Healthcare provider perceptions on the implementation of the Universal Test-and-Treat policy in South Africa: A qualitative inquiry

doi:10.21203/rs.3.rs-1979762/v1

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Research Article

Healthcare provider perceptions on the implementation of the Universal Test-and-Treat policy in South Africa: A qualitative inquiry

https://doi.org/10.21203/rs.3.rs-1979762/v1

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published 28 Mar, 2023

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Background

The number of people living with HIV (PLHIV) in South Africa was estimated at 7.1 million, accounting for approximately 20% of the 36.9 million PLHIV globally in 2017. In 2015, the World Health Organization (WHO) recommended the universal test and treat (UTT) intervention with UNAIDS 90-90-90 targets. South Africa began implementing the UTT strategy in September 2016. We conducted a qualitative study to understand the impact of implementing the UTT strategy on the patients, healthcare providers, and the health system in uThukela District Municipality (DM) in KwaZulu-Natal province, South Africa.

Methods

A qualitative study design approach was conducted with one hundred and sixty-one (161) healthcare providers (HCPs) within 18 healthcare facilities in three subdistricts, comprising of Managers (facility managers and PHC manager/supervisors); Nurses (enrolled, auxiliary, and professional nurses) and Lay workers (lay counsellors, community health workers, linkage officers) were included. HCPs were interviewed using open ended-survey questions to gather their experiences with providing HIV care under the UTT strategy. Participants were consented and interviewed in English or Zulu. The HCPs’ responses were recorded on Redcap and exported to Excel for quality checks. All interviews were analysed using ATLAS.ti v.8 software.

Results

Despite a general acceptance of the UTT policy implementation and delivery, healthcare providers expressed challenges such as work overload, caused by the increased number of service users and the need to meet the 90-90-90 targets. The surge in the workload under conditions of inadequate systems’ capacity and human resources, gave rise to a greater burden on healthcare providers in this study.

Conclusions

Health system strengthening such as providing more systems’ capacity, and human resources might decrease the already over-burdened system, and thus improve the delivery of the comprehensive UTT services to people living with HIV.

HIV

Universal-test-and-treat

Same-day ART

Healthcare provider

PLHIV

Globally there are 38 million people living with HIV (PLHIV) at the end of 2019 and 26 were initiated on treatment by the end of June 2020. [1, 2]. South Africa continues to have the largest number of PLHIV with an estimated 7.9 million prevalence, accounting for approximately 20% of the 36.7 million PLHIV in the world in 2017 [3, 4]. South Africa has achieved great strides in its response strategies on HIV treatment with the roll-out of ART that has led to a decline in HIV-related mortality rates [5, 6]. South Africa has been reported as having the largest HIV treatment programme in the world [7, 8]. The government has implemented a number of strategies to curb the disease, including the execution of the comprehensive ART Clinical Guidelines for the Management of HIV in Adults, Pregnancy, Adolescents, Children, Infants and Neonates [9].

In May 2016, following recommendations of the World Health Organization (WHO) [10], the South African government announced the progressive rollout of the universal test and treat (UTT), with an intention to reduce deaths and new infections by 2030 [11, 12]. The 2030 targets included the 95-95-95 targets, which state that 95% of HIV positive people should know their status, 95% of those who know their status should be on treatment and 95% of those on treatment should be virally supressed [13]. UTT advocates that all individuals testing for HIV be initiated on treatment regardless of their clinical staging or CD 4 count [14, 15], which is a promising strategy to improve the health of PLHIV [16, 17]. Given the high HIV prevalence in South Africa, the reported benefits of early treatment initiation for PLHIV done through the implementation of UTT gives hope to reduce HIV incidence rates.

Despite the importance of UTT, evidence shows that the implementation of UTT in South Africa is not fully guided by the capacity of human resources or infrastructure [18, 19]. This could have negative impacts in the effective implementation of UTT. Healthcare providers (HCPs) are key players in the implementation of UTT in the health facilities. They are the ambassadors of the Department of Health (DoH) in advocating for the new HIV treatment guidelines particularly in terms of communicating new guidelines to those diagnosed with HIV. In order to identify the health system gaps, it is therefore important to understand how HCPs navigate the new changes and impacts to their health service delivery. In this study, we aimed to explore HCPs’ perspectives on the implementation of UTT in the uThukela district, KwaZulu-Natal province.

Study design and setting

A qualitative study design approach was followed to understand the perceptions and experiences of HCPs on the implementation and delivering UTT. The study was conducted in the uThukela District Municipality (DM) in KwaZulu-Natal, South Africa. uThukela DM is a predominantly rural district with high HIV prevalence of 22.4 [20] and shares its western border with the country of Lesotho. The district is comprised of three local municipalities (LMs) namely Alfred Duma LM, Inkosi Langalibalele LM and Okhahlamba LM.

Key informant interview procedures

One hundred and sixty-one (161) HCPs were sampled for the purposes of providing their perceptions on the implementation of UTT (Table 1). The sample included HCPs from the 18 health facilities and three sub-districts, comprising of Managers (facility managers and PHC manager/supervisors); Nurses (enrolled, auxiliary, and professional Nurses) and Lay workers (lay counsellors, community health workers, linkage officers).

Table 1

*Selected facilities included in the* Linkage *to Care study in uThukela district between December 2017-July 2018*
	Local Municipality	Name of facility	Type of facility/service
1.	Alfred Duma	Ladysmith Gateway Clinic	Gateway Clinic
2.		Limehill Clinic	Clinic
3.		Outer West Mobile 1	Mobile
4.		Sigweje Clinic	Clinic
5.		St Chads CHC	CHC
6.		Walton Clinic	Clinic
7.		Steadville Clinic*	Clinic
8.		Watersmeet Clinic*	Clinic
9.	Okhahlamba	Bergville Clinic	Clinic
10.		Bergville Mobile 2	Mobile
11.		Bergville Mobile 3	Mobile
12.		Emmaus Gateway Clinic	Gateway Clinic
13.		Emmaus Hospital*	OPD
14.	Inkosi Langalibalele	Connor Street Clinic	Clinic
15.		Estcourt Gateway Clinic	Gateway Clinic
16.		Injisuthi Clinic	Clinic
17.		Ntabamhlophe Clinic	Clinic
18.		Wembezi Clinic	Clinic
*Facilities that were not part of the original sample but added later to replace facilities with low enrolment rates
Community Health center (CHC): A facility that normally provides PHC services, 24-hour maternity, accident and emergency services and beds where health care users can be observed for a maximum of 48 hours, and which normally has a procedure room but not an operating theatre. Clinic: A facility at and from which a range of primary health care services is provided and that is normally open eight or more hours a day based on the need of the community to be served., Gateway clinic: A primary health care (PHC) clinic, located in community health center (CHC) or a hospital Out-patient department (OPD) where patients with minor ailments are seen by trained primary health care workers free of charge, before being referred to the CHC or hospital. Every CHC/ hospital has a gateway clinic directly attached to it to serve the people in the immediate vicinity of the CHC.

Data collection procedure

An open-ended questionnaire adapted from Hoffman et.al, 2015 [21] was used to collect both quantitative and qualitative data from HCPs. While the quantitative data focused on demographic characteristics, work experience and attitudes of HCPs’ towards UTT, the qualitative data focused specifically on HCPs’ perceptions on the implementation of UTT. Participants were approached by interviewers and depending on availability, an appointment was secured in order not to disrupt the daily functioning of the health facilities. In most instances the interview, which lasted between 20 and 105 minutes, was conducted over more than one visit depending on the availability and time constraints of the individual.

Each respondent had a unique code, e.g., BISC-EN-M, which are added at the end of each quote to provide context. The first initial letters describe the facility area and the type (i.e., primary clinic, mobile clinic etc.), followed by participants’ job category (e.g., enrolled nurse - EN) and gender (F/M) at the time of the interview.

Data management and analysis

HCPs interviews were directly captured into REDCap, and thus did not require transcription. Interviews were then exported to Excel for quality checks. The analysis team, which comprised of three members, independently read through all the transcripts to gain a general understanding of the content and scope, and discussed initial emerging themes used to develop a structured coding framework. Coded information was linked to broader emerging themes across interviews. Data from HCP interviews were coded independently using ATLAS.ti v8 software. Comparative analysis between two skilled qualitative researchers was performed to ensure analysis accuracy. The analysis process was informed by the interview questions, literature, and the inductive approach to the data.

Of the 161 HCPs included in this study, 41% (66) were from Alfred Duma local municipality where eight of the 18 health facilities are located (Table 2). The study consisted of 97.5% (n = 157) Black African participants in uThukela District. Of these participants, 88.2% (142) were female, and most 90% (145) had obtained a tertiary level of education. While a fifth of the participants (33) were professional nurses, most participants, 98.1% (158) were employed in a public clinic setting (Table 2).

Table 2

*Demographic characteristics of HCPs in the Linkage to Care study disaggregated by subdistrict in uThukela district − 2018*
Characteristics	Total (n = 161)	Alfred Duma (n = 66)	uKhahlamba (n = 49)	Inkosi Langalibalele (n = 46)
Job category, n (%) Facility manager Professional nurses Lay counsellors Community Health Workers PHC Manager/ Supervisor Linkage Officers Enrolled nurses Enrolled nursing Assistants/ Auxiliary	17 (10.6) 33 (20.5) 30 (18.6) 19 (11.8) 3 (1.9) 10 (6.2) 34 (21.1) 15 (9.3)	8 (12.2) 13 (19.7) 11 (16.7) 6 (9.1) 1 (1.5) 5 (5.6) 15 (22.7) 7 (10.6)	6 (12.2) 10 (20.4) 10 (20.4) 6 (12.2) 1 (2.0) 1 (2.4) 10 (20.4) 5 (10.2)	3 (6.5) 10 (21.7) 9 (19.5) 7 (15.2) 1 (2.2) 4 (8.7) 9 (19.5) 3 (6.5)
Level of work, n (%) Facility Sub-district	158 (98.1) 3 (1.9)	65 (98.5) 1 (1.5)	48 (98.0) 1 (2.0)	45 (97.8) 1 (2.2)
Sex, n (%) Male Female	19 (11.8) 142 (88.2)	11 (16.7) 55 (83.3)	6 (12.2) 43 (87.8)	2 (4.4) 44 (95.7)
Ethnicity, n (%) Black African Coloured Indian/Asian	157 (97.5) 2 (1.2) 2 (1.2)	64 (97.0) 1 (1.5) 1 (1.5)	49 (100) 0 0	44 (95.7) 1 (2.2) 1 (2.2)
Education level, n (%) High School Matric Certificate Diploma Post graduate diploma Degree Post graduate degree	4 (2.5) 12 (7.5) 64 (39.8) 50 (31.1) 8 (5.0) 14 (8.7) 9 (5.6)	0 3 (4.6) 26 (39.4) 26 (39.4) 1 (1.5) 6 (9.1) 4 (6.1)	3 (6.1) 4 (8.2) 19 (38.8) 12 (24.5) 5 (10.2.8) 5 (10.2) 1 (2.0)	1 (2.2) 5 (10.9) 19 (41.3) 12 (26.1) 2 (4.4) 3 (6.5) 4 (8.8)

Healthcare providers’ perspective on UTT

Several themes and categories relating to HCPs’ perceptions on the implementation of UTT were identified. Figure 1 presents a summary of the general themes and categories, which range from the acceptance of UTT to the disadvantages of implementing UTT, highlighting issues of non-adherence and patient non-acceptance of HIV diagnosis. Four themes (Healthcare providers’ perspective on UTT, impact of UTT on healthcare providers, impact of UTT on service users, and impact of UTT on the organization of care in the health system), and 17 categories relating to HCPs’ perceptions on the implementation of UTT emerged from the data. We present in detail with illustrative quotes these themes and categories.

Positive outcomes

Acceptability of the new UTT policy guidelines

There seems to be a general acceptance and awareness of the UTT policy change amongst HCPs and they understand the significance of early ART initiation. The acceptance of UTT came with the understanding that starting treatment immediately will be beneficial to public health. HCPs felt that the introduction of UTT has improved patient management and care compared to the old HIV guidelines. Mostly because they do not have to treat very sick patients since UTT promotes same-day initiation after diagnosis. Clinical benefits were also seen as the positive benefit in the implementation of UTT as the UNAIDS 90-90-90 targets were met. In some facilities, enrolled nurses and clinic managers commented on the advantage of the implementation of UTT as it has improved the clinic flow and operations. These were some of the utterances from the HCPs on them embracing the new UTT policy change and implementation:

“With UTT we are able to reach targets and get TB patients because we have to screen patients after they have tested.” (EWCC008_EN_F)

“It [UTT] has helped us test more people and their partners if they tested positive (index testing).” (ESVC006_LO_F)

“It [UTT] has a very positive impact because they start treatment while the CD4 count is still alright, which reduces the number of infections; people live longer and are protected.” (DIGC002_LC_F)

“It [UTT] has also made things easy for patients, because they come once a month to fetch treatment, after they have been diagnosed with HIV and also everything (initiating, HIV classes and taking bloods) is done on the same day, patient doesn't have to keep on come back to do all these things on a weekly basis.” (KB2M002_LC_F)

“It [UTT] has increased the numbers of people who are on treatment for HIV which has improved the 90-90-90 programme.” (ECHC007_HM_F)

“It [UTT] has helped us know the number of people tested positive, initiated, with suppressed viral loads and to reach the 90-90-90.” (ESVC006_LO_F)

We also noted that HCPs were also happy with how implementation of UTT has positively impacted on the organization of care in the health system. These were some of the utterances:

“It [UTT] has increased the stats numbers for people initiated on medication.” (ECHC014_EN_F)

“[UTT] reduce the number of admissions because clients do not get sick.” (KEMP007_EN_F)

“Many people start treatment before they would get sick, therefore less people are admitted to the hospital for HIV.” (UECG007_EN_F)

Patient management

HCPs felt that the introduction of UTT has improved patient management and care compared to the old HIV guidelines. Mostly because they do not have to treat very sick patients since UTT promotes same-day initiation after diagnosis. These were their expressions:

“Getting to sit clients in one session and go through everything is better than breaking into several sessions.” (UCSC004_EN_F)

“With UTT we are able to reach target and get TB patients because we have to screen patients after they have tested.” (EWCC008_EN_F)

“It [UTT] has helped us test more people and their partners if they tested positive (index testing).” (ESVC006_LO_F)

Decreased workload

Some of the HCPs felt that their workload has decreased with the implementation of UTT. Others acknowledged that the UTT process is longer but more effective compared to the older HIV care guidelines.

“It [UTT] has decreased adherence classes.” (ECHC003_LC_F)

“It [UTT] has reduced the workload because one doesn't have to do pre-ART training, pre-ART folders. Test and treat allows for everything to happen simultaneously.” (DIGC002_LC_F)

Human resources

In some of the facilities, the implementation of UTT is reported to have improved the skills of HCPs through trainings provided to them. More manpower is also reported to be put in place in some facilities, which helps with the easing of the workload. HCPs expressed their appreciation of the acquired skills that came with the implementation of UTT.

“Personnel has been hired. Less money spent on minor ailments.” (PMSA1_CL_F)

“More experience on initiating and filling of clinical chart.” (UWBC004_CM_F)

“Yes, this is because us as health care providers were given training on HIV testing and treatment.” (KEMG005_EN_F)

Decreased burden on the system

“[UTT] reduce the number of admissions because clients do not get sick.” (KEMP007_EN_F)

“[UTT] reduces the number of lost to follow-up because they don't do pre-ART anymore.” (DIGC011_EN_F)

“Many people start treatment before they would get sick, therefore less people are admitted to the hospital for HIV.” (UECG007_EN_F)

Reaching NDoH targets

“It [UTT] has increased the numbers of people who are on treatment for HIV which has improved the 90-90-90 programme.” (ECHC007_HM_F)

“It [UTT] has helped us know the number of people tested positive, initiated, with suppressed viral loads and to reach the 90-90-90.” (ESVC006_LO_F)

“It [UTT] has improved the 90-90-90 programme.” (ECHC010_PN_F)

“More people are enrolled on treatment.” (UWBC004_CM_F)

“It [UTT] has increased the number of people getting tested and getting medication soon after they are tested positive.” (ESVC007_CHW_F)

“It [UTT] has increased the stats numbers for people initiated on medication.” (ECHC014_EN_F)

Negative outcomes

Increased workload and defaulters

One of the major challenges reported by the HCPs was that UTT implementation increased patient defaulters. They believe this is caused by overwhelming feeling of starting a lifelong treatment immediately after diagnosis. According to these HCPs, some patients would like to go back home and take some time to process the new journey as an HIV positive individual, but because they respect health care workers they go along with the immediate treatment after HIV positive diagnosis. The HCPs reported that the increased volume of defaulters is one of the reasons that leads to an increased workload causing a greater burden on them. They further reported that the over burden of work sometimes causes burnout and stress episodes. Below are some of the quotes from the HCPs.

I feel like it [UTT] creates a lot of defaulters, because most people who test positive before they accept their status, they are given treatment which they take just to please you as a health care worker, while they are not ready to take treatment; so they just take it once off and never come back.” (DLHC001_CM_F)

“…It [UTT] also have some disadvantages which is that we initiate them [HIV patient] same day assuming they are ready to start, yet they have not accepted [the new status) and they never come back and sometimes they provide incorrect information and when tracing them we never find them.” (ECHC008_PN_F)

The other reason for the increased workload reported by the HCPs was the fact that UTT process is long, and counsellors have to do everything in one session with patients.

“More work as counsellors have to do everything in one session with clients.” (BISC008_CHW_F)

“More work for them as they have to account also for patients, why they did not start ART.” (BISC006_CHW_F)

“It has created a huge workload of patient folders who don’t come back to the clinic, because either we have to create folders for people testing positive.” (UECG009_EN_F)

“The level of work has increased because they have to do post counselling, initiating, doing baseline bloods.” (DIGC006_NA_F)

Physiological and Psychological impacts

HCPs reported on the impacts of implementing UTT on their well-being. They mentioned some physiological and psychological impacts such as stress and burnout. One clinic manager and professional nurse highlighted issues of burnout and being overworked. Others highlighted issues around feeling under pressure and stressed.

“Burnout on staff” (BISC004_CM_F)

“It [UTT] has created a lot of stress and demand due to targets that has to be met.” (BNHC005_PN_F)

“UTT has made working easy but there is so much pressure and paperwork to be done.” (BISC009_EN_F)

Stakeholder involvement and financial aspects

Other concerning challenges highlighted by the HCPs include the need for more medical stock (ARVs) as the number of patients being initiated on ART increases. In some facilities the HCPs voiced their concern about ARV stock-outs and the increased financial burden that comes with purchasing more ARVs. This if further linked to the lack of involvement of stakeholders (i.e., health care facility managers) in the decisions to implement UTT in the under resourced facilities. Unhappy feelings were expressed by most HCPs on the processes followed to implement UTT. They mentioned not being part of the decision-making team, and highlighted gaps in the UTT implementation processes such as the absence of piloting UTT. These were their views:

“The drugs [ARVs] are running out.” (DIGC006EN_F)

“We run out of drugs [ARVs].” (DLHC008_EN_F)

“The money spent on ART is increasing.” (DIGC010_EN_F)

“I feel that we were not involved as people on the ground level; they [policy makers] didn’t consult with us when they were deciding on it [UTT]. So, the only people who were involved were people from the national level and we were not consulted before its implementation as well but were instructed to implement it.” (ESVC001_CM_F)

South Africa has made huge investments on human resources for the purpose of upscaling the UTT strategy aimed at improving linkage to and retention in care among PLHIV. This study is one of the very few conducted amongst South African healthcare providers to understand their views and perceptions about the impact of delivering UTT. Findings from this study highlight both advantages and disadvantages of the implementation of UTT in the uThukela District Municipality (DM) in KwaZulu-Natal province, South Africa.

Advantages of implementing UTT

This study reveals a general acceptance of the implementation of UTT by healthcare providers. The acceptance of UTT came with the understanding that starting patients on treatment immediately will give HIV-positive clients a better chance to live longer. The positive views on the implementation of UTT were similarly found in other studies [22, 23]. This positive acceptance from HCPs who are in the frontline and advocates of the new UTT policy guidelines gives hope that South Africa is in the right direction towards improved rates of HIV testing, linkage to care, and viral load suppression.

Above the general acceptance of UTT, the health care providers also reported on the positive impacts UTT has towards patients. The HCPs highlighted how UTT contributes towards patients’ good quality of life. They also mentioned that UTT reduced congestion and waiting times at clinics and therefore making clinic flows better for patient satisfaction. Similar findings were reported in other studies where HCPs emphasized patients’ health benefits resulting from the implementation of UTT [22–24].

Disadvantages of implementing UTT

The main disadvantage highlighted by HCPs was that UTT might cause an increase in patient defaulters, as some patients may not be ready to immediately initiate treatment. HCPs reported that the increased volume of defaulters has led to a surge in their workload since the implementation of UTT. The challenges about increased workload have been reported in other studies as well [25, 26], and may undermine the quality of care provided by healthcare workers. Improved counselling strategies are needed in these facilities in order to decrease the number of defaulters caused by overwhelmed patients. Health system strengthening such as providing more capacity and capability might decrease the already over-burdened system, and thus improve the delivery of the comprehensive UTT services to PLHIV.

Another disadvantage includes poor consultation from the National Department of Health on the implementation of the UTT. The poor consultation might have been the result of the gaps mentioned by some of the facility managers such as insufficient training for HCPs as some of their responses were not in line with UTT guidelines. One of the crucial aspects of providing quality health care is proper training of HCPs [27]. This study show that training provided to HCPs on the implementation of UTT were insufficient. Quality of care could be undermined by the lack of skills and training among HCPs, and staff shortages. These issues have been highlighted in other studies [18, 19, 22, 26]. To strengthen health system and provide effective UTT services, there is a need to explore better mechanisms to ensure that adequate information is available to HCPs, and that they are provided with the necessary training to offer comprehensive UTT services. The crucial importance of retraining HCPs with new policies can never be over stressed if there has to be adequate health workforce to deliver UTT services

This study shows that UTT has led to increased number of patients being tested and immediately initiated on treatment. It is concerning though to note that this increase translates to more medical stock required and that some facilities experience ARV stock-outs and increased financial burden that comes with purchasing more ARVs. Shortages of ARV’s can be a barrier in effective implementation of UTT as it means that patients might not be immediately initiated on treatment, and this may have a negative impact in the attainment of the 90-90-90 targets. Shortages of treatment has been reported in at least one out of three facilities in South Africa [28]. For the success of the UTT policy, it is suggested that the NDoH engage fully with the stakeholders to ensure the under resourced facilities are provided with the necessary health equipment and training so that HCPs can offer comprehensive UTT services.

Study Limitations

Most interviews were conducted in clinics, which might have caused discomfort and led to socially desirable responses. However, interviewers were well trained in managing these issues. Results from this study may not be generalizable as the study included a small sample from a single district in KZN province, which may be different from the other eight provinces in South Africa.

Our results highlight important gaps in the implementation of UTT in a high HIV burden district in South Africa. There is a need for policy makers to engage with facility managers around elements such as infrastructure, human resources, and financial capacity which are crucial in providing a comprehensive UTT programme. For a country such as South Africa, health system level interventions like UTT would need to also focus on clinic readiness in terms of providing patients with the necessary and effective health services such as proper counselling care and psychological assistance to manage their HIV status. This includes proper training for the counsellors to be able to provide appropriate counselling care in the management of patient readiness for the lifelong ART journey, ensuring availability of medicines based on the expected demand, and adequate human resources for the expected increase in workload thus reducing strain on the HCP. This would improve and increase the number of patients who link to care and remain in care, and thus meet the 90-90-90 targets.

This study highlighted issues with UTT acceptance by HCPs. More studies are needed on acceptability of UTT by health care workers in South Africa. Furthermore, for the success of the UTT policy, we recommend that the NDoH engage fully with stakeholders including HCPs to ensure that they are provided with the necessary training to offer comprehensive UTT services. The importance of retraining HCPs with new policies can never be over stressed if there has to be adequate health workforce to deliver UTT services.

Ethics approval and consent to participate

This study was approved by the South African Medical Research Council (SAMRC) ethics committee in October 2017 (EC021-7/2016). It was also reviewed in accordance with US Centers for Disease Control and Prevention (CDC) human research protection procedures and was determined to be research, but CDC investigators did not interact with human subjects or have access to identifiable data or specimens for research purposes. Additional approval was received from the KZN provincial Department of Health and uThukela district municipality in October 2017. Informed consent was obtained from all participants before participating in the study. Confidentiality and privacy were maintained using study pseudonyms instead of healthcare providers’ personal details in all our records. All methods were performed in accordance with the relevant guidelines and regulations in Ethics Approval and Consent to participate.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

We declare no competing interests.

Funding

This research has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the terms of Cooperative Agreement Number 1U2GGH001150.

Authors’ contributions

EN conceived and implemented the study design, modified the data collection instruments, conducted, and transcribed the interviews, performed data analysis and interpretation, drafted, and revised the manuscript. DB contributed to the study design, data analysis and interpretation, revised the instruments and the manuscript, while VM, NAJ, and WB contributed to data analysis, interpretation and revised the manuscript. In addition, VM contributed to the initial drafting of the manuscript, DP contributed to data collection, and MH provided critical revision of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We would like to extend our word of appreciation to the uThukela district manager, Dr T. Zulu as well as the deputy district manager of monitoring and evaluation, Mr. M. Asvat for their unending support to the project. We also appreciate the co-operation of the staff in the selected facilities for participating in this study, and would like to thank Ms T. Makowa, and the fieldwork team for data collection.

Authors' information

Dr Edward Nicol, Burden of Disease Research Unit, South African Medical Research Council, P.O. Box 19070, Tygerberg, 7505; Email: [email protected], ORCID 0000-0001-6019-9259

Disclaimer

The findings and conclusions in this paper are those of the author(s) and do not necessarily represent the official position of the funding agencies.

UNAIDS. AIDSinfo datasheet 2019. 2019. Accessed August, 2021. https://www.unaids.org/sites/default/files/media_asset/2019-UNAIDS-data_en.pdf
UNAIDS. Fact sheet-world AIDS day 2020. 2020. Accessed August, 2021. https://www.unaids.org/sites/default/files/media_asset/UNAIDS_FactSheet_en.pdf
Simbayi LC, Zuma K, Zungu N, Moyo S, Marinda E, Jooste S, Mabaso M, Ramlagan S, North A, van Zyl J, Mohlabane N, Dietrich C, Naidoo I and the SABSSM V Team (2019), South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2017. Cape Town: HSRC Press
SANAC 2018, Republic of South Africa 2018 global AIDS monitoring report, https://sanac.org.za/wp-content/uploads/2019/08/Global-AIDS-Report-2018.pdf. Retrieved July 2021
Bor J, Herbst AJ, Newell ML et al. 2013, Increases in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment. Science 339:961–5.
Mee P, Collinson MA, Madhavan S et al. 2014, Determinants of the risk of dying of HIV/AIDS in a rural South African community over the period of the decentralised roll-out of antiretroviral therapy: a longitudinal study. Glob Health Action 20:24826.
Simelela NP, Venter WD. A brief history of South Africa’s response to AIDS. S Afr Med J 2014;104(3 Suppl 1):249–251.
Venter, W D Francois. A South African decade of antiretrovirals. South African Medical Journal, [S.l.], v. 104, n. 1, p. 3, nov. 2013. ISSN 2078–5135. Available at: <http://www.samj.org.za/index.php/samj/article/view/7788/5722>. Date accessed: 20 Aug. 2022. doi:10.7196/SAMJ.7788.
NDoH, 2019. 2019 ART Clinical Guidelines for the Management of HIV in Adults, Pregnancy, Adolescents, Children, Infants and Neonates. https://www.knowledgehub.org.za/elibrary/2019-art-clinical-guidelines-management-hiv-adults-pregnancy-adolescents-children-infants. Retrieved 14 December 2021
World Health Organization. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Geneva; 2015.13. UNAIDS. Fast Track: Ending the AIDS epidemic by 2030: UNAIDS; 2014 [Available from: http://www.unaids.org/en/resources/documents/2014/JC2686_WAD2014report.
Perriat D, Balzer L, Hayes R, et al. Comparative assessment of five trials of universal HIV testing and treatment in sub-Saharan Africa. J Int AIDS Soc. 2018;21(1)
Onoya D, Sineke T, Hendrickson C, et al. 2020, Impact of the test and treat policy on delays in antiretroviral therapy initiation among adult HIV positive patients from six clinics in Johannesburg, South Africa: results from a prospective cohort study. BMJ Open 10: e030228.
UNAIDS. Fast Track: Ending the AIDS epidemic by 2030.: UNAIDS; 2014 [Available from: http://www.unaids.org/en/resources/documents/2014/JC2686_WAD2014report.
NDoH DoHSA. Natinoal Policy on HIV Pre-exposure Prophylaxis (PrEP) and Test and Treat (T&T). Final Draft. In: Africa DoHS, editor. Pretoria: NDoH; 2016
Girum T., Yasin F., Wasie, Shumbe T., Bekele F., Zeleke B. (2020). The efect of “universal test and treat”program on HIV treatment outcomesand patient survival among a cohort of adults taking antiretroviral treatment (ART) in low income settings of Gurage zone, South Ethiopia. AIDS Res Ther 17(19), doi:10.1186/s12981-020-00274-3
Grinsztejn B, Hosseinipour MC, Ribaudo HJ et al. 2014, Effects of early versus delayed initiation of antiretroviral treatment on clinical outcomes of HIV-1 infection: results from the phase 3 HPTN 052 randomised controlled trial. Lancet Infect Dis 14:281–290.
National Institutes of Health, US Department of Health and Human Services. Starting antiretroviral treatment early improves outcomes for HIV-infected individuals [news release]. https://www.nih.gov/news-events/news-releases/starting-antiretroviral-treatment-early-improves-outcomes-hiv-infected-individuals. Published May 27, 2015
Plazy M, Perriat D, Gumede D, Boyer S, Pillay D, Dabis F, et al. Implementing universal HIV treatment in a high HIV prevalence and rural South African setting—feld experiences and recommendations of health care providers. PLoS ONE. 2017;12(11):e0186883
Orange E. Assessing health policy implementation in South Africa: case study of HIV universal test and treat. Washington 2018. https://digital.lib.washington.edu/researchworks/handle/1773/41715
Cooperative governance and traditional affairs (COGTA). PROFILE: UTHUKELA DISTRICT MUNICIPALITY. https://www.cogta.gov.za/ddm/wp-content/uploads/2020/11/Uthukela-October-2020.pdf. Retrieved 14 December 2021.
Hoffman S. Linkage to HIV Care in South Africa: Qualitative and Quantitative Findings from Pathways to Care. Columbia University.
Onoya D, Mokhele I, Sineke T et al. 2021, Health provider perspectives on the implementation of the same-day-ART initiation policy in the Gauteng province of South Africa. Health Res Policy Sys 19:2
Dovel K, Phiri K, Mphande M et al. 2020, Optimizing test and treat in Malawi: health care worker perspectives on barriers and facilitators to ART initiation among HIV-infected clients who feel healthy. Glob Health Action 13:1728830.
Pell C, Reis R, Dlamini N, Moyer E, Vernooij E. 2019, ‘Then her neighbour will not know her status’: how health providers advocate antiretroviral therapy under universal test and treat, International Health, Volume 11, Issue 1, January 2019, Pages 36–41, https://doi.org/10.1093/inthealth/ihy058
Songo J, Wringe A, Hassan F et al. 2021, Implications of HIV treatment policies on the health workforce in rural Malawi and Tanzania between 2013 and 2017: Evidence from the SHAPE-UTT study. Global Public Health 16:256–273.
Laar AS, Dalinjong PA, Ntim-Adu C et al. 2018, Anaman-Torgbor JA. Understanding health facility challenges in the implementation of Option B + guidelines in Ghana: the perspectives of health workers. J Hosp Manag Health Policy 2:29–37.
Luxford K, Safran DG, Delbanco T. Promoting patientcentered care: a qualitative study of facilitators and barriers inhealthcare organizations with a reputation for improving the patient experience. Int J Qual Health Care 2011;23(5):510–515
Hodes R, Price I, Bungane N, Toska E, Cluver L. How frontline healthcare workers respond to stock-outs of essential medicines in the Eastern Cape Province of South Africa. S Afr Med J 2017;107(9):738–740

No competing interests reported.

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Healthcare provider perceptions on the implementation of the Universal Test-and-Treat policy in South Africa: A qualitative inquiry

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Journal Publication

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Abstract

Figures

Introduction

Materials And Methods

Results

Healthcare providers’ perspective on UTT

Positive outcomes

Acceptability of the new UTT policy guidelines

Patient management

Decreased workload

Human resources

Decreased burden on the system

Reaching NDoH targets

Negative outcomes

Increased workload and defaulters

Physiological and Psychological impacts

Stakeholder involvement and financial aspects

Discussion

Advantages of implementing UTT

Disadvantages of implementing UTT

Study Limitations

Conclusions

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1