higher MTCT rates (Wettstein et al.,
Mother-to-Child Transmission (PMTCT) strategies (De Cock 2012)aswellascultural,infrastructural,andsocio-economicbar-
etal.,2000; Johri&Ako-Arrey,2011; Luoetal.,2007).In2009, riers that influence PMTCT availability and accessibility
approximately 72,200 South African children were infected with (Amnesty International, 2014; Ladur, Colvin, Stinson, &
HIVthrough MTCT(Joint UnitedNations ProgrammeonHIV Thorne, 2015; Peltzer, Mosala, Shisana, Nqueko, & Mngqunda-
and AIDS [UNAIDS], 2011). Given the number of vertically niso, 2007; Skinner, Mfecane, Gumede, Henda, & Davids,
infected children in SouthAfrica(SA), UNAIDSimplemented a 2005). One suchrural areais Mpumalanga Province, whichhas
plan to reduce new HIV infections in children to 8300 by 2015 oneofthehighestantenatalclinicHIVprevalencerates(35.6%;
(UNAIDS, 2011), reduce the rate of MTCT of HIV to less than NationalDepartmentofHealth,2012)andsecondhighestpopu-
5%, and increase antiretroviral therapy (ART) uptake among lation-basedprevalenceofHIVinSA(14.1%;Shisanaetal.,2014).
infant-mother pairs to 90% (UNAIDS, 2013). In SA, national
PMTCTprogramingresultedinasubstantialreductioninMTCT BarrierstoPMTCTimplementationinMpumalangaincludeillit-
ratesinfacility-basedstudies,thoughtheimpactofhealthsystem eracy,mothers’unwillingnesstotestthemselvesortheirinfants,
programingonthesereductionsisunclear(Gogaetal.,2014). lack of government documentation, poor medical compliance
(Peltzer et al., 2009, 2011), and patient dissatisfaction (Ladur
PMTCT strategies are cost-effective in regions where HIV rates etal.,2015;Phaswana-Mafuyaetal.,2011).Patient-levelbarriers
arehigh(Johri&Ako-Arrey,2011).Since2009,SAhasachieved includepoornevirapine(NVP)uptakeandnondisclosureofHIV
an increase in PMTCT accessibility (Mayosi et al., 2012), 90% serostatus despite intervention (Phaswana-Mafuya et al., 2012).
VOL. 14 NO.1 2017 Journaldes Aspects Sociaux duVIH/SIDA 39
Original Article
Health system barriers include insufficient staff training, staff sub-district,andcliniclevels).Thisstudywasconductedincollab-
shortage, limited supervision (Ladur et al., 2015; Peltzer et al., oration with Protect Your Family (PYF), a PMTCT initiative
2009;Phaswana-Mafuyaetal.,2012),inadequatepatienttracking being administered at Community Health Centers (CHCs) in
(Peltzer et al., 2009) and loss to care before completing the Mpumalanga Province. Information regarding PYF CHC selec-
PMTCT protocol, the PMTCT cascade (Barker, Mphatswe, & tionhasbeenpublished(Jonesetal.,2014)andisdetailedonclin-
Rollins, 2011). Drop-out from the PMTCT cascade has been icaltrials.gov(protocolNCT02085356).
associated withlack ofon-siteHIVtesting,delayed HIVtesting
results,lackofHIVserostatusawareness,nondisclosuretopart- Recruitment,enrolment,andcompensation
ners and delayed ART initiation (Woldesenbet et al., 2015). Clinic staff interviews (n¼48) and patient focus group discus-
ThesebarrierstoPMTCThighlighttheneedtoidentifychallenges sions(n¼12FGDs)wereconductedatCHCs,andsmallgroup
and devise solutions to enhance PMTCT protocol implemen- discussions (n¼10; total n¼32 participants) were conducted
tation in rural South Africa. Proposed solutions to these chal- at the HSRC in Pretoria, SA, among attendees at a workshop
lenges have included peer support for PMTCT retention/ on dissemination and implementation of evidence-based inter-
adherence (Sam-Agudu et al., 2015), male partner involvement ventions. Three to nine female patients attending the CHCs for
(Jones et al., 2014; Jones, Chakhtoura, & Cook, 2013; Peltzer ante-and post-natalcareserviceswererecruitedforeachofthe
et al., 2009, 2011), HIV testing (Peltzer, Mlambo, & Phaweni, FGDs. The consenting process took place in private CHC
2010; Sprague, Chersich, & Black, 2011), ART initiation during offices in English, Zulu, or Sotho. Interviews ranged from
7 pregnancy (Tsague et al., 2010), improved clinic staffing, infant 1hour to 1hour and 24minutes (mean¼1hour and
1 follow-up post-delivery, intimate partner violence (IPV) screen- 9minutes), and FGDs ranged from 23 to 55minutes (mean¼
0
r 2 ing, and promotion of safer infant feeding practices (Peltzer 41minutes). FGD participants were compensated (cid:3)US$5 in
e
b et al., 2011). Improved protocol implementation may also South African Rand for their participation; interviewed staff
m
e reduce MTCT among women who seek care late in pregnancy andworkshopattendeesdidnotreceivemonetarycompensation.
pt
e (Lallemant et al., 2015). However, uptake of the proposed sol-
S
9 utionshasbeenlimited,andchallengescontinuetoimpactcom- HSRCstudypersonnel,socialscientistswithdoctoral,mastersor
1
9 prehensiveimplementationinruralcommunities. bachelordegreeswithspecializationinHIVresearch,conducted
4
3: all interviews, FGDs and facilitated the workshop. Rapport was
0
at Solutions geared to the local socio-cultural context may be more developed with participants by engaging in casual conversation
] effective in responding to local barriers (Gourlay, Birdthistle, prior to the interviews and FGDs. Interviews and FGDs were
6
4
8. Mburu,Iorpenda,&Wringe,2013)buthavereceivedlittleattention audio-recorded, transcribed verbatim, and translated. FGD and
5.7 inPMTCTresearch.Thisstudyusedacomprehensiveimplemen- interview transcripts resulted in 67,358 and 204,607 words,
25 tation science approach, the Consolidated Framework for respectively.
5. Implementation Research (CFIR), to evaluate the delivery of the
6
1
[ PMTCTprotocolandidentifyimplementationbarriersandnovel, Workshop
y
b culturally tailored solutions. The CFIR is designed to maximize Workshopattendeesweredividedintosmallgroupsofclinicians
d
e health outcomes by facilitating effective intervention implemen- andseniorlocalstakeholderstofacilitatetheinclusionofdifferent
d
oa tation,andiscomprisedoffivedomains:Interventioncharacteristics, perspectives.Threestemswereprovided:(1)brain-stormingchal-
nl outer setting(e.g.patient needs and resources), inner setting(e.g. lengesamongattendeesworkinginsimilarpositions,(2)explor-
w
o culture),characteristicsoftheindividualsinvolved(e.g.agency,influ- ing solutions among a group of varied attendees, and (3)
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ence),andimplementationprocess(Damschroderetal.,2009). discussing clinic strengths. A group leader recorded challenges
and solutions once consensus was reached and then reported
UtilizingthefiveCFIRdomainsandconstructs,theinfluenceof their ideas to all other attendees. Themes identified during the
healthcaresystem-,clinicstaff-,andpatient-levelchallengesand workshop guided University of Miami and Human Sciences
solutions were examined at each healthcare system level on Research Council staff in developing topics for the qualitative
implementation and execution of the PMTCT protocol. It was interviewsandFGDs.Theworkshopwasconductedon8and9
theorized that in-depth examination of PMTCT protocol pro- September,2014.
visioninruralSAcouldguideimplementation,uptake,andsus-
tainment of the program, thereby improving its effectiveness. It Clinicstaffinterviews
wasreasonedthatkeystakeholderswouldprovidethemostvalu- Questions and stems for clinic staff interviews are presented in
able information on challenges, solutions, and strategies to Table 1, and targetedinformationabout thestrengths, potential
enhance uptake of the PMTCT protocol in rural Mpumalanga solutions, and challenges of HIV care at CHCs. The individual
Province, and that study findings could guide implementation interviewformatwasusedtomaximizestaffdisclosureregarding
incomparableruralregions. thetopicspresented,asitwasbelievedthatagroupformatwould
hinder staff disclosure when discussing certain topics with co-
Method
workers or supervisors. Interviews were conducted from 5
Participants and procedures November2014to27May2015.
Prior to study onset, approval was obtained from the Human
SciencesResearchCouncilResearchEthicsCommittee,theUni- Patientfocusgroupdiscussions
versity of Miami Institutional Review Board, and the Mpuma- FGD questions and stems addressed testing, HIV prevention,
langa Department of Health and Welfare (provincial, district, treatment, infant feeding, family planning, safer sex, male
40 Journalof Social Aspects ofHIV/AIDS VOL. 14 NO.1 2017
Article Original
Table 1. Interview questions andstems forqualitativeinterviews.
Training,protocol,andclinicenvironment
1.DescribethetrainingyoureceivedtocareforpeoplelivingwithHIV.
i. Whatwerethemostusefulaspectsofyourtraining?Whatkindofongoingtraininghaveyoureceived?Whenwasthelasttraining?
ii. DoyouwishyoureceivedmoretrainingonHIVcareandPMTCT?Why?Howdoyoufeelaboutthetrainingyouhavereceived?
iii. WhatskillsdoyouusetocareforpeopletestingHIVpositiveduringpregnancy?
2.DescribethePMTCTprotocolatyourclinic.
i. Whatarestaffattitudesaboutprovidingtheprotocol?
ii. WhatchallengesarethereinprovidingthePMTCTprotocol?
iii. Whatgapsarethereforcare?
3.Describetheenvironmentatyourclinic.Howdostaffworktogether?
4.Forpatientswhotestpositive,describehowtheyreceivetheirresults?
i. WhateffortsaremadetogetmalepartnerstestedforHIValso?
ii. ForpatientswhotestpositiveforHIV,howaretheyengagedintreatment?Whateffortsaremadetogetthemengagedintreatment?
5.AtwhatstageinpregnancywouldyoulikewomentobeginattendingtheANC?
i. Whendowomentypicallybeginattending?Whyatthattime?
6.ForwomenattendingtheANC,whateffortsaremadetogetpartnerstoattend?
7 i. WhatarestaffattitudesaboutmenattendingtheANC?Wheredotheywait?
1
0 ii. Dotheycomeintheroomduringthewoman’svisit?
2
r 7.DescribesomeofthechallengesexperiencedbystaffinimplementingthePMTCTprotocol?
e
mb i. WhatdoyoufindchallengingaboutgettingwomenandtheirpartnerstotestforHIV?
e ii. WhatdoyoufindchallengingaboutthePMTCTprogram?
ept iii. Whatelementsoftheprotocolarethemostchallenging?
S
9 8.Canyoudescribeatimewhenallorpart(s)oftheprotocolwasnotfollowedornotworkingatyourclinicoratanother?
9 1 i. Whywastheprotocolnotfollowed?
4 ii. Whathappened?
3:
0 9.WhatchangeswouldyourecommendtoensurethattheprotocolforPMTCTisimplemented?
] at 10.Whataresomeofthebarriersthatpreventmakingthesechangestoimprovetheprogram?
6
4 i. Whatwouldneedtobeinplaceforthesechangestohappenandworkwell?
8. ii. Describewhatyouthinkcouldbebarrierstoadoptingthesechangesatyourclinicoratanyclinic.
7
5. 1. HowreadyarestafftochangeifitwouldimprovethePMTCTprogram?
25 2. Whatwouldneedtohappentohelpstaffgetreadyforchange?
5.
6 11.IsthereanythingyouwouldliketoaddorthinkwouldbeusefultoknowinimprovingtheimplementationofthePMTCTprotocolandachieving
1
[ itsgoals?
y
b
d PMTCTgoalsandpotentialsolutions
e
ad Thefollowingaresomeproblemsthatoccurinclinics.Whatkindofsolutionsareused?
nlo GOAL:Step1:EarlyANCbooking(,20weeks),counseling,HIVtestingandCD4testing
w
o 1. Manymotherscomelatefortheirfirstantenatalbooking
D 2. NotallmothersarecounseledandtestedforHIVtestingattheirfirstantenatalbooking
3. NotallHIV-positivemothershaveCD4testblooddrawn
GOAL:Step2:Treatmentforpatientsw/CD4.350
1. MothershaveCD4testdrawn,butdonotreturnforresults
2. MothersareoftendelayedbeforetheirreceiveARV/HIVmedicationwaitingforCD4countresults
Step3:CD4,350:rapidreferralandHAARTinitiation
1. HAARTclinicsareoverburdenedandpregnantwomenaredelayedinstartingARV/HIVmedication
2. ClientsarereferredforARV/HIVmedicationbutdonotpitchupatARVclinic
3. ClientsarereferredforARV/HIVmedicationbutnoinformationissenttothepatient,whichleadstodelaysandduplication
4. ClientsaredelayedforARV/HIVmedicationbecauseatreatmentsupporterhasnotbeenidentified
GOAL:Step4:Laborward:three-hourlyAZTduringlabor,sdNVPtomotherandbaby,andstartAZTtoinfant
1. ThedeliveryofPMTCTmedicinesisunreliableduringlabor
2. ItisnotalwaysclearwhichmothersarepartofthePMTCTProgram
3. SomemothersdidnotgettestedduringtheANCperiodbutcanstillreceiveARVforPMTCT
GOAL:Step5:HIVexposedbabiesgetPCRat6weeks
1. Thepost-natalcareclinicdoesnotalwaysknowwhichbabieswereHIVexposed.
2. PCRtestingisnotalwaysreliable.
VOL. 14 NO.1 2017 Journaldes Aspects Sociaux duVIH/SIDA 41
Original Article
GOAL:Adherence,exclusivebreastfeeding,maleinvolvement,familyplanning,reporting&datacapture
1. Somemothersmayfeelbabiesdonotgetenoughnourishmentonlybreastfeeding
2. Sometimesindividualpatientinformationisnotcorrectlyornotatallreportedinregistersandreportingtemplates–monthlysummaries.
3. SomewomenmaynottaketheirARVmedicationsasprescribed.
4. ItisdifficulttoinvolvethemalepartnerinPMTCT
involvement,personalexperienceswithPMTCTandHIVknowl- Intervention characteristics
edge (see Table 2). FGDs were conducted with mothers and The CFIR domain of intervention characteristics addresses
expectant mothers with HIV. A group format was used with whether an intervention – the PMTCT protocol – is intern-
patients to allow discussion among patients, which, given the ally or externally developed, as well as the perception of the
variety of issues faced by patients, theoretically provided a intervention by key stakeholders, intervention credibility and
broaderperspectiveofchallengesandsolutions.FGDswerecon- the potential for positive health outcomes. Within the CFIR,
ductedfrom18February2015to7May2015. intervention characteristics, e.g. intervention source, interven-
tion quality, relative advantage of intervention, adaptability,
Qualitative analyses complexity, indicate the potential for PMTCT to demonstrate
GroundedTheory (Glaser&Strauss,2009)was used forcoding effectiveness, considering stakeholder perceptions and the
17 andanalyzinginterview,FGD,andworkshopdata(Damschroder pros and cons of implementation (CFIR, 2014). PMTCT train-
0
2 et al., 2009), which were coded and analyzed closely to identify ing, disclosure of HIV status to partner/family and condom
r
be common themes related to barriers and solutions to PMTCT use emerged as the most influential themes in intervention
m
e implementation.Thecodingstrategiesusedtocodealltranscripts characteristics.
pt included open, axial, selective, and theoretical coding (Glaser,
e
S
9 2005; Strauss & Corbin, 1990). During the coding process, an
1
9 external coder was trained and asked to code five previously PMTCTtraining
3:4 coded transcripts to assess the levelof agreement and reliability Challenges. Among clinic staff, the majority expressed satisfac-
at 0 of identified themes and interpretations. The same procedure tion with the length and content of PMTCT training received,
] wasrepeatedwithathirdcoderandfourthcoder,withfewertran- felt confident about the skills they had gained, and understood
6
8.4 scripts (three). Coding and thematic disagreements, although PMTCT. Participants reported gaining interpersonal skills and
5.7 uncommon, were discussed until consensus was reached. In learning the PMTCT protocol, which helped them during
25 addition, regular meetings were conducted with the team to patient interactions:
5. discuss and redefine codes and themes, which were followed by
6
[1 reflections on the influence of perceptions and assumptions on The skills that is more important are interpersonal skills, in
by coding. Interview, FGD, and workshop themes were compared terms of counseling and then calming the patient down so
ed andcontrastedusingtheoreticalmemoing(Glaser,1998)toident- that they can understand and accept that HIV will be part
d
oa ifydifferentstaff-andpatient-levelperspectivesforinterpretation oftheirlife...(ProfessionalNurse,ClinicJ)
nl andreflectionbythecodersandauthors.
w
o SomeclinicstaffappearedconfusedregardingPMTCT,perhaps
D
Results
duetotheamountoftimeelapsedsinceinitialtraining.Thiscon-
Of those approached for interviews (n¼60, 5 per facility) and fusion underscored the benefit of regular follow-up/refresher
FGDs(n¼120,10perCHC),80%and63%agreedtoparticipate, trainingsessions:
respectively.Thereasonprovidedbythosedecliningwasprimar-
ily time constraints. Interview participants included lay counse- Idon’tremember[whenaskedaboutPMTCT]butIdohave
lors, facility operation managers, clinic facility managers, trainingsthatinvolveHIV.(ProfessionalNurse,ClinicR)
professional nurses, assistance nurses, staff/enrolled nurses, and
an HIV Counseling and Testing counselor. The workshop was Somestaffsharedthatnursesatvariousfacilitiesmayhavediffer-
heldwith32cliniciansandstakeholders,includingfacilityoper- ent levels of understanding regarding the protocol, which may
ation managers, clinic committee members, and district and leadtoincorrectapplicationofPMTCTprocedures:
sub-district HIV, AIDS, and sexually transmitted infections
(HAS) managers; all participated. Fifteen themes emerged from ...there are times where you feel there new drugs that are
interview, FGD and workshop data (see Table 3). Emerging introducedor therearenew bloodthatsupposedtobedone
themes are presented under the five CFIR domains to identify but you don’t know you just sticking to the old guidelines.
the challenges and solutions associated with each of the factors (ProfessionalNurse,ClinicY)
that have been found to be predictive of implementation
successorfailure(CFIR,2014;Damschroderetal.,2009).Itwas Solutions.Mostparticipants(79%)desiredadditionaltrainingto
theorized that organizing each of the themes by CFIR domains remaincurrentonPMTCTguidelines.Workshopattendeesand
would help future programs, interventions, and policies target clinic staff agreed that providingmonthly or quarterly refresher
andprioritizeareasofneed,whilevalidatingthedomainsaspre- trainings and mentoring/coaching following major updates to
dictorsofimplementationsuccessorfailure. thePMTCTprotocolguidelineswouldenhanceimplementation.
42 Journalof Social Aspects ofHIV/AIDS VOL. 14 NO.1 2017
Article Original
Table 2. Interview questions andstems for focusgroups.
Acceptability
1.WhathaveyouheardaboutantenatalcareandthePMTCTprogramattheantenatalclinic(ANC)?
i. WhatseemstoworkwellintheANCPMTCTprogram?
ii. WhatdoesnotworkwellintheANCPMTCTprogram?
iii. WhatcouldbechangedtoimprovethePMTCTprogram?
iv. Howcouldthe‘flow’ofservicesbechangedtoimprovetheprogram?
v. WhatissuesinthecommunityaffectthewayPMTCTprogramsareprovided?
vi. Howcouldthecommunitystrengthenorimprovetheprogram?
vii. WhataresomeotherissuesthataffectthewayPMTCTprogramsareprovided?
viii. WhathaveyouheardabouttheVikelaUmndeniproject?
ix. Describewhatyouknowabouttheproject.
Fidelity
2.WhathaveyoulearnedaboutthecomponentsofthePMTCTprotocolfromtheclinicstaff?Thesecomponentsincludetesting,HIVprevention,
ARVtreatment,infantfeeding,familyplanning,safersexandinvolvingyourpartnerinyourpregnancy.
i. Whathaveyouheardabouttheamountoftimepatientsspendattheclinicduringpregnancy?
ii. Whendowomencomeforantenatalcare/pregnancycareforthefirsttime?
7 iii. Whatkindofexperienceshavepeoplehadwithobtainingtheirtestresultspromptly?
1 iv. WhatexperiencesdopeoplehaveinreceivingtheirARVtreatment?
0
2 v. Howcanservicesbeimproved?
er vi. Whatelsecouldbedoneinthewayofnewprograms,likeVikelaUmndeni?
b
m 3.Whathaveyouheardaboutcommunicationbetweenpatientsandthehealthcarestaffattheclinic?
e
pt i. Whathaveyouheardaboutcommunicationbetweenpatientsandthehealthcarestaffattheclinic?
e
S ii. Howdoescommunicationaffectreceivinghealthcareduringpregnancy?
9 iii. Whatkindsofchangescouldimprovecommunication?
1
9 4.Whathaveyouheardaboutstaffappearingfatigued(wornout,tired)orburnedout(lessinterestedinwork)withpatients?
4
3: i. Howdoesstafffatigueorburnoutaffectthewayprovidehealthcare?
0
] at iiiii.. HWohwatdkoinedssstoafffcfhaatniggueesocroubludrnreoduutceaftfehcetsntaefwfbpurrodgerna?ms,likeVikelaUmndeni?
6
4
8. Coverage
7
5. 5.Whathaveyouheardaboutstaffappearingfatigued(wornout,tired)orburnedout(lessinterestedinwork)withpatients?
5
2 i. Aresomeclinicsmorepopularthanothers?
5.
6 ii. Whatmakesthembetterorworse?
1
[ iii. Whydidyouchoosethisclinicforyourcareduringpregnancy?
by iv. Ifyouattendedadifferentclinic,whydidyouchoosethatotherclinic?
d 6.Thefollowingaresomeproblemsthatoccurinclinics.Howcouldtheseproblemsbesolved?
e
d
a i. Manymotherscomelatefortheirfirstantenatalbooking.
o
nl ii. NotallmothersarecounseledandtestedforHIVtestingattheirfirstantenatalbooking.
w iii. NotallHIV-positivemothershaveCD4testblooddrawn.
o
D iv. MothershaveCD4testdrawn,butdonotreturnforresults
v. MothersareoftendelayedbeforetheirreceiveARV/HIVmedicationwaitingforCD4countresults.
vi. HAARTclinicsareoverburdenedandpregnantwomenaredelayedinstartingARV/HIVmedication.
vii. ClientsarereferredforARV/HIVmedicationbutdonotpitchupatARVclinic.
viii. ClientsarereferredforARV/HIVmedicationbutnoinformationissenttothepatient,whichleadstodelaysandduplication.
ix. ClientsaredelayedforARV/HIVmedicationbecauseatreatmentsupporterhasnotbeenidentified.
x. ThedeliveryofPMTCTmedicinesisunreliable(notalwaysdone)duringlabor
xi. Thepost-natalcareclinicdoesnotalwaysknowwhichbabieswereHIVexposed
xii. Somemothersmayfeelbabiesdonotgetenoughnourishmentonlybreastfeedingandmaymixedfeedtheirbabies.
xiii. SomewomenmaynottaketheirARVmedicationsasprescribed.
xiv. ItisdifficulttoinvolvethepartnersinPMTCT,insomecases,menarenotinvolved.
OneclinicstaffmembersuggestedthatPMTCTprotocolchanges AnassistantnursesuggestedthatHome-BasedCare(HBC)per-
shouldbeprovidedtoallclinicsimmediately: sonnel should be trained in PMTCT; HBC workers monitor
and control the spread of tuberculosis (TB) by visiting patients
Theremustberefreshertrainingsatleasttwiceayear.(Lay at home, a model that could be implemented with PMTCT
Counselor,ClinicS) patients:
Wemustalwaysbeupdatedifthereissomethingnew.(Pro- Womentodohomevisitssothattheycancheckifthepatients
fessionalNurse,ClinicP) aretakingtheirpillsornotbecauseotherdon’ttaketheirpills
anditbecomesachallenge.(AssistantNurses,ClinicO)
Weshouldhavementors....(ProfessionalNurse,ClinicH)
VOL. 14 NO.1 2017 Journaldes Aspects Sociaux duVIH/SIDA 43
Original Article
Table 3. Themes categorized by ConsolidatedFrameworkfor ImplementationResearch (CFIR)
domains.
Summary
Theme
Challenges Solutions
Interventioncharacteristics
1.PMTCTtraining ContinuousadditionsandchangestoPMTCTprotocol Needforacontinuoustrainingtomatchthefrequencyof
thatstaffarenotalwaysinformedabout. changesinprotocol.
2.Disclosuretofamilyand FearoflosingsupportupondisclosureofHIVserostatus. Decreasingfearregardingpotentialnegativereactionsto
partners Mixedfeedingresultsfromnondisclosuretoinfant disclosurewithcurrentsupportsystem.Promotethe
caretakers.Lowratesofcondomuse,potentially useofpeereducationandmentorshiptofacilitate
increasingtheriskofre-infection. strongerbondswithsupportsystem.Promote
disclosureofHIVserostatusasmenaremorelikelyto
useacondomwhentheyareofawareoftheir
partner’sserostatus.
Outersetting
3.Facilityspace Limitedfacilityspacetomeetpatientdemandsaffecting Increasefacilityspace.Intheabsenceoffinancial
7 patientprivacyandattendance,andmaleinvolvement. resources,maintainingappointmentlogstolimittothe
1
0 Increasedriskofairborneinfectionsincrowdedspaces. numberofpatientsseensimultaneously,orproviding
2
r HBC.
e
b
m 4.Patienthealthrecord Poorpatienttrackingduetohumanerror,lackof ImprovepatienttrackingthroughHBCworkers,or
e management resources,andparticipantmisreporting. implementationofelectronicmedicalrecord.
pt
Se 5.Clinicstaffshortage Staffoverburdenandpatientsleavingtheclinicwithout Increasepatientoutreach,createmobileclinics,modify
9 beingseenortreated. staffscheduletohavemorepersonnelonbusierdays,
1
9 increasestaffproductivity,andimprovepatient
3:4 scheduling.
0
at Innersetting
6] 6.HIVtestingand ShortagesandlackofsuppliestocompletePMTCT Continuedreliabilityonotherclinicsforneededsupplies,
8.4 medicationsupplyuse proceduresresultinginlatedetectionofpregnancyand orworkingwithpharmaceuticaldistributorsfor
7 andavailability HIV,lateonsetoftreatment,andunprotectedsex. planningofneededsupplies.
5.
5 7.Staff–patient Factorsaffectingpatientattendancetoclinicforservices Thepotentialroleofimprovingstaffattitudeasawayto
2
5. communicationand andbarrierstostaff–patientcommunication(e.g.staff increasepatientuptakeofclinicservices.
6
1 relationship attitudeandtemperament).
[
y 8.Transportationand Personalsafetyconcerns,lackoftransportation,andpoor Increasingtheavailabilityofservicesandresources
b
d scheduling availabilityofemergencyservicesduringlabor. availabletowomenduringpregnancyandlaborto
e
d servethetransportationneedsofclinicpatients.
a
o
nl Characteristicsofindividuals
w
o 9.Professionalrelationships Factorsaffectingandimpedingacollaborativeworking Increasingmentorshipandsupervision.Conduct
D
amongstaff environment. evaluationsofstaffperformancewhichinclude
recognition.
10.InitialANCvisit Misunderstandingofpregnancyamongpatients,lackof Providinginformationonhowtoidentifypregnancy
motivation,andinadequateunderstandingofPMTCT earlier,andincreasingmotivationbyemphasizing
guidelines. potentialbenefits.
11.AdherencetoPMTCT Poorsocialsupport,medicationsideeffects,lackof Increaseattendancetoandawarenessofsupportgroups;
treatment educationandunderstandingofthePMTCTprotocol, buildingatherapeuticalliancebetweenthepatientand
cursoryorinadequateexplanationsoftreatment provider.
instructions.
12.Cultureandstigma Cultural,communitymisconceptions,andsocietalbeliefs Increasinglevelofcomfortforpatientsattheclinic,as
affectPMTCTimplementationanduptake. wellasraisingcommunityawarenessandeducationto
dispelHIVmythsandmisconceptions.
Implementationprocess
13.Patientcounselingand Patientdissatisfactionwithclinicservices,andunfamiliarity Aneedforpromotionofsupportgroupavailabilityby
education withsupportgroupservices. clinicstaff.
14.Delayedreportingof DelayedCD4counttestingasaresultoflaboratorydelays Increasingreliabilityofmessengerservicesandpatient
CD4testresults inreleasingresults,lackofsupplies,andmisplacement outreach,andwhenfeasible,provisionofon-siteCD4
orerroneousdeliveryofresults. testingandresults.
15.Maleinvolvement Maleinvolvementisaffectedbymanyfactors,suchas Betteroutreachandeducationaimedatmalepartner
traditionalperceptionsofpregnancy,clinicschedules engagement,suchasinvolvingmoremenPMTCT
conflictwithmalepartners’workschedules,andlimited serviceprovision,anddispellingthenotionthat
clinicspacetoaccommodatemalepartnerattendance. pregnancyisonlyawoman’sissuethroughmalepeer
interaction.
44 Journalof Social Aspects ofHIV/AIDS VOL. 14 NO.1 2017
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Disclosuretofamilyandpartners It’s important [to disclose] because if he doesn’t know he’ll
Challenges.FailuretodiscloseHIVstatuswasamajorbarrierto refuse to use a condom but if he knows our statuses he’d
receiving PMTCT care; in many cases, mothers left their babies understandheshouldfollowtherules.(FGD,ClinicK)
withcaretakersunfamiliarwithPMTCTprotocol:
Outer setting
Sometimes you leave your child at home and no one knows
TheCFIRoutersettingsdomainaddressespatientoutreach,net-
that you’re HIV positive and they start mix-feeding the
working, accessing/providing resources, cosmopolitanism, peer
childbecauseyoudidn’tdiscloseyourstatus.(FGD,ClinicO)
pressure, external policy, and incentives (CFIR, 2014). Facility
space,patienthealthrecordmanagement,andclinicstaffshortage
MostFGDparticipantsreporteddifficultiesdisclosingtheirHIV
emergedasouter-settingthemes.
serostatus.Manyfearedotherswouldtreatorperceivethemdif-
ferently,and25%ofparticipantsfearedabandonmentorIPVby
theirpartner: Facilityspace
Challenges.Clinicstaff(32%)feltthattheirfacilitywastoosmall
Sometimesitisdifficult[todisclose]becauseyoudon’tknow to meet patient demands, which contributed to problems with
how the person would react, because maybe the person patientprivacy–e.g.multiplepatientsbeingseensimultaneously
would kill you or leave you...I was relying on him to buy – andwithindividualandgroupcounseling.Theclinics’physical
7 mefood.(FGD,ClinicJ) infrastructure also presented a major challenge to male partner
1 involvementinPMTCT.
0
2
r Many FGD participants acknowledged not consistently using
e
b condoms (58%) due to nondisclosure, misinformation, and If maybe there is two ladies there [labor room], we don’t
m
e inabilitytoinfluencemalepartners,whowerecommonlyident- allow them [male partners] but they are scared of clinic,
pt
e ified as decision-makers for condom use. FGD participants let alone to hear what we are saying. (Facility Operation
S
9 repeatedlyassertedthatcondomlesssexincreasedthepossibility Manager,ClinicK)
1
9 ofinfection/re-infection,whichencouragedmanycouplestouse
4
3: condoms: ...one-to-onecommunicationisdeprived.Wehavetoscreen
0
at aroundinbetweenpatientsandsomedon’tfeelconfidentto
] ...they[nurses]havealsotaughtusaboutHIVandhowone talk.(ProfessionalNurse,ClinicN)
6
4
8. cangetinfected,andalsotoldusthatifwearebothHIVposi-
5.7 tiveweshouldn’tstopusingcondombecausewearegoingto Patients sometimes waited outside due to limited space and left
25 re-infecteachother...andthedoctorswillnolongerbeable the queue without being seen, resulting in some patients not
65. tocontrolit.(FGD,ClinicO) returning for care. In some cases, patients attended a different
1
[ clinicand,duetothelackofatransferrablerecord,medicalhis-
y
b Solutions. FGD participants and staff asserted that addressing tories were unavailable. Generally, in all clinics and CHCs, one
d
e women’s anticipation of negative post-disclosure reactions dayissetasideforANCvisit,whichlimitedoperatingtimeand
d
oa may promote an environment conducive to disclosure. Work- ledtocliniccongestion.However,ANCclinicdayswereaneffec-
wnl shop attendees suggested that women should identify mentors tivestrategyforminimizingtheriskofcontractingairbornedis-
o to guide them pre- and post-natally, as well as through the eases, such as TB, which arose from mothers standing in a
D
process of disclosure. Addressing clinic- and individual-level mixed-reason-for-visitclinicqueue:
challenges to male involvement prenatally could increase
societal acceptance of men in the antenatal process and help Idon’tthinkit’sarightthingforbabiestobemixedwithTB
women build stronger bonds with their partners, which may patients; it doesn’t make sense to me because the children
decrease fears surrounding disclosure and increase male inhalesTBquickly.(LayCounselor,ClinicP)
partnersupport:
Solutions. Some clinics circumvented problems associated with
WhenI arriveat home from theclinic,he asks how itwent theformationofmixed-reason-for-visitclinicqueuebyimmedi-
at the clinic and when I arrive with treatment I explain to ately treating patients who outwardly exhibited signs of conta-
him what it is for and how is going to help the baby and gious infections. It was also suggested that infants could be
me. Even after birth it is going to be easy to give the baby treatedonspecificdaystominimizeexposuretoairbornediseases:
treatment because he knows the situation. And even
when you explain how long the baby is going to be If we notice that a person is coughing and has TB without
on treatment, he is going to understand. And he being screened, we make sure that we remove that person
must also know about breastfeeding and he must fromthequeue...(LayCounselor,ClinicP)
know about how the baby takes the treatment. (FGD,
Clinic P) Babiesdon’thavetheirowndayattheclinicsoitbecomesa
problem.(LayCounselor,ClinicP)
ItwasalsosuggestedthatpromotingdisclosureofHIVserostatus
could effectively combat inadequate condom use among HIV In addition to increasing facility space, it was suggested that
affectedcouples: clinicscouldbenefitfrommaintainingappointmentlogsinstead
VOL. 14 NO.1 2017 Journaldes Aspects Sociaux duVIH/SIDA 45
Original Article
ofhavinganopen,setschedule(i.e.onesix-hourANCday)pro- on busier days and from scheduling patient-specific appoint-
vidingPMTCTcounselingandeducationusingHBC. ments. Clinic staff and workshop participants suggested hiring
more staff and creating mobile clinics to reduce staff shortages,
Patienthealthrecordmanagement theorizing that waiting times would decrease and increase
Challenges.Forty-fourpercentofclinicstaffandworkshopatten- patientsatisfaction:
dees reported multiple errors related to health record manage-
ment,influencedbybothpatientsandstaff: Addmoreclinicsandaddmorestafftothosefacilitiesandhave
mobileclinicsforoutreach...(ProfessionalNurse,ClinicX)
...they[staff]don’t markonthechildbookletwhetherthe
mother was HIV positive or not. (Professional Nurse, Inner setting
ClinicN) TheCFIRinner-settingdomainincludesallaspectsofthepatient
experience (CFIR, 2014): clinic service hours, clinic staff com-
Wedohavehumanerrors...maybethereisalineandIhave munication and interaction with patients, patient testing,
tomarkpatient10,butImakeamistakeandmarkpatient patienteducationandsupportservices,andclinic-directedhealth-
no.11.(ProfessionalNurse,ClinicJ) care campaigns. The themes, e.g. HIV testing and medication
supply availability, quality of communication or interaction
Files aregetting misplaced or lost because we have only one betweenstaffandpatientsandavailabilityofclinictransportation
7 datacapturer...(ProfessionalNurse,ClinicW) forpatients,wererelatedtotheinner-settingdomain.
1
0
2
r ...thoseyoungmothers,firsttheydon’ttakecareofthebaby’s HIVtestingandmedicationsupplyuseandavailability
e
b cliniccard,sometimestheylosethecards...(AssistantNurse, Challenges. Thirty percent of staff reported test kit, condom,
m
e ClinicJ) medication shortages. Clinics order their medical supplies from
pt
e pharmaceuticaldistributorsandshortagesexperiencedbythedis-
S
9 Solutions. Many clinics had procedures in place to prevent and tributorsaffectedtheentireprovince.
1
9 abateerrorsrelatedtohealthrecordmanagement,suchastrain-
4
3: ingandmeetings.Ifthepatientdestroyedtheirsummarycardto We sometimes have a shortage of testing kits both for preg-
0
at hidetheirserostatus,staffhadtheinformationrecordedintheir nancyandforHIV.(FacilityOperationManager,ClinicK)
] records:
6
8.4 ...lastyearwestayedplusminus3monthswithoutcondoms.
5.7 Wealsowriteinthepostantenatalhistorysothisbookwill (LayCounselor,ClinicX)
25 tell me even if the patient destroyed the card. (Professional
5. Nurse,ClinicK) Fornewborns,sometimesthere’snoNVP.Thenwehaveuse
6
1
[ lamivudine and others don’t understand how to replace the
y
b Double-checking data entries was recommended to prevent treatment.(ProfessionalNurse,ClinicJ)
d
e errors, and an assistant nurse suggested use of a national elec-
d
oa tronicmedicalrecords(EMR)tohelpimprovepatienttracking. Solutions.Manyclinicsdealtwithsupplyshortagesbyborrowing
nl suppliesfromneighboringclinicsandhospitals,althoughthiswas
w
o Clinicstaffshortage notapermanentsolutionduringperiodsofregionalshortages:
D
Challenges. Half of participants (56%) reported that long wait
periodsduetostaffshortagesandincreasingpatientcensusdis- Ifwedon’thavethosespecimenthingsweaskournextclinic
couraged ANC attendance. Clinic staff from multiple clinics likeneighbors...(ProfessionalNurse,ClinicN)
reported that they might see up to 6500 patients in a given
monthwithonly3sistersavailableonagivenday: Workshop participants asserted that supply shortages could be
prevented by working with pharmaceutical distributors for
There were only 3 Sisters, and patients end up going home stock planning at the district- and province-level. One clinic
around6pm.(ProfessionalNurse,ClinicJ) nurse confirmed that her clinic did not experience the same
shortagesasotherclinicsbecauseitplanneditsstockbeforehand,
Staffshortagespreventedsomestafffromperforminghomevisits. usingtheclinicpatientloadasareference:
Becausewomenwhowerelateringestationwereattendedtoby
staff beforewomenearlier ingestation, staffshortages alsocon- Planning can assist by making sure that we have enough
tributedtowomen’suntimelyaccessofANC. equipment and resources to do the job, like for an example,
having all the necessary material like stationery and stock
That’s why they don’t come early...the patients will com- medication.(ProfessionalNurse,ClinicY)
plain and think it is better to come late for booking...
becausewhentheycomeearlytheydon’tgethelp(LayCoun- Staff–patientcommunicationandrelationship
selor,ClinicN) Challenges. Most FGD participants asserted they communicated
well with clinic staff. Three participants reported thatfair treat-
Solutions. Workshop participants suggested that in addition to ment and clinic reputation influenced their decision to attend a
more personnel, clinics would benefit from having more staff clinic.
46 Journalof Social Aspects ofHIV/AIDS VOL. 14 NO.1 2017