Who is providing HIV testing services? The profile of lay counsellors providing HIV testing services in Johannesburg, South Africa in the treat-all era

We describe lay counsellors providing HTS in the PHC setting in Johannesburg, South Africa, in the era of universal HIV treatment access. Lay counsellors enrolled in our study primarily comprised female lay counsellors, reflecting the prevailing pattern in South Africa [27, 30, 41]. This gender imbalance can present a limitation when it comes to expanding services to male clients who are less likely to know their HIV status and have suboptimal HIV treatment and prevention coverage [2, 4, 42]. Overall, lay counsellors faced operational barriers in their workplace, including a lack of designated space for counselling, insufficient supervision and support, and emotional support, and a notable 60% felt overwhelmed by their workload. Furthermore, our findings indicate that lay counsellors continue to perform auxiliary duties alongside their primary function of providing HTS. This, coupled with their reported heavy workload, places them at risk of burnout, potentially resulting in a decline in the quality of service provision. Lay counsellors have faced similar challenges in the pre-UTT era since the start of the HTC campaign in 2010 [16, 29, 30]. These challenges indicate continued difficulties clarifying and streamlining their workplace roles and responsibilities and providing adequate supervision and support.

Almost a quarter of the study participants had not completed high school; this is lower than 40–50% reported in previous cohorts evaluated in the pre-UTT era [30, 43]. A grade 12 education is one of the minimum requirements for lay counsellors, as stated in the HTS and Adherence guidelines [21, 23, 44]. Therefore, it may hinder future integration into the health workforce. Moreover, those with low education levels may find it difficult to comprehend training curriculums and may require training approaches that simplify complex concepts, preferably provided in their vernacular.

Although there were gaps in formal education, the current cohort had universal participation in basic HIV counselling and testing training, a considerable improvement from the pre-UTT era when basic training was limited or absent [29, 30, 45]. However, we found training adequacy lower among less experienced counsellors who were also younger. This may suggest a shift in lay counsellors’ training and support landscape over time (less for new entrants). More experienced lay counsellors who developed from HIV peer support in the HIV epidemic’s early years were likely exposed to more training and support opportunities to meet changing policy contexts when donor funding was still plentiful as the national program matured and task-shifting was implemented [13, 33, 46].

Persistent disparities in training and skills among lay counsellors in the UTT era limit the national program’s capacity to achieve universal ART access and end the HIV epidemic by 2030. Observed training gaps highlight the need for lay counsellors to be adequately trained based on current policies and work context supported through quality assurance strategies such as mentoring and routine skill assessments and feedback. In addition, even with high ART knowledge, some study participants were unaware of the preventative properties of ART after rape (post-exposure prophylaxis), and some believed HIV could be cured by ART. Therefore, future training should also address lay counsellor knowledge gaps as scientific advances in HIV and ART continue, including the benefits of early ART and treatment as prevention. Furthermore, existing differences in counsellor profiles may present an opportunity for those with extensive experience and training to be upskilled to become more specialized lay counsellors providing support or mentoring to others. This strategy can also help address the lack of career pathing previously identified in this cadre [28, 29].

Job satisfaction was moderate; a previous pre-UTT cohort had higher job satisfaction [29], which may be indicative of policy changes that may have added complexities to their job with no improvements in the work environment. Additionally, 50% of lay counsellors actively sought alternative employment, with more than twice as many Department of Health lay counsellors having high turnover intentions. These results suggest persistent differences in employment conditions between NGO counsellors and Department of Health lay counsellors, with NGO counsellors earning higher salaries and having clearer reporting lines and supervision through their organizations [14, 33]. Despite these challenges, more counsellors seem confident in their core counselling and testing skills of adolescents, couples, infants and children, whom previous cohorts self-reported having difficulty serving [16, 29, 30]. However, they remain less confident in counselling and testing members of key populations [16, 29, 30].

Almost a fifth of lay counsellors reported experiencing major depressive symptoms; the same proportion experienced low psychosocial well-being. Previous studies have shown below-average emotional well-being and high levels of emotional exhaustion, job stress, and depression among lay counsellors in South Africa [28, 29, 43]. In addition, very few study participants participated in debriefing activities to help them cope with their work’s emotional burdens. Accordingly, there is a very high risk of burnout and an inability to maintain interpersonal sensitivity, which has been previously highlighted [43, 47, 48]. Depressive symptoms and low psychological well-being were more prevalent in those with less counselling experience, possibly due to fewer opportunities to develop coping skills and resilience through differential access to work support over the years. Counsellor training programs should incorporate self-care and debriefing elements to support counsellors in coping. Moreover, ongoing support through workplace debriefing and emotional support programs is also essential to their well-being.