Background
The HIV and aids epidemic in Uganda
Methods
Research design
Study sites and selection
ACCRONYM | OWNERSHIP | LEVEL OF CARE [31] | SETTING | SUB-REGION | ANNUAL ART PATIENT VOLUMES (As at June 2015) | |
---|---|---|---|---|---|---|
1 | PUB-001 | PUBLIC | Referral Hospital | Urban | South West | 24,408 |
2 | PUB-002 | PUBLIC | Referral Hospital | Urban | Kampala | 2408 |
3 | PUB-003 | PUBLIC | Referral Hospital | Urban | Central 2 | 6414 |
4 | PUB-004 | PUBLIC | District Hospital | Urban | East Central | 598 |
5 | PUB-005 | PUBLIC | Health centre IV | Peri-urban | Mid-East | 458 |
6 | PUB-006 | PUBLIC | Health centre IV | Rural | Mid-north | 2034 |
7 | PUB-007 | PUBLIC | Health centre IV | Rural | East-Central | 263 |
8 | PUB-008 | PUBLIC | Health centre IV | Peri-urban | Mid-west | 298 |
9 | PUB-009 | PUBLIC | Health centre IV | Rural | North East | 126 |
10 | PNFP-001 | NOT FOR PROFIT | Referral Hospital | Urban | Kampala | 4337 |
11 | PNFP-002 | NOT FOR PROFIT | Referral Hospital | Urban | East central | 1727 |
12 | PNFP-003 | NOT FOR PROFIT | Health Centre IV | Rural | Mid-East | 647 |
13 | PNFP-004 | NOT FOR PROFIT | Health Centre IV | Peri-urban | South West | 402 |
14 | PFP-001 | FOR-PROFIT | Health centre III | Urban | Mid-West | 324 |
15 | PFP-002 | FOR-PROFIT | Health Centre II | Urban | Central 2 | 29 |
16 | PFP-003 | FOR-PROFIT | Health Centre II | Rural | Mid-North | 46 |
Data collection
Structured questionnaire
Semi-structured interviews
Health worker respondents |
n = 78
|
Head of ART clinic (16), facility in-charges (16) |
n = 32
|
Clinicians |
n = 46
|
Sex | |
Male | 41 |
Female | 37 |
Age (years) | Range: 22–59 |
Median 36 | |
Work experience | Range: 1–20 |
Median: 5.4 | |
Focus Groups (ART Clients) |
n = 68
|
Sex | |
Male | 37 |
Female | 31 |
Age (years) | Range 38–59 |
Median: 44 |
Focus group discussions
Selection of participants
Data analysis
PRINCIPLE | |
---|---|
Prolonged engagement | Multiple on-site visits were made to the case-study facilities. Investigators engaged in informal discussions with clinicians and HIV clinic managers as well as conducting formal, face-to-face interviews with multiple informants per health facility. |
Use of theory | This study draws upon the analytical framework by Shediac-Rizkallah & Bone (1998). |
Case selection | Sixteen health facilities which run a stand-alone HIV clinic were purposefully selected from a nationally-representative sample of 195 health facilities across Uganda participated in the pilot national ART roll-out phase. |
Sampling | We aimed to have a sample that had appropriate representation of health facility demographics in Uganda with respect to a) setting(rural/urban), b) ownership-type(public, for-profit, not-for-profit) c) Level of care(tertiary, secondary, primary). |
Multiple methods | Multiple methods were used including face-to-face interviews, a structured questionnaire and informal engagements with clinicians and the head of the ART Clinic |
Triangulation | Case descriptions were constructed based on triangulation across multiple data sources (Questionnaire data and, interviewee data). |
Peer debriefing and support | Data analysis involved a team-based process involving at least three authors. |
Respondent validation | A data validation workshop was conducted with involving the head of the HIV clinic in 14 of the participating health facilities. |
Results
Characteristics of the intervention
HIV-related stigma
‘At first when we started HIV services we could prescribe drugs and send our patients to the general hospital pharmacy to get drugs but then there was a problem of stigma. Also, the waiting time was long because most patients at this hospital pay for the services but HIV services were mostly free so they would work on the paying patients first and then handle HIV patients last which stigmatized clients ‘[Interviewee 2, PNFP-001].
‘People with HIV suffer discrimination. There is a lady health worker in the labour ward who does not attend to HIV positive mothers. She promptly refers them to the district hospital because she says they will infect her. She cannot touch their blood if she is on duty’ [Patient 121, PUB-008].
‘HIV infected clients attending HIV clinics require a ‘one-on-one touch’ that may be difficult to offer in general clinics’ [Interviewee 3, PUB-006].
‘General clinics do not have dedicated counsellors who are critical to the care processes for HIV-infected clients right from diagnosis, through to start of treatment, adherence patterns and follow up with adverse drug reactions among others’ [Interviewee 1,PFP-002].
‘We then advocated for having our own store for ARVs (antiretroviral drugs) which was later expanded into the clinic. When we opened up the place (HIV clinic) people flocked in because they liked the privacy because we were located in a hidden part of the hospital’ [Interviewee 2, PNFP-001].
‘That time we had challenges with getting laboratory services in the OPD (out patients department) because the place was highly congested and we were there with other patients so we had to follow one queue and they were not considerate of us since we face severe hunger after waiting for long hours unlike other patients’[Patient 126, PUB-002].
Organizational context
Health-system barriers to service integration
‘The guidelines are changing so fast but the health system is remaining more less the same. If you see what is required of a health worker to handle a single HIV patient. The workload is dizzying. Do you have a cough today? Then I am supposed to fill the presumptive TB register. Then fill a laboratory request form. Conduct counselling, clinical examination, cancer screening. In addition, I have to go back and fill the HIV forms’ [Interviewee 1, PUB-005].
‘The workload on each individual health worker increases when you implement integrated services because it would mean that health facilities provide all services; malaria, nutrition, family planning together. It means you are the doctor to review the patient, you are the TB specialist, you are the eMTCT specialist, you take off my blood for CD4 and viral load. That while you are seated in that chair, you can handle all of my needs so that you avoid the client walking at different points in the clinic. Can we cope with such a workload? [Interviewee 1, PUB-007].
‘Human resource challenges remain critical. HIV work is specialized and labor intensive in view of the multiple complexities that clients have. Integrating HIV services with non-HIV services will call for additional reinforcements in human resources to manage the demand. Additionally, there is need for continuous medical training for all those involved in HIV care to ensure that they keep abreast with the rapidly changing treatment and care algorithms in order to offer quality services’ [Interviewee 2, PNFP-002].
‘Most HIV clinics from the sub-district level and above have huge client loads for HIV clients and yet the human resource capacity has not been supported in commensurate ways. It is very difficult to integrate the general HIV clinic in say the entire OPD and have them attended to in a pool of general OPD clients with the limited human resource capacity’[Interview 3, PUB-004].
‘The problem with the laboratory is that we share it with the OPD (Out Patients department). We have to run blood smear and malaria parasites tests and at the same time do CD4 tests. The CD4 machine takes 30 minutes to run tests for one person so if you have 30 people it will take the whole day’[Interviewee 1,PUB-008].
‘They would often draw blood from you but the results would never come out as fast as they did when we had the ART Clinic. In fact, after our donor withdrew, it was impossible to get CD4 count results from the general hospital laboratory’ [Patient 128, PUB-002].
‘There was a moment of confusion. Patient blood samples for CD4 tests were frequently lost in the general hospital laboratory. They would draw your blood from the main hospital laboratory under a request from a health worker in the ART clinic. The requesting ART clinic staff would not be around to follow up on samples. Even when you yourself followed up with the main Laboratory there was no one to ask since they did not originate the laboratory request. It was a moment of chaos. [Patient 121, PUB-008].
‘Being the regional referral hospital, we continually get patients referred to us from lower-level health centres especially those who have failed on first line and second line drugs and need more advanced clinic care which lower health centres aren’t able to handle. We are a regional centre of excellence and have expertise to offer advanced HIV care’ [Interviewee 1, PUB-001].
‘We have the TB clinic here within our HIV clinic complex. Our TB clinic is a one-stop shop. All TB cases in the hospital come to us. When we test you and find you are HIV positive, you remain with us. If you are HIV positive we follow you up’ [Interviewee 1, PNFP-001].
‘Specialized HIV clinics are critical especially in referral settings. As people stay on treatment for several years, there are several adherence, toxicity, drug failure issues that are coming up on a day-to-day basis. These need to be managed critically to avoid future treatment failure challenges with the limited treatment options’ [Interviewee 3, PNFP-002].
“The space is not enough. We have one tent for the patients and even some of the client counselling is done in the open which makes the patients uncomfortable.” [Interviewee 3, PUB-007].
Broader-environment factors
HIV funding architecture
‘There is a historical aspect to this. HIV services in most of the health facilities in Uganda were introduced in a vertical fashion with heavy donor funding. There has also been a heightened focus on HIV treatment roll out in an effort to test and treat all HIV infected persons which has promoted the growth of vertical clinics’ [Interview 1, PFP-003].
‘One of the reasons why we have been able to sustain HIV treatment for all this time is our funders from the United Kingdom, from Canada, from United States. For instance, they have been funding treatment of opportunistic infections (OIs) and other care costs which are not catered for by our main funders’ [Interviewee 1,PNFP-001].
‘Individual donors from the West made it possible to re-model a former laundry room for hospital staff into the present HIV clinic building. The central hospital management was inspired to start dedicated HIV services with donor support’ [Interviewee 3, PUB-002].
HIV demand-side factors
‘There was no HIV clinic to start with. Services began as a three-hour service, once a week on a Monday. There was no ART at the time. Essentially it was management of opportunistic infections (OIs) and counselling. The three-hour services were provided in a large room which was partitioned into two to accommodate clinicians and counsellors. The key driver for transforming into a fully- fledged clinic was the consistent increase in patient numbers’ [Interviewee 2, PNFP-001].
‘At the beginning it was a one day clinic. When the patient numbers grew bigger, we improvised one of the rooms under an un-used theatre. We partitioned the room into two. One for the counsellor and another for the second counsellor. We started with 10 clients then the number rose to 69 and subsequently to 300 patients. In terms of staffing, the clinic began with 3 staff which rose to 10 and then 50. Staff were seconded to the HIV clinic when the demand for HIV services increased’ [Interviewee 1, PUB-004].