Abstract
Prompt antiretroviral therapy (ART) initiation maximises the therapeutic and prevention benefits of a treat-all strategy for HIV therapy. Using in-depth semi-structured interviews with men and women 18 years and older (N = 41), who were highly motivated and seeking treatment, this study examined salient factors that were associated with delays in treatment access and initiation. Results revealed clinic-related barriers including an onerous, inefficient multi-step process to initiate ART. Participants experienced additional delays due to difficulties accessing care (e.g., being turned away from clinics and referred elsewhere) and health service challenges. Health service challenges included difficulty securing appointments, administrative mistakes (especially lost clinic folders and test results), difficulty navigating the clinic system (e.g., failure to collect a queue card or waiting for incorrect services) and negative clinic-patient interactions. Overall, there was a pervasive negative perception of clinics. Results strongly indicate the need for more patient-centred models of care and the need to reduce unnecessary patient-days at clinics.
Similar content being viewed by others
References
UNAIDS. The Gap Report. Geneva: Joint United Nations Programme on HIV/AIDS; 2014. http://www.unaids.org/en/resources/campaigns/2014/2014gapreport/gapreport. Accessed 13 Dec 2016.
UNAIDS. South Africa takes bold step to provide HIV treatment for all. Geneva: Joint United Nations Programme on HIV/AIDS; 2016. http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2016/may/20160513_UTT. Accessed 13 Dec 2016.
WHO. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Geneva: World Health Organization; 2016. http://www.who.int/hiv/pub/arv/arv-2016/en/. Accessed 13 Dec 2016.
Bor J, Herbst AJ, Newell M-L, Bärnighausen T. Increases in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment. Science. 2013;339:961–5.
Johnson LF, Mossong J, Dorrington RE, et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLOS Med. 2013;10:e1001418.
Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505.
Montaner JSG, Lima VD, Barrios R, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010;376:532–9.
Tanser F, Bärnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa. Science. 2013;339:966–71.
Plazy M, Dray-Spira R, Orne-Gliemann J, Dabis F, Newell M-L. Continuum in HIV care from entry to ART initiation in rural KwaZulu-Natal, South Africa. Trop Med Int Health. 2014;19:680–9.
Patten GE, Wilkinson L, Conradie K, et al. Impact on ART initiation of point-of-care CD4 testing at HIV diagnosis among HIV-positive youth in Khayelitsha, South Africa. J Int AIDS Soc. 2013;16:18518.
Naik R, Doherty T, Jackson D, et al. Linkage to care following a home-based HIV counselling and testing intervention in rural South Africa. J Int AIDS Soc. 2015;18:19843.
Kranzer K, Zeinecker J, Ginsberg P, et al. Linkage to HIV care and antiretroviral therapy in Cape Town, South Africa. PLOS ONE. 2010;5:e13801.
Katz IT, Essien T, Marinda ET, et al. Antiretroviral therapy refusal among newly diagnosed HIV-infected adults. AIDS. 2011;25:2177–81.
Govindasamy D, Kranzer K, van Schaik N, et al. Linkage to HIV, TB and non-communicable disease care from a mobile testing unit in Cape Town, South Africa. PLoS ONE. 2013;8:e80017.
Bassett IV, Regan S, Luthuli P, et al. Linkage to care following community-based mobile HIV testing compared with clinic-based testing in Umlazi Township, Durban, South Africa. HIV Med. 2014;15:367–72.
Smith LR, Amico KR, Shuper PA, et al. Information, motivation, and behavioral skills for early pre-ART engagement in HIV care among patients entering clinical care in KwaZulu-Natal, South Africa. AIDS Care. 2013;25:1485–90.
Kohler PK, Ondenge K, Mills LA, et al. Shame, guilt, and stress: community perceptions of barriers to engaging in prevention of mother to child transmission (PMTCT) programs in Western Kenya. AIDS Patient Care STDs. 2014;28:643–51.
Mugglin C, Estill J, Wandeler G, et al. Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis. Trop Med Int Health. 2012;17:1509–20.
McGrath N, Glynn JR, Saul J, et al. What happens to ART-eligible patients who do not start ART? Dropout between screening and ART initiation: a cohort study in Karonga, Malawi. BMC Public Health. 2010;10:601.
Otieno PA, Kohler PK, Bosire RK, Brown ER, Macharia SW, John-Stewart GC. Determinants of failure to access care in mothers referred to HIV treatment programs in Nairobi, Kenya. AIDS Care. 2010;22:729–36.
Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilitators for linkage to antiretroviral therapy care: a systematic review. AIDS. 2012;26:2059–67.
Rosen S, Maskew M, Fox MP, et al. Initiating antiretroviral therapy for HIV at a patient’s first clinic visit: the RapIT randomized controlled trial. PLOS Med. 2016;13:e1002015–9.
Myer L, Zulliger R, Pienaar D. Diversity of patient preparation activities before initiation of antiretroviral therapy in Cape Town, South Africa. Trop Med Int Health. 2012;17:972–7.
Ingle SM, May M, Uebel K, et al. Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study. AIDS. 2010;24:2717–25.
Larson BA, Schnippel K, Brennan A, et al. Same-day CD4 testing to improve uptake of HIV care and treatment in South Africa: point-of-care is not enough. AIDS Res Treat. 2013;2013:1–7.
Thompson MA, Aberg JA, Cahn P, et al. Antiretroviral treatment of adult HIV infection: 2010 recommendations of the International AIDS Society–USA Panel. JAMA. 2010;304:321–33.
Galárraga O, Genberg BL, Martin RA, Barton Laws M, Wilson IB. Conditional economic incentives to improve HIV treatment adherence: literature review and theoretical considerations. AIDS Behav. 2013;17:2283–92.
Operario D, Kuo C, Sosa-Rubi SG, Galárraga O. Conditional economic incentives for reducing HIV risk behaviors: integration of psychology and behavioral economics. Health Psychol. 2013;32:932–40.
Department of Health, Republic of South Africa. National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults. Pretoria: Department of Health; 2014. [updated 24 December 2014]. http://www.kznhealth.gov.za/family/HIV-Guidelines-Jan2015.pdf. Accessed 13 Dec 2016.
Kinkel HF, Adelekan AM, Marcus TS, Wolvaardt G. Assessment of service quality of public antiretroviral treatment (ART) clinics in South Africa: a cross-sectional study. BMC Health Serv Res. 2012;12:228.
Wouters E, Heunis C, van Rensburg D, Meulemans H. Patient satisfaction with antiretroviral services at primary health-care facilities in the Free State, South Africa—a two-year study using four waves of cross-sectional data. BMC Health Serv Res. 2008;8:210.
Amuron B, Namara G, Birungi J, et al. Mortality and loss-to-follow-up during the pre-treatment period in an antiretroviral therapy programme under normal health service conditions in Uganda. BMC Public Health. 2009;9:290.
Duff P, Kipp W, Wild TC, Rubaale T, Okech-Ojony J. Barriers to accessing highly active antiretroviral therapy by HIV-positive women attending an antenatal clinic in a regional hospital in western Uganda. J Int AIDS Soc. 2010;13:37.
Bogart LM, Chetty S, Giddy J, et al. Barriers to care among people living with HIV in South Africa: contrasts between patient and healthcare provider perspectives. AIDS Care. 2013;25:843–53.
Pilcher CD, Ospina-Norvell C, Dasgupta A, et al. The effect of same-day observed initiation of antiretroviral therapy on HIV viral load and treatment outcomes in a U.S. Public Health Setting. J Acquir Immune Defic Syndr. 2017;74(1):44–51.
Wilkinson L, Duvivier H, Patten G, et al. Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa. South Afr J HIV Med. 2015;16:1–7.
Department of Health, Republic of South Africa. Adherence Guidelines for HIV, TB and NCDs. Pretoria: Department of Health; 2016. https://www.nacosa.org.za/wp-content/uploads/2016/11/Integrated-Adherence-Guidelines-NDOH.pdf. Accessed 9 May 2017.
Acknowledgements
The authors gratefully acknowledge the staff of the Tutu Tester Mobile Clinic for their significant contribution to the iLink study fieldwork and Genoviva Sowemimo-Coker who made a valuable contribution to the data analysis.
Funding
This study was partially funded by the National Research Foundation, South Africa, through the Research Career Advancement Fellowship. Support for this study was also provided by the South African Social Science and HIV (SASH) Programme, an initiative funded by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (Award #R24HD077976). CK and ML derived support for analysis, interpretation and writing from the National Institute of Mental Health (Grants K01MH 096646 and R01 MH106600). The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
All authors declare that they have no conflict of interest.
Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Human Research Ethics Committee, Faculty of Health Sciences, University of Cape Town provided study approval (Ref: 849/2014).
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Maughan-Brown, B., Kuo, C., Galárraga, O. et al. Stumbling Blocks at the Clinic: Experiences of Seeking HIV Treatment and Care in South Africa. AIDS Behav 22, 765–773 (2018). https://doi.org/10.1007/s10461-017-1877-4
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10461-017-1877-4