The findings emerging from this study are divided into socio-demographic characteristics, ART care services provided at the CDDPs, barriers and facilitators to utilization of community drug distribution points. The findings from this study were presented according to the themes derived from Levesque et al. (2013). The major themes included individual level, family related and health system barriers to utilization of the CDDPs among the ALWHIV.
Social demographic characteristics of study participants
Overall, 29 qualitative interviews were conducted with a total of 12 FGD, 12 IDI and 5 key informants. ALWHIV and caregivers of minors were of average age of 13 and 44 years respectively. 96% of the participants attained primary level of education (Table 1).
Table 1
Socio-demographic characteristic of study participants
Variable | | Marital status | Gender | Level of education |
Frequency | | Married | single | Male | Female | Primary education | No formal education |
Adolescents | 0 | 74 | 42 | 32 | 74 | 0 |
Care givers | 30 | 13 | 23 | 20 | 38 | 5 |
Health care services provided at the CDDPs
ALWHIV and caregivers of minors seeking ART care services from CDDPs interviewed were asked about the health care services provided during scheduled visits. Our findings revealed that the core HIV care services were provided by the lay heath care workers with basic training in HIV care and treatment. The core HIV care services offered included health assessment, provision of ART refills during scheduled appointment visits, and regular psychosocial support and home visits on a monthly basis as well as viral load monitoring.
“Health care services provided at the CDDPs included teaching ALWHIV on importance of compliance with taking ART every day at the right time, assessment of clinical status and nutrition status, and provision of drug refills every 2 months or 3 months depending on the result of the viral load. If the result is good, then you are given drug refill for three months”. Female, participant 5, IDI
BARRIERS AND FACILITATORS TO UTILIZATION TO CDDPS
From qualitative interviews, we generated two (2) broad themes, barriers and facilitators to utilization of CDDPs. From the broad themes, the research team generated three (3) sub themes to barriers to utilization of CDDPs namely individual level related barriers, family related barriers and health system barriers. Facilitators to utilization of CDDPs included ease of access to ART services, desire to remain healthy and productive, reduced time spent accessing care, and peer support and group encouragement.
Barriers to utilization of CDDPs
Individual level related barriers
Interviews with ALWHIV and caregivers of minors revealed that a number of barriers affecting utilization of CDDPs. These barriers included limited level of privacy, individual fears and worriers, distance to CDDPs and longer waiting time.
Limited level of privacy at the CDDP
During health service delivery at the CDDP, ALWHIV were asked about the physical comfort of the venues designated as “suitable infrastructure” used as CDDPs. Across all the interviews, our study revealed that the agreed venues included some of the churches, primary schools, shades of trees in the community and homes of residences. Most of these outreach points has limited level of privacy and were open to the neighborhood and passersby. The limited level of privacy at the CDDPs was reported as one of the main barriers to utilization of CDDPs. As one of the ALWHIV said:
“We gather under this mango tree for collecting drug refills, those with problems are counselled here because there is no any other place with privacy. Being an open place, some of ALWHIV do not openly talk about their problems, instead they keep quit and go back to their homes without telling the health care providers at the CDDPs”. Female, participant 6, IDI.
To the ALWHIV, limited level of privacy meant that people in the nearby community knowing your HIV status, being labelled as those suffering from HIV translating into individualized stigma which negatively affect disclosure of health problems, adherence to medication and retention at the CDDPs.
“At the CDDPs, many ALWHIV gather and are attended to under the shade of a tree in the residence of the community member. Every community member in this area knows our HIV status which is not good. Those with health or home related problems are attended to in the open with almost no privacy. This makes some of us not to tell our problems to the health care providers”. Female, participant 2, IDI.
Our in-depth interviews with participant attached to one of the CDDPs revealed that if any ALWHIV has health problems during the scheduled appointments, then he or she has to wait until the end of the session to be counselled. One participant said:
“Those with problems have to wait until up to the end of provision of drug refills so that they can be attended to privately because of lack of space”. Female, participant 3, IDI.
Individual fears and worriers
Interviews with ALWHIV, caregivers of minors and health care providers at the CDDPs found that individual fears and worries arise partly from the group nature of ART delivery services provided during the CDDPs. Our study revealed that this group kind of health care services unintentionally discloses HIV sero-status of ALWHIV to their peers without their voluntary consent causing fears and worries, HIV related stigma and discrimination among peers on ART. Loss of friendship, finger pointing and back biting by the community were also reported across all the interviews.
“Some of the ALWHIV experiences individualized shame because of being in a group given the same date of appointment for collecting drug refills at the CDDPs which cause fears that peers, other people collecting drug refills and the nearby community would know that they have HIV and taking treatment”. Male, participant 1, KII.
Distance to CDDP
CDDP as one of the community-based models is expected to be within a walkable distance with almost no cost incurred. When the participants were asked the how long they take to walk to the nearest CDDP closer to their homes, their responses varied from 10 minutes to maximum of 3 hours. The majority of ALWHIV walked between 30 to 45 minutes from their homes to the nearest service points to access medication. Our study revealed that some few ALWHIV from the periphery of CDDPs still walk longer distances than required and sometimes fail to collect their drug refills on scheduled appointment visits. As one participant said:
“My home is at the extreme end of the parish where I collect the drugs from. There is no bicycle at home to ease my movement to the CDDP. I have to walk for more than 2 hours to the CDDP”. Male, participant 2, FGD 3.
Long waiting time
Long waiting hours was a common theme across interviews with ALWHIV and health care providers. It emerged that both the ALWHIV and health care providers contribute to longer waiting time at the CDDPs. Interview with both health care providers and ALWHIV revealed that time wasters included late coming by both ALWHIV and health care providers at CDDPs. Our study revealed that health care providers lacked reliable means of transport to reach the CDDPs which negatively health care services. Those who come early had to wait for the late comers until a reasonable number is realized for the health care providers to start offering ART services at the CDDP.
“As one of the health care providers reported that ALWHIV are told to come by 9:00am in the morning. Some of them observe the time of appointment while others do not. Those who come late cause their peers to wait longer than required which discourages others from coming early in the subsequent scheduled appointments”. Male, participant 1, KII.
Our interviews also revealed that, apart from some of the ALWHIV coming late, at times health care providers bring drugs late to the CDDPs because of lack of transport purposely allocated to regularly deliver the pre-packed treatment on the scheduled visits.
“Sometimes the health care providers lack reliable means of transport and reach late at CDDPs when some of ALWHIV have already waited for so many hours. Even when they reach late, they delay to start the activities at the CDDPs as they wait for a good number ALWHIV to be together”. Male, participant 3, KII.
Family related barriers
Our interviews with the caregivers and ALWHIV revealed that ALWHIV who were total orphans staying with their step fathers, aunties, uncles, grandparents and those from divorced parents experience daily heavy load and insults. Some of the family members tell the ALWHIV to leave their homes and look for where to stay which make them think that they are not worth living. One of the participants said:
“My step father who remarried my mother who is on ART abuses me every day saying that “I should leave his home and look for where my late father was buried and stay there because his land is only adequate for his biological children.” All these insults make to think that am not worth living, no need to continue collecting and taking drugs every day”. Female, participant 6, FGD4.
Because of insults and heavy work load levied on ALWHIV, some of them do no collect their drug refills on the scheduled appointment dates interrupting adherence to medication.
“For instance, my aunty told me to fetch water, cook food and wash clothes before going to the CDDP to pick my drugs. I was tired by the time I completed work, it was late and could not move to collect the drugs. I was not able to keep the scheduled appointment”. Female, participant 7, FGD5.
Other family related barriers affecting ALWHIV from utilization of CDDPs reported included forgetfulness of the date of collection of drug refills, lack of money to buy soap for ALWHIV to wash dirty clothes prior to scheduled visits and having ALWHIV from divorced parents not settled in one place.
Health system related barriers
Our interviews with health care providers attached to the CDDPs revealed that the main barriers affecting health care service provision on scheduled visits is lack of reliable means of transport allocated to HCP to delivery pre-packed drug refills to the CDDPs. If drugs are delivered late, services start late and ALWHIV leave late.
“I do not have a bicycle meant for this work. I use my own transport to ferry the drugs from the health facility up to the CDDPs which is more than doing voluntary work”. Female, participant 4 KII.
Other health facility related challenge is mismatch in the dates recorded in the health facility files and personal record books which may result into missed appointments.
“Some of the ALWHIV and or their caregivers do not turn up for drug refill because of differences in the date written in their books which may not match with that in the health facility files”. Female, participant 1, IDI.
Health care providers’ competency
Findings from this study revealed that health care providers attached to the CDDPs had basic training in HIV care and treatment which is not adequate to manage other health conditions at the CDDPs. As one of the health care providers said:
“There are no qualified health care providers who periodically offers medical checkup to the ALWHIV transferred to the CDDPs. As a lay health care provider, my level of education and training is low to address all the health care needs of the ALWHIV”. Female, participant 5, KII.
FACILITATORS TO UTILIZATION OF CDDPS
Themes that emerged from the facilitators of CDDPs included ease of access to care, shorter waiting time, need to remain healthy and productive, and peers support and group encouragement.
Ease of access to ART services
Most ALWHIV interviewed stated that CDDPs were nears to their residences, within walkable distances and experienced no transport challenges in accessing ART refills. For those coming from far places beyond 10 km from the CDDPs, ART refills were being delivered to their homes by the health care providers. As one participant said:
“CDDP is near to our home. There are few people who collect their drug refills from here. We take a short time of about one hour at the CDDP from the beginning up to the end of picking drug refills”. Male, participant 9, IDI.
Desire to remain healthy and productive
Across all the interviews, the desires to remain healthy like other clients on ART motivated ALWHIV to continue collecting drug refills and taking them promptly as required.
“I come to the CDDP to look for my life”. These drugs keep my life. I do not miss collecting my drugs from the CDDP on the date of appointment because my life depends on these drugs”. Male, participant 3, FGD 3.
Reduced time spent accessing care
Regarding the waiting time spent while collecting drug refills, ALWHIV stated that they spent few hours at the CDDP when seeking for ART care services.
“Health care services at the CDDP take a short time from 8:00am to 10:00am and ALWHIV are served quickly and return back home fast”. Male, participant 2, KII.
Peer support and group encouragement
Community based models such as CDDPs have been reported to be the source of group encouragement and support which enabled ALWHIV to share experiences and navigate through the common challenges which they encounter in their life. ALWHIV interviewed reported that they had separate scheduled appointment dates different from those of adults which enabled them to share experience, gain confidence and continue to support each other to collect drug refills and utilize ART care from the CDDPs. In addition, health care providers offered ALWHIV continued group encouragement and support through monthly home visits, health education sessions, counselling, provision of psychosocial support and consistent ART services at the CDDPs.
“Most ALWHIV don’t fear to come and pick the drugs because they know that they are not alone on treatment. There are many other on the same drugs. They get encouraged”. Female, participant 2, IDI.