Background
Methods
Study design, setting, sampling and participants
Data collection
Semi-structured interviews
Observations
Data analysis
Results
PVTCC1 | PVTCC2 | PVTCC3 | PVTCC4 | PVTCC5 | PVTCC6 | |
---|---|---|---|---|---|---|
1. Infrastructure | ||||||
• Facility registered to provide VCT services? | Yes | Yes | Yes | Yes | Yes | Yes |
• Adequate counselling room/s available (well lit, spacious, ventilated, private, equipped with 3 chairs and 1 table)? | No | No | No | No | No | Yes |
• Room (s) is equipped to accordingly perform a test? | No | Yes | No | No | No | No |
• Penile model available and on display? | No | No | No | No | No | No |
• Room/s and waiting area well maintained and clean? | Yes | Yes | No | No | Yes | Yes |
• Adequate waiting area (chairs and space)? | Yes | No | No | No | Yes | Yes |
2. Supply and storage | ||||||
• Uninterrupted and adequate supply of rapid test kits in stock? | No | No | No | No | No | No |
3. Referral system | ||||||
• Referral system in place and functioning? | Yes | Yes | Yes | Yes | Yes | Yes |
• Referral directory/list available? | Yes | Yes | Yes | Yes | Yes | Yes |
• Designated referral site for care and support? | Yes | Yes | Yes | Yes | Yes | Yes |
• Post-test support available (post-test counselling, people living with HIV, etc.)? | Yes | Yes | Yes | Yes | Yes | Yes |
4. Record and information system | ||||||
• Uninterrupted and adequate supply of VCT data forms and client cards? | No | No | No | No | No | Yes |
• System for anonymous client coding in place and functioning? | No | No | Yes | No | No | No |
• Easily retrievable copies of quarterly reports sent to the regional level available? | Yes | Yes | Yes | Yes | Yes | Yes |
• Accident/incident book available and used?? | Yes | Yes | Yes | Yes | Yes | Yes |
5. Information, Education & Communication (IEC) materials | ||||||
• Signboards, signs, labels and directions for VCT room/s? | No | No | No | No | No | Yes |
• Opening hours prominently displayed? | No | No | No | Yes | No | Yes |
• Door tags used for privacy (please enter/counselling in progress)? | No | No | No | No | No | No |
6. Financial management | ||||||
• Fee charges prominently displayed? | No | No | Yes | No | No | No |
• Records of accounts available? | Yes | Yes | Yes | Yes | Yes | Yes |
• Clear policy and measures in place for clients unable to pay? | No | No | No | Yes | No | No |
7. Guidelines/client-provider interaction | ||||||
• Did VCT staff in charge of counselling attended an official training programme and obtained a degree? | Yes | No | No | Yes | Yes | Yes |
• Did VCT staff performing the rapid test attended an official training programme and obtained a degree? | No | No | No | No | No | No |
• VCT services available on advertised days? | Yes | Yes | Yes | Yes | Yes | Yes |
• Informed consent (signature) obtained before HIV testing? | No | No | No | No | No | No |
• Condoms supplied where appropriate? | No | No | No | Yes | No | Yes |
• Same-day blood testing conducted on site? | No | No | No | No | No | No |
• Correct testing algorithm used? | Yes | Yes | Yes | Yes | Yes | Yes |
• Test results given same day? | No | No | No | No | No | No |
• All forms are checked for missing items at the end of each day? | No | No | No | No | No | No |
• Community mobilization activities being conducted? | No | Yes | No | Yes | No | Yes |
• All counsellors attending regular group supervision? | Yes | Yes | Yes | Yes | No | Yes |
• All counsellors receiving individual or peer supervision? | Yes | Yes | Yes | Yes | Yes | Yes |
• Counsellors working scheduled hours (not assigned to other non-VCT services)? | Yes | Yes | Yes | Yes | Yes | Yes |
• Each counsellor sees <10 clients/day? | Yes | Yes | Yes | Yes | Yes | Yes |
Demographic characteristics of the research participants
Characteristics (n = 22) |
N (%) |
---|---|
Participants per PVTCC | |
PVTCC1 | 3 (14) |
PVTCC2 | 4 (18) |
PVTCC3 | 3 (14) |
PVTCC4 | 4 (18) |
PVTCC5 | 4 (18) |
PVTCC6 | 4 (18) |
Age in years; mean (SD) | 42 (9) |
Position | |
Counselor | 16 (73) |
Nurse | 6 (27) |
Training | |
Yes | 21 (95) |
No | 1 (5) |
Working experience in years; mean (SD) | 5 (3) |
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Infrastructures, work environment, privacy and confidentialityAll the PVTCC are located within the district hospitals and are an integral component of the district management units. Only one PVTCC had enough and adequate rooms for the each lay counsellor to insure privacy and confidentiality during counselling sessions, this being a major concern among the participants: “…First of all, our working environment is very stressful because I think in modern health facilities, things are organized so that the management of confidentiality is reasonably ensured. Many clients complain about the lack of privacy and confidentiality. The working environment must be less stressful. The client must feel comfortable and confident. So, when it comes into the counselling room, he must feel confident. Otherwise, it could affect his reaction later ». (Lay counsellor-PVTCC2)In two PVTCCs, the lay counsellors share the same room and sometimes they receive their clients at the same time. Very often, in three PVTCCs, this office is cramped and not ventilated as mentioned by this lay counsellor: « …firstly, the workplace is not adequate, then we work in precarious conditions and there is no ventilation here…» (Lay counsellor-PVTCC3).
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Lack of equipment and materialsNone of the PVTCC had adequate equipment to perform rapid screening tests as recommended by the WHO. Nevertheless, one of the centers performed rapid screening test on-site. However, positive results must be confirmed by a second rapid screening test in the hospital lab. In the other centers, clients are directed to the DH lab for the rapid testing (blood sampling and testing) after the pre-test counselling. Almost in all of these centers, staffs experience a shortage in rapid test kits as mentioned by this lay counsellor: « … there is another factor; it is the lack of reagents» (Lay counsellor-PVTCC1). Furthermore, IEC material (i.e.,: video, poster) is obsolete or non-existent. One of the nurses commented: « …If we have enough IEC materials, it suits us. Because there are patients who are illiterate, who do not speak French, who can neither read nor write and therefore do not understand what we say. With images, it should be better. That’s lacking. We had a VCR but it is no longer fashionable. If we had perhaps a more modern device to view, it would suit us » (Nurse-PVTCC5) ».
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Training and qualification of lay counsellorsRegarding human resources, head nurses under a physician’s supervision manage the PVTCCs. All the studied PVTCC have at least two counsellors as required. The lay counsellors are educated and come from various professional fields (education, sociology, economy, community health worker) and are generally trained by local NGOs. Almost all the counsellors are trained but there is no specific training curriculum accredited that leads to a formal registration as a PVTCC staff. The lay counsellors’ training differs both by length and content. Only selected counsellors trained by one NGO seem to have suitable training. Unfortunately, this NGO only trained only 10 counsellors in the city of Douala. Moreover, the continuing training of these personnel is not ensured. Even more serious, as reported by this lay counsellor, sometimes the staff is assigned to counselling without any initial training: « …I still haven’t received a specific training. Gradually, as I see my colleagues work, I also adapt myself ». (Lay counsellor-PVTCC4)
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Recognition and remuneration of lay counsellorsMany of the lay counsellors who participated in this study complained about their working conditions and specifically their salary conditions. Apart from a few who are financially supported by the NGO, which trained them, the others continue to work without remuneration. From their point of view, Cameroon’s government promised to incorporate them into the civil service as reported by this lay counsellor: « …The other big problem is the management of support staff as us. It is for love of the human being that we continue to work. But do we have to be sacrificed? We are a large group, we are everywhere in all hospitals. Some were incorporated. Others like me continue to volunteer» (Lay counsellor-PVTCC3) ». They are considered as support staff in hospitals, without any recognition as explained by this lay counsellor: «… It is the [name of NGO] program that makes us work in the hospital…the hospital does not take us into consideration. This aspect must be improved …» (Lay counsellor-PVTCC6).
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Cost of the screening test and consentOnly one PVTCC clearly displays the testing fees. Moreover, the screening tests fees are not the same in all centers. Prices range from 500 FCFA, the official price to 2000 FCFA depending on the PVTCC as indicated by one of the participant: « … When [the name of the NGO] was there, the test cost 500 FCFA. When they left, the hospital has just supported the cost of testing for a few months and then the meeting with the hospital’s staff, we tried to see the price that is affordable to all; and then we adopted the price of 2000 FCFA …» (Lay counsellor-PVTCC3).Concerning the consent, according to few participants, it’s often happens that without being warned, the clients are sent to the counsellor’s office when they had just come for a medical consultation and not planned to undergo an HIV test. In the PVTTCs, only oral consent is requested. In none of them, written consent is sought. Moreover, in one PVTCC, even the oral consent is skipped because the clients are seen before in the pre-counselling session as explained by a lay counsellor: « Elsewhere, when clients come for a screening test, at the reception desk, they are sent to the counsellor for an interview. After the interview, they are free to go or not to pay for the test. Here, though, clients begin with the payment before realizing that it was for the HIV test. Sometimes they did not want to do it but when they look at the money they have spent, they feel compelled » (Lay counselor-PVTCC1).
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Waiting time for resultsDespite the availability of rapid tests and their ease of use, none of the PVTCC delivers the results on the same day. The waiting time varies from 24 to 48 h for the screening test and several days or weeks for the confirmation in the case of a positive test. People who tested must therefore return to the PVTTC another day for the post-test counselling and results. This increases the waiting time, which discourages some clients. Therefore, they fail to return and abandon their results. According to most of the participants, this is partly explained by the workload at the hospital’s lab. Indeed, in addition to HIV tests the lab staff should perform all other hospital tests: This is why the blood samples are tested only later in the afternoon when the clients are gone and results available the next day at the best: « I have asked the lab staff, they tell me they have too much work to do, they have not only the HIV screening tests. They take the blood samples in the morning and perform the tests later in the afternoon in order to make the results available the next day » (Lay counsellor-PVTCC5).As this counsellor also said, sometimes clients have to return to the PVTCC not only one time but several times before getting their results: « Here, the problem of results is the lab. Because someone did the test on Monday, for example, and he returns all week, the result is not available. Sometimes it takes a week or two weeks. That’s why the results are abandoned. Because logically, when someone did a test today, the day after, the result must be available… On the other hand, the biologist must validate the result is available…It’s the same for the confirmation test; the result can take two weeks. People return several times without being able to have their results » (Lay counsellor-PVTCC1).