Delivering HIV services in partnership: factors affecting collaborative working in a South African HIV programme

Abstract Background The involvement of Global Health Initiatives (GHIs) in delivering health services in low and middle income countries (LMICs) depends on effective collaborative working at scales from the local to the international, and a single GHI is effectively constructed of multiple collaborations. Research is needed focusing on how collaboration functions in GHIs at the level of health service management. Here, collaboration between local implementing agencies and departments of health involves distinct power dynamics and tensions. Using qualitative data from an evaluation of a health partnership in South Africa, this article examines how organisational power dynamics affected the operation of the partnership across five dimensions of collaboration: governance, administration, organisational autonomy, mutuality, and norms of trust and reciprocity. Results Managing the tension between the power to provide resources held by the implementing agency and the local Departments’ of Health power to access the populations in need of these resources proved critical to ensuring that the collaboration achieved its aims and shaped the way that each domain of collaboration functioned in the partnership. Conclusions These findings suggest that it is important for public health practitioners to critically examine the ways in which collaboration functions across the scales in which they work and to pay particular attention to how local power dynamics between partner organisations affect programme implementation

Targeted mentoring for human immunodeficiency virus programme support in South Africa

Background: Mentoring is a required component of health systems strengthening technical assistance interventions in low- and middle-income countries (LMICs). Mentoring is useful because it does not necessarily compromise service delivery and promotes the sharing of newly acquired knowledge and skills. However, there is a lack of research on the implementation of mentoring in the context of the HIV epidemic in southern Africa. Objectives: This qualitative evaluation focussed on understanding the implementation process of targeted mentoring for clinical practice, data management and pharmacy management, at public health care facilities in South Africa; and on identifying critical factors influencing the effectiveness of mentoring as a technical assistance intervention in this context. Methods: Purposive sampling was used to select participants from public health facilities in three South African Provinces. Participants were invited to take part in structured interviews. Datawere analysed using thematic analysis, and two core themes were identified: mentoring as knowledge and skills transfer; and mentoring as psychosocial support. Results: In terms of knowledge and skills transfer, the sequential implementation of proactive and reactive mentoring was critical. Initial proactive mentoring involved mentors initiating training and developing professional relationships with mentees. Thereafter, a reactive mentoring phase allowed mentees to request support when required. This enabled mentors to leverage real-world problems faced by health workers to support their implementation of new knowledge and skills. The availability and accessibility of mentors alongside the relationships between mentors and mentees provided psychosocial support for health care workers which facilitated their self-efficacy in implementing new knowledge and skills. Conclusion: These findings suggest that the success of mentoring programmes in LMICs may require specific attention to both knowledge transfer and the management of interpersonal relationships

Disclosure of human immunodeficiency virus status to children in South Africa : a comprehensive analysis

CITATION: Van Elsland, S. L., et. al. 2019. Disclosure of human immunodeficiency virus status to children in South Africa : a comprehensive analysis. Southern African Journal of HIV Medicine, (20(1):a884, doi:10.4102/sajhivmed.v20i1.884.The original publication is available at http://www.sajhivmed.org.za/Background: The extent of disclosure of HIV status to children and adolescents and the context facilitating their disclosure process have received little attention. Objectives: To assess disclosure and provide a comprehensive analysis of characteristics associated with disclosure to children (3–14 years) receiving antiretroviral treatment in a South African semi-urban clinic. Methods: This cross-sectional study used structured interview administered questionnaires which were supplemented with medical record data. Predictors included child, caregiver, clinical and socio-economic characteristics, viral suppression, immune response, adherence, health-related quality of life and family functioning. Results: We included 190 children of whom 45 (23.7%) received disclosure about their HIV status, of whom 28 (14.7%) were partially disclosed and 17 (8.9%) were fully disclosed. Older age of the child and higher education of the caregiver were strongly associated with disclosure. Female caregivers, detectable viral load, syrup formulation, protease inhibitor (PI) regimens with stavudine and didanosine, and self-reported non-adherence were strongly associated with non-disclosure. Conclusion: When children do well on treatment, caregivers feel less stringent need to disclose. Well-functioning families, higher educated caregivers and better socio-economic status enabled and promoted disclosure. Non-disclosure can indicate a sub-optimal social structure which could negatively affect adherence and viral suppression. There is an urgent need to address disclosure thoughtfully and proactively in the long-term disease management. For the disclosure process to be beneficial, an enabling supportive context is important, which will provide a great opportunity for future interventions.https://sajhivmed.org.za/index.php/hivmed/article/view/884Publisher's versio

Disclosure of human immunodeficiency virus status to children in South Africa: A comprehensive analysis

Background: The extent of disclosure of HIV status to children and adolescents and the context facilitating their disclosure process have received little attention. Objectives: To assess disclosure and provide a comprehensive analysis of characteristics associated with disclosure to children (3–14 years) receiving antiretroviral treatment in a South African semi-urban clinic. Methods: This cross-sectional study used structured interview administered questionnaires which were supplemented with medical record data. Predictors included child, caregiver, clinical and socio-economic characteristics, viral suppression, immune response, adherence, health-related quality of life and family functioning. Results: We included 190 children of whom 45 (23.7%) received disclosure about their HIV status, of whom 28 (14.7%) were partially disclosed and 17

Strengthening primary eye care in South Africa: An assessment of services and prospective evaluation of a health systems support package

Visual impairment is a significant public health concern, particularly in low- and middle-income countries where eye care is predominantly provided at the primary healthcare (PHC) level, known as primary eye care. This study aimed to perform an evaluation of primary eye care services in three districts of South Africa and to assess whether an ophthalmic health system strengthening (HSS) package could improve these services. Baseline surveys were conducted in Cape Winelands District, Johannesburg Health District and Mopani District at 14, 25 and 36 PHC facilities, respectively. Thereafter, the HSS package, comprising group training, individual mentoring, stakeholder engagement and resource provision, was implemented in 20 intervention sites in Mopani District, with the remaining 16 Mopani facilities serving as control sites. At baseline, less than half the facilities in Johannesburg and Mopani had dedicated eye care personnel or sufficient space to measure visual acuity. Although visual acuity charts were available in most facilities, <50% assessed patients at the correct distance. Median score for availability of nine essential drugs was <70%. Referral criteria knowledge was highest in Cape Winelands and Johannesburg, with poor clinical knowledge across all districts. Several HSS interventions produced successful outcomes: compared to control sites there was a significant increase in the proportion of intervention sites with eye care personnel and resources such as visual acuity charts (p = 0.02 and <0.01, respectively). However, engaging with district pharmacists did not improve availability of essential drugs (p = 0.47). Referral criteria knowledge improved significantly in intervention sites (p<0.01) but there was no improvement in clinical knowledge (p = 0.76). Primary eye care in South Africa faces multiple challenges with regard to organisation of care, resource availability and clinical competence. The HSS package successfully improved some aspects of this care, but further development is warranted together with debate regarding the positioning of eye services at PHC l

Exploring programme design, evaluation of programme performance and describing the clinical outcomes of a public sector based ARV treatment programme in a semi-rural area in the Western Cape over the past 6 years (2004-2010)

Background: A national roll-out of antiretroviral therapy in the public sector was started in 2004, and Paarl was one of the first sites to start these services in the Western Cape. Operational research is required to guide the continuous improvement of such services. This research aimed to describe the characteristics of the treatment cohort started at TC Newman CDC’s ARV clinic in Paarl, to determine the retention in treatment rate and to assess the clinical and virological outcomes. Methods: A retrospective descriptive and observational study was done at the TC Newman ARV clinic in Paarl. All adult HIV positive patients that were started on antiretroviral therapy in the given time period were included. Patient and treatment data had been collected in an electronic database (e-register) and were extracted and analysed. Results: Starters: Out of the 2469 patients that were enrolled for ARV treatment between February 2004 and December 2010, 2254 started locally (the rest transferred in). 64% of them were female (decreasing rate over the years). Strugglers: By June 2011 51.5% of patients were still on ARVs, 6.9% patients had died, 16.7% had been ‘transferred out’and 24.7% were reported as ‘Lost to Follow-up’. 40% of the attrition of the cohort occurred in the first 6 months, 70% in the first 18 months. Stayers: Of the 1172 patients retained after start at TC Newman CDC, 1023 (87.3%) were still on Regime 1 and 149 (12.7%) on Regime 2. Conclusions: The results of this treatment cohort (mortality, treatment retention and regimen durability) equal those in other published treatment cohorts, although very limited comparable data are available. However, the high ‘lost to follow-up’ rate is of concern and needs further investigation. Changes in the programme structure and environment tend to have an immediate effect on initiation numbers of new patients

Exploring programme design, evaluation of programme performance and describing the clinical outcomes of a public sector based ARV treatment programme in a semi-rural area in the Western Cape over the past 6 years. (2004-2010)

Thesis (MFamMed)--Stellenbosch University, 2012.ENGLISH ABSTRACT: Background: A national roll-out of antiretroviral therapy in the public sector was started in 2004, and Paarl was one of the first sites to start these services in the Western Cape. Operational research is required to guide the continuous improvement of such services. This research aimed to describe the characteristics of the treatment cohort started at TC Newman CDC’s ARV clinic in Paarl, to determine the retention in treatment rate and to assess the clinical and virological outcomes. Methods: A retrospective descriptive and observational study was done at the TC Newman ARV clinic in Paarl. All adult HIV positive patients that were started on antiretroviral therapy in the given time period were included. Patient and treatment data had been collected in an electronic database (e-register) and were extracted and analysed. Results: Starters: Out of the 2469 patients that were enrolled for ARV treatment between February 2004 and December 2010, 2254 started locally (the rest transferred in). 64% of them were female (decreasing rate over the years). Strugglers: By June 2011 51.5% of patients were still on ARVs, 6.9% patients had died, 16.7% had been ‘transferred out’and 24.7% were reported as ‘Lost to Follow-up’. 40% of the attrition of the cohort occurred in the first 6 months, 70% in the first 18 months. Stayers: Of the 1172 patients retained after start at TC Newman CDC, 1023 (87.3%) were still on Regime 1 and 149 (12.7%) on Regime 2. Conclusions: The results of this treatment cohort (mortality, treatment retention and regimen durability) equal those in other published treatment cohorts, although very limited comparable data are available. However, the high ‘lost to follow-up’ rate is of concern and needs further investigation. Changes in the programme structure and environment tend to have an immediate effect on initiation numbers of new patients

Disclosure of human immunodeficiency virus status to children in South Africa : a comprehensive analysis

CITATION: Van Elsland, S. L., et. al. 2019. Disclosure of human immunodeficiency virus status to children in South Africa : a comprehensive analysis. Southern African Journal of HIV Medicine, (20(1):a884, doi:10.4102/sajhivmed.v20i1.884.The original publication is available at http://www.sajhivmed.org.za/Background: The extent of disclosure of HIV status to children and adolescents and the context facilitating their disclosure process have received little attention. Objectives: To assess disclosure and provide a comprehensive analysis of characteristics associated with disclosure to children (3–14 years) receiving antiretroviral treatment in a South African semi-urban clinic. Methods: This cross-sectional study used structured interview administered questionnaires which were supplemented with medical record data. Predictors included child, caregiver, clinical and socio-economic characteristics, viral suppression, immune response, adherence, health-related quality of life and family functioning. Results: We included 190 children of whom 45 (23.7%) received disclosure about their HIV status, of whom 28 (14.7%) were partially disclosed and 17 (8.9%) were fully disclosed. Older age of the child and higher education of the caregiver were strongly associated with disclosure. Female caregivers, detectable viral load, syrup formulation, protease inhibitor (PI) regimens with stavudine and didanosine, and self-reported non-adherence were strongly associated with non-disclosure. Conclusion: When children do well on treatment, caregivers feel less stringent need to disclose. Well-functioning families, higher educated caregivers and better socio-economic status enabled and promoted disclosure. Non-disclosure can indicate a sub-optimal social structure which could negatively affect adherence and viral suppression. There is an urgent need to address disclosure thoughtfully and proactively in the long-term disease management. For the disclosure process to be beneficial, an enabling supportive context is important, which will provide a great opportunity for future interventions.https://sajhivmed.org.za/index.php/hivmed/article/view/884Publisher's versio

Disclosure of human immunodeficiency virus status to children in South Africa: A comprehensive analysis

Background: The extent of disclosure of HIV status to children and adolescents and the context facilitating their disclosure process have received little attention. Objectives: To assess disclosure and provide a comprehensive analysis of characteristics associated with disclosure to children (3–14 years) receiving antiretroviral treatment in a South African semi-urban clinic. Methods: This cross-sectional study used structured interview administered questionnaires which were supplemented with medical record data. Predictors included child, caregiver, clinical and socio-economic characteristics, viral suppression, immune response, adherence, health-related quality of life and family functioning. Results: We included 190 children of whom 45 (23.7%) received disclosure about their HIV status, of whom 28 (14.7%) were partially disclosed and 17 (8.9%) were fully disclosed. Older age of the child and higher education of the caregiver were strongly associated with disclosure. Female caregivers, detectable viral load, syrup formulation, protease inhibitor (PI) regimens with stavudine and didanosine, and self-reported non-adherence were strongly associated with non-disclosure. Conclusion: When children do well on treatment, caregivers feel less stringent need to disclose. Well-functioning families, higher educated caregivers and better socio-economic status enabled and promoted disclosure. Non-disclosure can indicate a sub-optimal social structure which could negatively affect adherence and viral suppression. There is an urgent need to address disclosure thoughtfully and proactively in the long-term disease management. For the disclosure process to be beneficial, an enabling supportive context is important, which will provide a great opportunity for future interventions

Understanding health worker data use in a South African antiretroviral therapy register

OBJECTIVE : To evaluate how electronic data management systems affect data use practices in antiretroviral therapy (ART) programs within local health districts, and individual health facilities. METHODS : We used a data quality audit to establish a baseline of the quality of data in the electronic register alongside in‐depth interviews with health workers and managers, to understand perceptions of data quality, data use by facility staff and challenges affecting data use. RESULTS : The findings provide a four‐level continuum of data use that can be applied to other settings and recommendations for optimising facility‐level data use. CONCLUSION : By defining four levels of data use our findings suggest the potential to encourage a structured process of moving from passive data use, to more active and engaged data use, where data could be used to anticipate patient behaviour and link that behaviour to differentiated care plans.http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-31562019-09-03hj2018Medical Microbiolog