Characteristics of participants and repeat clients
A total of 617 participants of median age 33.0 (IQR: 26.0–41.0) years, were included in the analysis from both HTS models (284 and 333 participants for standard of care HTS and integrated NCD-HTS, respectively), and the largest proportion of participants were females (61.3%, [n = 378/617]), black African (99.2%, [n = 612/617]), South African (96.6%, [n = 592/613]), Zulu speaking (45.3%, [n = 279/616]), single (70.7%, [n = 434/614]), educated up to high school (40.1%, [n = 247/616]), and employed (36.9%, [n = 227/615]). More than one quarter were within the third wealth quintile category (i.e.; middle class; 26.6%, [n = 164/617]). Participants of standard of care HTS were significantly older (median age was 35.0 (28.0–43.0) years vs. 31.0 (25.0–40.0) years; p = 0.0003), likely to be divorced (6.7%, [n = 19/282] vs. 2.4%, [n = 8/332]; p = 0.0091) and be tertiary educated (27.9%, [n = 79/283] vs. 20.1%, [n = 67/333]; p = 0.0234) compared to those of integrated NCD-HTS. Standard of care HTS had significantly less proportions of females (53.9%, [n = 153/285] vs. 67.6%, [n = 225/333]; p = 0.0005), Zulu speakers (41.0%, [n = 116/283] vs. 49.0%, [n = 163/333]; p = 0.0480) and clients reporting their parents as their source of income (13.0%, [n = 37/284] vs. 20.5%, [n = 68/331]; p = 0.0135) as compared to integrated NCD-HTS.(Table 1)
Of the 333 Phase 2 clients who completed a survey, 10.2% (n = 34/333) went on to become repeat clients within Phase 2.
Reasons for declining HTS services for each HTS model
Only two clients opted out of HTS services in standard of care HTS, with one client dismissing CD4 count testing as she preferred to have it conducted at her ART referral clinic and another client declining being screened for STI symptoms as she responded that she was currently abstinent. A total of 36 survey responders (10.8% of clients) reported opting out of services in integrated NCD-HTS. Among these, 40% (n = 16/40, all women) refused cervical cancer screening for reasons related to reproductive health (i.e.; menstruation [n = 13/40, 32.5%]; having had a hysterectomy and therefore no cervix present [n = 2/40, 5.0%]; and sharing, ‘[I am] No longer interested in having babies’ [n = 1/40, 2.5%], which also represents a misunderstanding surrounding the purpose of the Pap smear procedure). Other reasons included the desire to reschedule their clinic visit (n = 10/40, 25.0%); being unprepared for or unsure of the new screenings (n = 6/40, 15.0%) (specifically for the pelvic exam); lack of time (n = 4/40, 10.0%), including either needing to return to work or needing to leave due to family obligations; worried about potential results (n = 2/40, 5.0%); having recently had a Pap smear or currently having an STI (n = 1/40, 2.5%, each).
Client satisfaction with pre-test and post-test counselling by HTS model
There were four main suggestions from seven standard of care HTS responders on how to improve pre-test counselling: minimise the paperwork (n = 3/7), provide in-depth information on health and/or disease (n = 2/7), explain the rapid testing technology and screening machines used (HIV test kits and BP cuff and monitor) (n = 1/7), and strengthen communication (n = 1/7), presumably around the rapid testing process and instruments used. Four responders in integrated NCD-HTS suggested different improvements for pre-test counselling. They were providing further health information, inclusive of ‘relationship goals and health practice’; creating set appointments times between ‘8–15hrs’; providing additional screenings, such as ‘prostate cancer’; and explaining the new rapid testing machines (glucometer and lipidometer).
Only one standard of care HTS client shared a suggestion to improve post-test counselling, which was for the counsellor to provide ‘tips on what the client should work towards’. Presumably this relates to strengthening risk reduction counselling.
Client satisfaction with health screening procedures by HTS model
Most participants were very prepared for the health screening procedures in standard of care HTS (90.8%, [n = 256/282]) and integrated NCD-HTS (90.6%, [n = 300/331]); and very comfortable with the level of comfort/discomfort while being tested in standard of care HTS (90.7%, [n = 254/280]) and integrated NCD-HTS (94.0%, [n = 311/331]). In standard of care HTS, of those who saw the nurse, 96.5% (n = 82/85) found speaking with the nurse very helpful, while 98.3% (n = 172/175) did in integrated NCD-HTS. Overall, the majority of participants were very satisfied with the experience they had at Zazi in both standard of care HTS (97.8%, [n = 272/278]) and integrated NCD-HTS (97.9%, [n = 320/327]). (Fig. 2)
Only ten standard of care HTS responders (3.5% of clients, [n = 10/284]) made suggestions to improve health screening procedures. Three responders desired additional health screenings such as ‘STI test and blood sugar test’ and also requested there to be less paperwork/administrative tasks; and one individual suggested each of the following: offer circumcision, improve the current testing procedure, explain the data collection process, and provide home visits. Integrated NCD-HTS contained only four responders (n = 4/333), of which three suggested additional integrated HTS to include breast cancer and eye screening; and one client requested standardised appointments for certain screenings for which one might be unprepared (e.g.; Pap smear).
Clinic flow time and time-related client satisfaction by HTS model
Participants in standard of care HTS took a significantly shorter median time (in minutes) in the counsellor-led HTS process relative to those in integrated NCD-HTS (36.5, IQR: 31.0–45.0, [n = 284/284] vs. 41.5, IQR: 35.0–51.0, [n = 332/333]; p < 0.0001) minutes (Table 2, Fig. 3). The majority of participants in standard of care HTS (93.2%, [n = 262/281]) and integrated NCD-HTS (94.9%, [n = 313/330]) were very/somewhat satisfied with the time spent at reception; though the median time in minutes was significantly shorter in standard of care HTS relative to integrated NCD-HTS (15.0, IQR: 9.0–21.0, [n = 265/284] vs. 19.0, IQR: 12.0–28.0, [n = 331/333]; p < 0.0001). Overall, participants felt very/somewhat satisfied by the amount of time spent on pre-test counselling (97.6% [n = 596/611]). The median time taken to conduct screenings (17.0, IQR: 13.0–22.0, [n = 281/284] vs. 21.0, IQR: 17.0–27.0, [n = 332/333]; p < 0.0001) and for post-test counselling (7.0, IQR: 5.0–8.0, [n = 284/284] vs. 8.0, IQR: 6.0–10.0, [n = 332/333]; p < 0.0001) was significantly shorter in standard of care HTS relative to integrated NCD-HTS. (Fig. 3)
Factors associated with total time (in minutes) spent in the clinic
Controlling for sex, living together/married (est = 6.548; p = 0.0467), number of tests a client underwent (est = 3.922; p < 0.0001), and higher overall satisfaction score (est = 1.210; p = 0.0201) were associated with longer time spent in the clinic. Those who matriculated spent less time in the clinic (est=-7.250; p = 0.0253) (Supplementary Table 3).
What clients liked by HTS model
There were 246 (86.6%, [n = 246/284]) responders depicting what clients liked about the clinic in standard of care HTS. Of these, 49.6% (n = 132/266) reported that they enjoyed the services and/or customer care they received. Two responders stated, ‘Good services, as I am a regular participant’ and ‘Good service I got from reception to end’. Additionally, 12.8% (n = 34/266) stated they liked the friendly and supportive staff they interacted with, and 9.4% (n = 25/266) shared they appreciated the clinic provider communication style. For example, one client shared, ‘I was treated with respect and the staff was very friendly and kind. They explained to me everything and answered all my questions satisfactorily.’ Other responses depicted clients liked feeling comfortable (6.4%, [n = 17/266]), the in-depth and professional counselling session (4.1%, [n = 11/266]), and the warm and welcoming clinic environment (3.4%, [n = 9/266]).
In integrated NCD-HTS, 307 (92.2%, [n = 307/333]) clients shared what they liked about ZAZI. The majority of responses shared that of Phase 1 responses – 35.5% (n = 124/349) appreciated the service, specifically the new screenings; 22.3% (n = 78/349) enjoyed the welcoming, professional and supportive staff; and 8.6% (n = 30/349) liked the effective communication of and information shared by the health care providers. One client responded, ‘The staff member are very patient and explain things very well.’
What clients disliked by HTS model
Of the 206 (72.5%, [n = 206/284]) responders for standard of care HTS, 91.3% (n = 190/208) shared they did not dislike anything about Zazi. Of the remaining responders, the most common reasons for dissatisfaction were with the amount of time spent waiting in the clinic (2.9%, [n = 6/208]) and administration time spent during the clinic visit (i.e.; client registration systems and paperwork; 2.4%, [n = 5/208]). Other reasons for dissatisfaction were that treatment (1%, n = 2/208]), contraceptives (0.5%, [n = 1/208]), and snacks (0.5%, n = 1/208]) were not offered onsite; and outcome of results (unacceptance of one’s HIV diagnosis), wanting additional screenings, and untidiness of the reception area (0.5%, [n = 1/208] each).
Of the 300 (90.1%, [n = 300/333]) responders for integrated NCD-HTS, 88.7% (n = 268/302) disliked nothing. Of the remaining responses (n = 34/302), the top two reasons for dissatisfaction were duration of the clinic visit (55.9%, [n = 19/34]), with responses being ‘I spent more time than expected’ and ‘[I] waited for too long at reception’; and the amount of administrative paperwork conducted (17.7%, [n = 6/34]).
What clients wish ZAZI would have provided
When integrated NCD-HTS clients were asked to share if they wished the clinic would have provided them anything else, 23.7% (n = 79/333) made suggestions. Of these responders, 45.6% (n = 36/79) wished medications – ART, and for both chronic conditions and over-the-counter – were available onsite. Additionally, 20.3% (n = 16/79) requested additional services (e.g.; prostate and breast cancer screening, regular follow-up calls, and home visits for terminally ill patients); and 16.5% (n = 13/79) would have liked refreshments served. Only 7.6% (n = 6/79) clients wished the clinic could minimise time spent waiting.