Abstract
Background: A provider-initiated counselling and testing (PICT) strategy replaced the voluntary counselling and testing (VCT) strategy with respect to the provision of human immunodeficiency virus (HIV) counselling and testing (HCT) in KwaZulu-Natal province with the aim of increasing the uptake of HIV services. VCT depended on clients requesting HCT, whereas HCT is routinely offered to all persons utilising health facilities, regardless of the reason for the visit with the provision of PICT. This study reports on the feasibility and early outcomes of using the PICT strategy in KwaZulu-Natal.
Method: Health workers were trained to provide PICT to patients presenting at the outpatient department (OPD) of two public health institutions in KwaZulu-Natal from December 2010 to May 2011. Data on the offering and uptake of HIV services were recorded and analysed using univariate and multivariate analysis to compare HCT uptake and other systematic barriers before and after the introduction of PICT.
Results: A significant change in the uptake of HCT after the introduction of PICT at both sites (p = 0.242 and p = 0.224) and in the uptake of HIV testing (p = 0.062 and p = 0.224) was not observed. PICT offering was weakest at the OPDs (p < 0.001), and was solely provided by counsellors (85.5%). Few (29.2%) clients were screened for tuberculosis. Immunological and clinical staging was performed on 29.8% and 1.0% of HIV-positive patients, respectively. The linkage to prevention services was low with 12.2% of clients referred for further care.
Conclusion: PICT implementation and integration with other services faces human resource, infrastructural and conceptual barriers, and is not currently feasible at OPDs. The urgent provision of operational guidance and training for providers is needed.
Introduction
The province of KwaZulu-Natal has the highest prevalence of human immunodeficiency virus (HIV) (24.7% vs.17.3% national prevalence) in adults aged 15-49 years in South Africa.Citation1 Knowledge of HIV status remains low.Citation2 Prior to 2010, HIV testing was predominantly based on symptomatic or asymptomatic clients actively seeking voluntary counselling and testing (VCT) services at health facilities or dedicated testing sites.Citation3 With the introduction of free antiretroviral therapy (ART), the expansion of other prevention services in public sector facilities and a growing recognition of the need to expand access to HIV counselling and testing (HCT) services, the South African National guidelines on HCT were amended in 2010 to include provider-initiated counselling and testing (PICT). With PICT, all persons utilising public sector health facilities, regardless of the reason for the visit, are routinely offered HCT to facilitate knowledge of their HIV status and linkage to appropriate prevention and treatment.
PICT provision requires the involvement of an expanded staff complement of healthcare workers (counsellors, nurses and clinicians), and integration into all the services being provided, as opposed to VCT, which is heavily dependent on counsellors, and which is typically a dedicated service. Notwithstanding the potential benefits of PICT with respect to early access to appropriate HIV services,Citation4 especially in sub-Saharan Africa where a disproportionate burden of the HIV infection globally is borne, there are limited available data on the operationalisation of PICT services,Citation5–7 and even less on its impact on linkage to HIV services.
We report on a prospective operational research study carried out to determine the feasibility and outcomes of implementation of a PICT strategy. The PICT strategy was part of an integrated HIV prevention programme which consisted of HIV screening and the treatment of sexually transmitted infections (STIs), tuberculosis screening, the provision of barrier methods, and linkage to voluntary medical male circumcision and other HIV health services. All of these services were accessed by clients utilising the outpatient department (ODP) of two public health institutions in KwaZulu-Natal. The aim of the study was to obtain such results to inform an efficient and acceptable scale-up of the PICT strategy in KwaZulu-Natal.
Method
Study design and setting
This longitudinal, field intervention study was undertaken between 2010 and 2011. Temporal trends in the uptake of PICT compared to VCT, linkage to appropriate services and provider acceptability of and capacity for PICT provision, were compared in two public sector health facilities in KwaZulu-Natal.The study was conducted in the OPD, antenatal clinic (ANC) and direct medical male circumcision (MMC) clinic at a community health centre (CHC) in the KwaZulu-Natal Midlands (MCHC) and a state-aided urban district hospital in Durban (DDH). The CHC was an urban facility in the uMmgungundlovu Health District situated in Pietermaritzburg, the capital of KwaZulu-Natal province. The CHC provides a 24-hour comprehensive primary healthcare (PHC) package that includes maternity services. The catchment area of the CHC consists of 178 000 people according to 2008 District Health Information System (DHIS) estimates, and also services cross-border patients owing to its geographical location and the surrounding bus and taxi ranks.
The urban state-aided hospital is a 200-bed, level one district hospital, serving a population of 1 023 000 people living in the inner and outer west operational entities of the Durban metropolitan area. This area, according to the 2011 National Antenatal Sentinel HIV & Syphilis Prevalence Survey in South Africa, has one of the top eight highest HIV prevalence rates in the country (38%). It is the referral hospital for 24 government community clinics, and serves the urban, peri-urban and some of the rural population in the western areas of Durban.
Clients seeking HCT, STI, ANC, family planning and tuberculosis services at these two health facilities between December 2010 and May 2011 were included in the study, and offered PICT services, regardless of the reason for their visit.
This study was conducted under ethical oversight of the Biomedical Research and Ethics Committee of the University of KwaZulu-Natal (Ref BF 035/010).
Study procedures and systems
The Comprehensive Package Register
The initial process entailed the design of an integrated programmes data collection tool [the Comprehensive Package Register (CPR)] to enable the daily documentation of service provision and uptake. The process involved the merging of data elements from the existing standalone VCT, tuberculosis, STI, pre-ART and ART registers, and expansion to include PICT service provision, as well as uptake and reasons for the uptake or for declining the service.
Provider training
The relevant health workers were then trained on the provision to clients of an integrated disease prevention package and on the use of the CPR to record the data.
Service provision
All services, including counselling and testing, were provided by healthcare workers in accordance with the South African Department of Health guidelines. Clients were encouraged to refer their partners for one or all components of the integrated disease prevention and counselling package, and provided with a partner notification slip in order to monitor partner uptake of the services as a result of these referrals. A separate column in the CPR was created to document partner referrals and partner uptake of the services.
Data capture and analysis
Data were entered onto the integrated registers by the healthcare workers who provided the service. The data were subsequently captured using SPSS® software version 21. Data analysis was initiated with a check of the data for outliers, missing information and normality through skewness and kurtosis for values which might have affected relations between the variables. The data analysis was primarily conducted within a quantitative framework, making use of univariate (means, standard deviations, frequencies and percentages) and multivariate (Pearson’s chi-square test and Fisher’s exact test of associations) analysis. A p-value < 0.001 was considered to be statistically significant.
The feasibility of implementation of PICT by the health facilities was assessed through three mechanisms:
| • | By using the Department of Health indicator for the uptake rate of HCT to calculate the uptake rates of HCT at different entry points for the duration of the study (after the introduction of PICT), and comparing this with the same period in the previous year, prior to the introduction of PICT in 2009 and 2010. The prescribed formula for calculating PICT for individuals aged five years and older at the time of this study according to DOH protocols was as follows: | ||||
| • | By determining the HIV testing rate for clients based on the official Department of Health protocols which depict the ratio of patients tested compared to those who received pre-test counselling. This ratio was then compared to that for the same period in the previous year (2009 and 2010) using the data obtained from the DHIS. | ||||
| • | The DHIS data were used as they record the total PHC and OPD headcount at the institutions, whereas data from the study registers reflect clients who were registered at the OPD/PHC, ANC and direct MMC clinics only, and do not represent the total picture of client flow at the institution. Therefore, clients who presented at other entry points at facilities would not have been recorded at the study entry points. The data recording was also dependent of the efficiency of staff working at these points. | ||||
| • | By analysing the data on the participation of healthcare-provider categories in the provision of HCT services, as recorded in the CPR. | ||||
Results
A total of 10 806 clients were registered at the two sites, i.e. the MCHC (n = 5 234) and the DDH (n = 5 572). Half of the patients were from the urban hospital (51.5%) and 48.4% from the urban PHC clinic. The highest patient headcount was at the institutions’ main OPD entry point (66.8%), followed by the ANC entry point (16.8%). 16.4% presented directly for services at the MMC entry point. Females comprised 6 118 (57.2%) of the patient load and males 4 580 (42.8%) of the sample. The median age of the participants was 27 years. Most patients were in the 25–34 year-old age group (35.1%). Most (78%, n = 8 426) received HIV pre-test counselling, and 64.3% (n = 6 950) HIV post-test counselling. A total of 2 481 clients had never been tested for HIV before (26.1%). One per cent of the patients declined to be HIV tested.
Changes in HCT uptake following the introduction of PICT
There was a minor and statistically insignificant change in the uptake of HCT before and after the introduction of PICT (Table ) at both study sites. There was no statistically significant change in the HIV testing rates after the introduction of the PICT strategy, although a small increased was noted with respect to the data from the Durban site.
Table 1: HCT uptake and HIV testing rates pre- and post-PICT introduction
Entry point capacity to provide PICT
The study data showed a statistically significant association between HCT uptake and the entry point at which the HCT services were offered. More patients were likely to be offered HCT at the ANC and direct MMC entry points than at the OPD entry point (p < 0.001). Descriptive data from the CPR are listed in Table . The average HIV testing rate in the CPRs was 78% for clients.
Table 2: Entry point effectiveness
Healthcare worker participation in PICT provision
PICT services were predominantly provided by counsellors (85.5%). Nursing personnel were involved in 14.4% of the cases. The clinicians at both sites were not involved. There was also an association between the providers of PICT and the entry points (p < 0.001). More services were offered solely by counsellors at the OPD and ANC entry points, compared to the direct MMC entry point, where a combination of nurses and counsellors provided services.
Feasibility of partner referral for services
Data recording for partner testing and partner referral for the integrated package of services was poor. Only 14.4% (n = 1 526) of the clients were recorded as having been issued partner notification slips for HCT, STIs and MMC. The majority of clients (85.6%, n = 9 280) were either not issued the slips, or this information was not captured on the registers. The referral data show that 0.7% of clients were referred by partners. The majority of clients (87.8%) were self-referrals. Few women were offered the partner notification slips to refer partners for MMC and other HIV-prevention interventions (32.7%, n = 582) at ANC clinics. Most cards were issued at the OPD and ANC entry points, as opposed to the direct MMC entry point (p < 0.001).
Linkage to other services
A third (29.2%) of the clients who presented at the various entry points were screened for tuberculosis. Most (69%) of the clients were either not screened, or the information was not documented in the registers. The OPD was more likely to offer tuberculosis screening services than the other entry points (p < 0.001), followed by the ANC entry point (27.5%) and the direct MMC entry point (18.7%). Overall, 60% of patients who were screened for tuberculosis were not found to be tuberculosis suspects. Of the remaining 40% who were suspects, only 1.9% of these clients were referred for further management. Clinical staging was performed on 1% of HIV-positive people. A CD4 cell count test was conducted on 29.8% of the HIV-positive patients. The inter-referral for prevention services between the different patient entry points reflected that most patients (87.8%) were self-referred and 12.2% were referred from other service points within the institutions.
Discussion
The study showed that currently the change to PICT strategy at the two public health facilities has not resulted in a significant shift in the uptake of HCT. The uptake of HCT is known to be influenced by several factors, including social issues, such as stigma and lack of privacy.Citation8–10 The HIV testing rate in this study was high (78%), indicating the presence of mainly operational barriers, rather than social barriers, to the anticipated increased uptake as a result of the introduction of the PICT strategy. The finding of an insignificant shift in the uptake of HCT following the introduction of PICT is inconsistent with those of other studies, where uptake was markedly higher, although to varying degrees.Citation11,12
Generally, there was a poor understanding of the operational guidelines with respect to PICT among the staff at the study sites prior to the provision of training relating to the study. The instruments (data registers) in use were unchanged, and the clinicians and nursing personnel were unsure of their role in PICT. The slight improvement in the HIV testing rate at the Durban site may be attributed to improved data recording as a result of training personnel when the study was introduced, rather than as a consequence of the introduction of PICT.
Patient entry point capacity and personnel roles
Most patients at the study sites were seen at the OPDs. Therefore, the OPD is a critical entry point to ensure intensified counselling and testing and the appropriate triaging of patients to the related prevention and treatment services. However, the OPDs were shown to be the weakest entry point for the delivery of PICT, compared to the other entry points (Table ). However, a high uptake of HCT at the direct MMC and ANC entry points has been an established finding in other studies.Citation13 The high uptake at ANC clinics is mainly attributed to the mature implementation of the prevention of mother-to-child transmission of HIV strategy at health facilities, which ensured that dedicated counsellors were allocated at these points to provide HCT services. Most staff working at the direct MMC and ANC entry points are employed to provide dedicated services, and such services are typically inclusive of HCT. Therefore, acceptance of the PICT role by staff was more efficient at such entry points, compared to the main OPD as an entry point, where staff members have other roles and service responsibilities. The greatest dilemma facing OPD capacity in implementing the PICT strategy appeared to be the selection of the best model for PICT customised for specific conditions and patient load (headcount), rather than a “one size fits all” approach. Such a model needs to be acceptable to both patients and healthcare providers.
Several models have been proposed, which can either be used alone or in combination,Citation14 where:
| • | Healthcare providers refer patients to a single point for HCT | ||||
| • | Healthcare providers routinely offer and deliver HCT as part of the clinical consultation | ||||
| • | A nurse or counsellor offers HCT to persons waiting in the OPD prior to the clinical consultation. | ||||
The study demonstrated that the provision of PICT remained the sole preserve of counsellors at healthcare institutions. It was observed at both sites that the number of counsellors remained the same or had decreased after the introduction of PICT, yet the expectation was that every patient who entered the health facility should be offered HCT. The shortage of counsellors has been a common finding in other studies with regard to barriers to the uptake of HIV prevention services.Citation15–19 Personal communication with clinicians and nursing personnel indicates that these categories of personnel do not view their role to include HCT services, and regard it as an additional burden to their already demanding work schedule. Lack of participation by clinical staff has been attributed to insufficient time, a burdensome consent process, lack of knowledge or training, pre-test counselling requirements, competing priorities and the inadequate reimbursement of clinicians in other studies.Citation20 Intensive training and a change in the work schedule of such personnel is required in order to create the capacity to provide PICT, and for the necessary data recording for services rendered to be performed.
Linkage to related services and referral of patients
The study showed the poor channelling or linkage of eligible patients to the appropriate services owing to unchanged staff roles and practice, a finding that is consistent with other studies on this subject.Citation21,22 There were a few inter-referrals of patients from various points within the institutions. (Most of the patients who were seen were self-referrals). While the specialised clinics, i.e. the direct MMC and ANC entry points, were most efficient in providing the PICT service, these entry points tended to be the weakest in the provision of integrated services. This was evidenced by a situation in which only 18.7% of the clients who presented at VMMC entry points were screened for tuberculosis at the two sites. The number of clients screened for tuberculosis at the OPD and ANC entry points was much higher.
It was not demonstrated in this study that a significantly higher number of positive clients were screened and referred for early HIV treatment. Poor understanding of the programme guidelines by the healthcare workers added to the scenario of poor integration, as evidenced by the low number of clients who were offered World Health Organization staging, even though they had tested HIV positive and displayed advanced disease symptoms. The general understanding was that immunological staging (a CD4 cell count) had to be conducted in all cases, resulting in delayed treatment and delayed further management of clients. The provision of aids, such as flow charts and pictorial aids, could be a useful measure with which to address understanding of the guidelines, as training does not extend to all staff. Also, frequent rotations do not allow for continuity or the imparting of knowledge by those who have been trained.
Our study showed that the introduction of partner notification slips for all prevention services was not feasible under the current conditions. Partner notification slips have been demonstrated to be beneficial in increasing the case finding and treatment of STIs, in particular, but are also the most preferable method of referral by partners following screening and treatment services.Citation23,24 The use of partner notification slips was not effective either from a healthcare provider perspective (who failed to record the issuing and return of partner notification slips) or from that of patients (who did not return the slips or refer their partners for services).
Structural and health system constraints to PICT provision
Most OPDs do not have adequate space for the required number of counselling rooms, while generally, staff work in a semi-private setting which is often overcrowded, thereby providing a disincentive for patients needing to undergo HCT. The fact that most patients who present at OPDs are very sick in general also means that the OPD is not an ideal environment in which to provide PICT as the demand is mainly for medical attention, unlike that at the other entry points where the patients who are seen are mostly well.
The unsupportive infrastructure at the OPDs may also have contributed to the poor referrals in our study. Some clients might have experienced difficulty in finding a referral entry point owing to inadequate or confusing signage. Physical space also tends to be open at OPDs, with screens being used to separate clients during consultations. This makes it difficult for nursing personnel to guarantee the privacy required for the HCT process.
The segregated data collection materials also posed a constraint for the nurses and doctors, most of whom were never trained on their use. Therefore, they did not understand the data elements, some of which were similar for different programmes.
Conclusion
PICT success depends on human resource capacity, a supportive infrastructure and an effective health system. Within the context of an overburdened public healthcare system in KwaZulu-Natal, the implementation of PICT presents significant challenges which require individual facility-based situation analysis to determine the best-fit approach to HCT services.
Operational guidance is needed for OPD personnel, in particular, regarding the best-fit strategy for each institution. An inadequate understanding of the implementation guidelines for PICT and the integration of services has resulted in a situation in which healthcare practitioners are continuing to implement the previously advocated VCT practice, or are channelling clients to a HCT site where service bottlenecks occur, resulting in frustrated patients and missed testing opportunities. The poor operational guidance and over-reliance on counsellors to provide PICT services may also be an influential factors with respect to the low commitment by clinicians to the provision of PICT.
Persistent infrastructural limitations, such as inadequate counselling space which limited the success of the VCT strategy, remain at health facilities and limit the capacity of institutions to provide effective PICT services. Such infrastructural constraints are less pronounced at specialty entry points, i.e. the direct MMC and ANC clinics as entry points. Thus, these speciality entry points facilitate an increased offering of PICT services, compared to the OPD as an entry point.
More training and technical assistance on the implications of service integration within the existing health systems, and the improvement of data management and physical infrastructure adjustments is required to ensure the successful implementation of PICT strategy. Increased on-site mentoring is needed to ensure an efficient transition from the traditional silo-based offering of services to an integrated approach to services.
Limitations of the study
This investigation was of an observational nature and was not powered to permit the analysis of data at country or provincial level. The results are useful in informing policy with regard to provincial implementation and may need to be evaluated for country level. Data recording by the healthcare workers was not optimal. Hence, some data from the DHIS were used for the HCT and HIV testing uptake rates. Data collection was for a limited period. Therefore, data from this investigation were not sufficient to predict the long-term sustainability of the PICT intervention. Data from this investigation may also not be generalisable outside the catchment areas represented in this study or in healthcare facilities with more limited provisions.
Acknowledgements
: Special thanks are extended to the healthcare workers at the study facilities, the KwaZulu-Natal Department of Health, the Society for Family Health organisation and the study participants.
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