Background
Methods
Study sites and participants
Study procedures
Data management and analysis
Results
Participant characteristics
Variable | Mean (range) or n (%) |
---|---|
Age (years) | 35 (25–52) |
Sex | |
Male | 4 (29%) |
Female | 10 (71%) |
Level of education | |
College diploma | 12 (86%) |
Postgraduate | 1 (7%) |
Certificate | 1 (7%) |
County | |
Kisumu | 7 (50%) |
Homa Bay | 7 (50%) |
Urban/rural facility | |
Urban | 5 (36%) |
Rural | 9 (64%) |
Public/faith-based facility | |
Public | 9 (64%) |
Faith-based | 5 (36%) |
Facility volume & performance | |
High-volume high-performance | 6 (43%) |
High-volume low-performance | 4 (29%) |
Low-volume high-performance | 2 (14%) |
Low-volume low-performance | 2 (14%) |
Length of working time as an HTS provider (years) | 5 (1.3–12) |
Length of working time doing APS (years) | 1.7 (0.7–3) |
Theme 1: overall experience of delivering APS
“When you are introducing APS, you don’t expect it to work on the same day you have introduced it and succeed. It will be something gradual.” (KII 018, from a high-volume high-performance public facility in rural area)
“You know for some clients—this APS is something new to them, so some are shocked when you tell them that you want their sexual partners. So I have to create a rapport and explain to them what APS is. ... There are some who decline ... [for those] I give them time but I contact them from time to time to see if they are now ready." (KII 030, from a high-volume high-performance public facility in rural area)
“The good side is that at least it is specific; I mean you just go to that person—it even saves on the resources. Maybe someone stays in somewhere and so you will just go to one person, not like you will go around the places testing from door to door.” (KII 028, from a high-volume low-performance public facility in urban area)
“APS is concerned with these male sexual partners who are not able to be tested. … I can say on my side most of the positive clients I have achieved are from APS, especially male.” (KII 019, from a low-volume high-performance public facility in rural area)
“I do it to help and to leave other families happier or healthy, compared to when I know something and I just leave or I just keep calm yet within myself I know that this person could be having HIV so when I go, whether I get the person positive or negative I still find it good, I find I am happier and in my feel I have assisted.” (KII 025, from a high-volume high-performance mission hospital in rural area)
“When we started we found it difficult when we go for tracing, we didn’t even have the words to tell our clients for them to accept easily and get tested. But now after being taken for trainings and support supervision, we have learnt from other side we have shared our experiences and we are finding it easier compared to when we started.” (KII 025)
“if you want to tell me about contract referral, there is that fear, somebody will tell you, ‘if I go and do it alone, how will I deliver it? How will I start telling my partner?’ … So you find provider is worth doing because with the skills that we have and the guidelines that we have been given or that they have set for us makes it very easy for us now to reach them as opposed to the other methods.” (KII 023, from a high-volume high-performance mission hospital in rural area)
“In contract referral as the names suggest, you have to sign something with the [index] client that you are going to do it within a particular period and... because our catchment area is big, some of these clients are maybe out of our catchment area. So getting the client might take long. ...So that makes me like the provider referral rather than contract.” (KII 024, from a high-volume high-performance mission hospital in rural area)
Theme 2: challenges and facilitators of provider referral
“I might say we have a suggestion box and your number was picked from the suggestion box. Or say maybe ‘I’m calling from maybe the Ministry of Health, we had a directory so this number we have picked from a directory or Safaricom subscribers.’” (KII 024)“The index demands the results sometimes and this has been a challenge on my side. …I will tell the client ‘Since you know this guy, and you have the number, just call him and he will tell you our experience and the outcome.” (KII 022, from a high-volume high-performance mission hospital in rural area)
“The moment you try to elicit more sexual partners, they feel that you will look at them like they are not morally upright, so there is that fear of judging them.” (KII 016, from a high-volume low-performance public facility in urban area)
“As a counsellor, you will need to do a proper counseling to make the [index] client understand that it is ok to have even up to 10 sexual partners... So the moment you put that partner at peace and if you develop that good relationship, then with time you will get more.” (KII 016)
“What can prevent me from doing provider referral is when the index client gives me the contacts of these sexual partners, most of these contacts are not going through; or the location she gave me is not the true location.” (KII 018)
“You know where I work it rains a lot. And sometimes you don’t have gumboots and you need to go look for a client where it is so muddy…” (KII 020)
“You find that it is also hard in that during the physical tracing, you need to go out and the sun is so scorching and you have to walk very far where the motorbikes cannot reach.” (KII 021, from a low-volume high-performance mission hospital in urban area)
“Some will ask you ‘Where did you get my number?’ And they will insist and become very rude. Some throw nasty words at you or they will insult you: ‘You are a con woman. You want to con me!’” (KII 027, from a high-volume low-performance public facility in urban area)
“If you can involve in contacting these male sexual partners, sometimes they feel 'Why are you asking me my sexual partners?’ Sometimes they think that you want to be involved with that female sexual partner in sex activity.” (KII 019)
“I have been working in this community, they know that this is the person show tests for HIV at the facility. So when they see me, they just run away. They don’t want me to go to their home.” (KII 021)
“In some areas there is a lot of insecurity. You never know whether you will be attacked or not. … Like a case I tried to follow and the partner came out with a panga. And I ran away.” (KII 016)
“It is how you create the rapport with the client. If you are harsh, rude, the client will not agree but if you talk to the client slowly and tell them the benefits of knowing their status, you know, some of them will just agree.” (KII 020)
“Before you do anything more with the client, you have to ask for the clients’ health first. So after contacting the client, promote other health services so that when you talk also about HIV, they will not reject. That is the method I have been using.” (KII 019)
“I link a fellow provider who is a female to deal with this male partner who is difficult. … Yes, men are more open to females.” (KII 022)
“Maybe a client will see me as a bit elderly and when we have a younger person to talk to the youth, they will accept because they will feel like this provider is the same age as them.” (KII 023)
“When I am doing it out of my pocket then I might find it sometimes difficult and I feel like 'ah, today I might not do this because I don’t have enough cash.' So I will weigh, between myself, my family and the client...” (KII 018)
“It (the protocol) shouldn’t be too limited because sometimes you will find that you have filled the tracing form and the client is still yet not cooperative. And remember you should do it 6 times and then give up on this client. But again you think this client needs help… so I think they should not be so strict.” (KII 017, from a low-volume low-performance public facility in rural area)
Theme 3: contextual factors affecting provider acceptability of APS
“In rural areas, homes where the clients come from never change. And most people don’t go to work … compared to towns somebody might be living in Migosi today, next time you go you find that she moved to somewhere where neighbors do not even know. Another thing, when you are going to test this client mostly during the day, people in town they go to work and that is the time when we are also at work, so scheduling with this person is hard.” (KII 025)
“You will find someone starting to go to a facility that is far much interior… Most of the clients don’t want to go to facilities that are along the road… So doing APS in a facility that is interior like a dispensary is easier than doing APS in facilities that are situated along the road.” (KII 018)
"In rural, you will find people who are not literate. Giving information is like you are digging your own grave [laugh]. ... like now where I work the level of poverty is high. Will someone allow you to give them information on HIV and yet they are hungry? … Some will tell you, 'instead of telling me this, give me money so that I can feed first.'” (KII 023)
"In small facilities, the flow of clients is not there, the rate of positivity is also down. But in a bigger hospital like the county hospital or the sub county hospital, the number of clients who normally come for the test is high and so getting a client from this large number of clients is not a problem." (KII 018)
“The remuneration is a bit low and it is not very easy to make ends meet for our families. This is a discouragement.” (KII 016)
“We normally give health talks. We normally have some outreaches. We have some satellites and so when we go there we talk about the APS. Within the facility every Thursday once a month a counsellor talks about APS. So the community they understand it.” (KII 022)