Knowledge and Perceptions of People Living With HIV Regarding The HIV Services That Are Offered By The Community Health Workers in KwaZulu-Natal, South Africa

Background: KwaZulu-Natal (KZN) is the province with the highest HIV prevalence in South Africa (SA). Community Health Workers (CHWs) are key to delivery of HIV services at community level. Evidence on knowledge and perceptions of people living with HIV (PLWH) regarding the HIV services that are offered by the CHWs is limited. Therefore, this study seeks to determine knowledge and perceptions of PLWH regarding the HIV services that are offered by the CHWs in KZN. Methods: The study design was a quantitative survey using an administrator-administered questionnaire. A total of 303 PLWH from 3 selected KZN clinics were interviewed to determine their knowledge and perceptions of HIV services offered by the CHWs. Statistical Package for Social Sciences (SPSS) version 27 was used to describe the population and testing for associations between variables. The signicant level was set at a p value ≤ 0.05 and at 95% condence internal. Results: Among the 303 PLWH surveyed, 24 (8%), knew about the HIV services offered by the CHWs and of the 89 (29%) participants that were visited by CHWs, 73 (82%) had a positive perception about these services. Participants who were visited by a CHW were more likely (OR=1.57, 95% CI: 0.57-4.35) to know about the HIV services. Knowledge of HIV services was signicantly associated with the positive perception of the HIV services (p<0.05). Knowledge and perception of the HIV services was not associated with age, gender, level of education or duration of visiting the clinic. Conclusion: The majority of PLWH in KZN have poor knowledge of HIV services offered by the CHWs and most of them have never been visited by a CHW in their homes. Those that were visited by CHWs were more likely to have positive perceptions regarding their HIV services. The ndings of the study should trigger the scaling up of HIV community targeted initiatives that are delivered by CHWs in order to curb the HIV epidemic in the province.


Introduction
KwaZulu-Natal (KZN) remains the province with the highest prevalence of Human Immunode ciency Virus (HIV) in South Africa (SA) [1][2][3] . Community health workers (CHWs) have contributed to the strengthening of the HIV programme by linking people living with HIV (PLWH) to HIV healthcare, promoting ART adherence, and improving retention in care [4][5][6][7] . However, antiretroviral treatment (ART) uptake is poor in KZN and this is related to multiple psychosocial, socioeconomic and socio-medical barriers that act at many levels including the level of the individual [8][9] . In KZN, PLWH have mixed feelings about CHWs, where some are satis ed with the HIV services they provide in the communities [10] and some do not trust them due to their perceived lack of con dentiality [11] .
The roles of CHWs have been expanded as a strategy to strengthen HIV healthcare services and provide longitudinal patient support in KZN [5,8,12] . Furthermore community HIV interventions by CHWs have been seen as an important predictor of HIV treatment success [13] . The expansion is also part of the primary healthcare (PHC) re-engineering programme in SA that culminated in the launch of Ward Based Primary Healthcare Outreach Teams (WBPHCOT) framework policy in 2018 for which CHWs are the key components [14] . In 2016, the KZN Department of Health (KZN-DOH) also implemented the universal test and treat (UTT) strategy for meeting the 90-90-90 targets of the United Nations Programme on HIV/AIDS (UNAIDS), and to ensure that PLWH continue to take ART and therefore achieve viral suppression [15] .
However the UTT targets are off track and have not been met in the province [16][17][18][19] . In spite of the community interventions through the HIV services provided by CHWs in KZN, ART uptake, which is the second 90 of the UNAIDS 90-90-90 targets, is less than 90% for those diagnosed with HIV in the province [4-5, 9, 19-22] . Optimal HIV testing and treatment, will only be achieved when the operational and implementation challenges limiting access to care and treatment, often context-speci c, are properly addressed [16] There is a dearth of evidence related to the knowledge and perceptions of the HIV services that are offered by the CHWs to PLWH in KZN, therefore this study seeks to nd this evidence. Understanding the knowledge and perceptions of PLWH regarding the HIV services offered by CHWs, may provide guidance to both the CHWs and the HIV programme on how to best utilize CHWs in providing effective HIV services to PLWH.

Study setting and design
The study was conducted in three of the seven sub-districts of the uMgungundlovu district in KwaZulu-Natal (KZN), the second populous district with a population of 1 095 865 [23] . The KZN district has a wellestablished CHW programme and has a HIV prevalence of 27.9% [1] . To nd out the knowledge and perceptions of PLWH regarding the HIV services provided by the CHWs, a descriptive, quantitative survey was conducted amongst PLWH. Purposive sampling was used to select three uMgungundlovu subdistricts and one clinic with the highest HIV prevalence in each sub-district. To calculate the required sample size of 303, the Cochran formula, , which is mostly used for large target populations as in this study [24] , was used, where n = the sample size that was required in order to generalize the results to the total population; Z=statistic corresponding to 95% con dence interval (1.96); p=proportion of the phenomenon in the population (HIV prevalence was 27.9% at KZN [1] =0.27) ; q=1-p (1-0.27) and e=margin of error at 5% (0.05). Probability proportional to size was used to determine the sample size per clinic.

Data Collection
People living with HIV that were ≥ 18 years and routinely come to the clinic to collect their ART treatment were interviewed using an administrator-administered questionnaire.  As seen in Table 2., there was a moderate positive linear correlation between age and the duration of visiting the clinic (r = 0.31, p = 0.05). Older people were more likely to have been visiting the clinic for longer compared to younger people.

Knowledge of HIV services offered by CHWs
There were ten questions with a score of one point for each correct response making the total knowledge score out of ten. Incorrect responses were scored a zero (0).
Participants with a score of nine to ten were categorized as having knowledge of HIV services offered by CHWs. Participants who scored from zero (0) to eight (8) were categorized as having no knowledge of the HIV services offered by the CHWs. The mean score was 7.13 (95% CI: 6.78-7.48). As seen in Table 3., of the 303 participants, 117 (38.6%) reported that they knew the HIV services provided by the CHWs at households (Table 2.) However, only 24 (20.5%) of them had a knowledge score of nine or ten which indicated that they knew the HIV services that are offered by the CHWs.
Overall, eight percent (24/303) of the study population knew about the HIV services provided by the CHWs. The knowledge of HIV services provided the CHWs was not signi cantly associated with age (p = 0.63, 95% CI: 0.63-0.7). However, the majority (37.5%) of the 24 participants who had knowledge of the HIV services, were from the 31-40 yrs.
age group who also had higher level of education compared to other age groups. There was a statistically signi cant relationship between age and education (p = 0.00, 95% CI: 0.00-0.01). Participants who were between 31-60 yrs. had better education than the other age groups. However, education was not associated with the knowledge of HIV services (p = 0.66, 95% CI: 0.66-0.77).

Perceptions about HIV services offered by the community health workers
Only the participants that were visited by CHWs (N = 89) were asked about their perceptions of HIV services that they received from a CHW (Table 4). There were ve questions that scored one point for each correct response and zero for every incorrect response. The total score was then ve (5). Participants who scored a total of 5 and less than 5 were categorized as having a positive perception and a negative perception respectively. The mean perception score was 4.76 (95% CI: 4.62-4.90) that the CHWs lacked con dentiality, were most likely to have a negative perception towards the HIV services that were rendered by CHWs (p = 0.00; OR = 37.0, CI: 9.5-172).

Discussion
This study sought to determine the knowledge and perceptions of PLWH regarding the HIV services that are offered by the CHWs in the KZN province.
The study found that the majority of PLWH do not know about the HIV services that are provided the CHWs and less than a third of them have received HIV services offered by CHWs in their homes.
In addition, the study found that PLWH are more likely to know and subsequently have a positive perception towards the HIV services that are offered by CHWs if they were visited by CHWs. These ndings are similar to other studies conducted in KZN and in other similar settings, where CHW visits were associated with good HIV knowledge [25][26] . Regarding our nding that some of the PLWH have negative perceptions towards the HIV services offered by the CHW, a systematic review conducted in Middle East and North African countries, showed that in general, PLWH have low knowledge and have a negative attitude towards HIV prevention and and treatment interventions [27] .
The odds of knowing about the HIV services offered by the CHWs, were higher among those who received CHW visits than those who were never visited by a CHW. However, the majority of PLWH in KZN have never been visited by a CHW and therefore are less likely to know about the HIV services that CHWs provide and from which they can bene t. Similar ndings were found in KZN and other similar settings, where the uptake of CHW-led HIV services was low due to a variety of reasons including the health system related barriers that CHW were faced with, HIV stigma, community and political contexts [26,[28][29][30][31] .
In addition, the study found that the minority that ever received a CHW visit, were not all offered HIV related services by the CHW. This indicates missed opportunities of HIV education and treatment for HIV in the province. This is in spite of the evidence that the uptake of HIV treatment reduces HIV transmission [4,16,18,32] . The low numbers of CHW-referrals may also be linked to the province's poor and delayed linkage to care for people that have tested positive and referred for HIV testing and treatment by the home based care programmes [33][34][35][36] .
The majority of PLWH who were visited by CHWs, mostly had positive perceptions towards the HIV services offered by CHWs while the minority had negative perceptions. Negative perceptions towards HIV services offered by CHWs were due to the idea that CHWs are not well educated, are not well informed about HIV but mostly that they lacked con dentiality. This nding is consistent with other studies that were conducted in KZN and South Africa [11,[37][38][39] ]. Perceptions of poor con dentiality has diminished trust towards CHWs and have been associated with negative attitudes and low acceptance of this cadre [11,[37][38][39] . Furthermore, the communities in KZN have been reported to disrespect CHWs and have a perception that they lack professionalism compared to professional nurses [40] . Although education and source of income have been found to be signi cantly associated with a positive response towards HIV services offered by the CHWs [2,9] , in this study education and employment were not associated with any perception of the same services.
The sampling method, using a statistical formula contributed to the strength of the study and therefore the study ndings can be generalized to the entire population of KZN. However, sampling was from only one of the eleven KZN districts which may pose bias to the study. In future, sampling for a similar study may need to be from other districts in KZN.
In conclusion, the study results suggest that the majority of PLWH in KZN are not bene ting from the HIV services offered by the CHWs and have a negative attitude towards these services. The study ndings should trigger the scaling-up of HIV community targeted initiatives that are delivered by the CHWs in order to curb the HIV epidemic in the province.

Recommendations
A CHW intervention is most effective when implemented within a carefully de ned target population and when this population has been educated about the programme to understand the roles and tasks of CHWs [41] . The provincial CHW programme planners and policy makers, may need to implement the Intervention model designed by Masquiller et al. of a CHW-led intervention as the way to improve knowledge and acceptance of CHW-HIV services among PLWH [42] . In addition, CHWs may use the existing community health promotion campaigns and home visits as a platform platform to educate and gain trust among communities regarding the HIV services that they provide.
Furthermore, CHWs should be encouraged to be part of the community peer and youth groups for the formulation of trust and lasting relationships with the communities. When they are trusted by the communities, the perception of the HIV services that they offer can also improve. The perception of HIV services offered by CHWs can also be improved by providing knowledge about these services through pamphlets, community radio stations and routine health promotion campaigns.

Conclusion
There is increasing reliance on and utilization of CHWs to provide chronic disease management among The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interest.

Funding Details
The study did not receive any funding.
Author contribution GEK wrote the study proposal with the assistance of EL and TPM. BS assisted GEK with data collection data capturing. GEK drafted the manuscript. EL, BS & TPM substantially provided input towards the draft manuscript until the nal draft. All authors read and approved the nal manuscript.