Facility-Based Service Delivery
Opportunity for comprehensive care
Participants generally felt that regular (1-2 monthly) attendance at facilities for medical reviews with clinicians, possible laboratory tests and medication refills had advantages. They associated a clean bill of health from providers to a better life as exemplified in the following narratives:
“Coming here, I get to see the doctor, go to the lab and get to do other things in the hospital that is why I like coming here.” (Female, 7 years on ART, FGD2)
“When we come to the hospital, it helps because they talk to us on various things to make sure we take the drugs. Different healthy meals are also talked about, and other things for a good life. I believe coming to clinic has a psychological effect also because the moment you meet a doctor you start to feel better. So I prefer coming over to see the doctor every time”. (Male, 7 years on ART, FGD4)
“All I want is to come (to the health facility). Maybe there will be something that needs to be checked in my system before the doctor gives more medication. If the drugs are brought to me at home by someone that cannot be detected”. (Male, >10 years on ART, FGD1)
The benefit of distance to the clinic
Many in the groups felt that, coming to a health facility far away from their communities was actually a way of maintaining anonymity and avoiding unintended disclosure of their HIV status, and the associated stigma and discrimination in their communities as below.
“I come to this hospital to avoid people I know seeing me. I could have gone to the Saltpond hospital (closer to participant) but I come all the way here. After all who ever will see me in this clinic also has the HIV”. (Female, 8 years on ART, FGD5)
Challenges with distance to the clinic
Despite the construct of the distance to the clinic being beneficial, some participants also saw it as a challenge due to the cost implication and effect on honouring clinic appointment. “Transportation is very costly for me. My child and I spent ₵160 ($40) today when coming and that is my problem. It make it difficult for me and sometime I cannot come.” (Male, 22 years on ART, FGD1)
Increase interval between clinic visits
Participants in this study also presented constructs of the challenges associated with the facility based service provision which impacts them negatively. In their constructs, they offered possible solutions which in their opinion would improve the care of PLHIV:
“Now they give many of us 1 month or two. We wish they give us longer time to come back”. (Males, all participants, FGD1)
“I prefer coming but would want to take the medication for like 4 to 5 months. When I’m due for the next set, then I come for my drugs”. (Female, 3 years on ART, FGD2)
Efficient clinic organization to reduce waiting times
The need to improve the organization and efficiency of service delivery during clinic visits were also highlighted. As can be seen from quotes below, participants felt that they spent too much time at the clinic and some offered possible interventions to reduce the time for all clients.
“As she is saying, then the folders should be arranged well. This is because you cannot come and sit here from dawn and waste your whole time. People come on empty stomachs and come from far so the folders need to be arranged well. So the queue should be arranged well”. (Female, 8 years on ART, FGD5)
“Again, the time we spend here is too much here. We have to come and go back to our jobs. We come very early but leave quite late.” (Male, 7 years on ART, FGD 1)
Among these study groups of PLHIV, the concept of community based ART delivery and follow up was met with very strong opinions. While the concept in general was acceptable to some, no group had a consensus.
The convenience of “home” service delivery
For participants who indicated their preference for community-based service delivery, the focus seemed to be on reduction in the cost of travelling and convenience of accessing medications at the comfort of their own home:
“I live in Takoradi (1 hour drive away) but come all the way here to take my medication. This is because I do not want people I know to find out. I will not want to visit any hospital close by to take my drugs, but if they can bring them to our homes, then that will be fine”. (Female, about 2 years on ART, FGD3)
“I believe that in advanced countries, you can order your drugs even when you are home so if I’m in my community and my health care practitioner brings my drugs it is rather to my advantage. So if my drugs are brought to me in my comfort zone, I will be glad”. (Male, 9 years on ART, FGD4)
Inadvertent disclosure with resultant stigma and discrimination
Participants from all 5 FGDs expressed strong feelings about any service provided in their community on the basis of fear of accidental disclosure and its associated stigma and discrimination. The general construct was of the opinion that such an approach will require visits from health care workers and others to their homes. They felt that, it will be almost impossible to arrange such community-based strategies without people becoming suspicious:
“We do not want people to know that we have this condition. It is a private issue. If they start coming that often to our houses, people will start asking questions.” (Female, 1 year on ART, FGD3)
“I do not like that idea (community-based service) I prefer to come here (the health facility). People will start getting suspicious when we meet at a particular spot in our communities.” (Male, 2 years on ART, FGD1)
“The nurses in my community will be the very ones to broadcast my disease to people. Some of the nurses talk too much.” (Female, 10 years on ART, FGD2)
Doubts regarding the organization of community-based service delivery
Participants were unsure about how such a model will be organized. One participant felt that this service would depend on having a significant number of PLHIV in a particular community. Such numbers would have allowed a peer-led approach but the current situation, he felt, might make it impractical to organize across the country:
“If we were to be about 10 or 15 then it would have been better to group ourselves and meet someone at a particular place for our drugs. We really wish to have the drugs brought to us but we cannot force if we are very few or even just one person in a particular place”. (Male, 2 years on ART, FGD3)
Uncertainty about how this would be organized, led to constructs about how this could cause problems rather for PLHIV as seen below:
“How about when the doctor comes and meets your absence. He or she will definitely leave the drugs and that will obviously give you the patient up. So I really don’t support the drugs being brought to our communities.” (Male, 6 years on ART, FGD4)