We conducted 40 in-depth interviews with healthcare providers: 26 professional nurses; 2 medical doctors, and 12 lay counsellors (Table 1). The majority (34) were women and the median years of work experience in the current role was 5.5 years (interquartile range, IQR, 2, 7).
Coherence
Health care workers views of HTS and the universal HTS policy demonstrated their understanding of the purpose of these processes with the broader workplace goals of improving patient health and care outcomes. Healthcare providers correctly described the Department of Health HTS policy (offering HIV testing to all patients): “I think provider initiated testing counselling says that any patient that comes, I offer them HIV [testing] whether they came with headache or having whatever…” (nurse) (Table 2). Many healthcare providers also articulated a justification explaining that you cannot tell whether a person is HIV positive just by looking at them. This highlighted the importance of universal testing as described in national HTS policy. This was described by one provider as follows: “It’s usually each and everybody, we do not say you will see this one thin. You will see this one big, but still they might have HIV. So we offer each and everybody” (nurse).
Table 2
Facilitators and challenges to normalization of HTS
Facilitator | Quotes | Challenge | Quotes |
Coherence | |
Health care workers’ understanding of policy to test all patients. | 1–1: My understanding is that every patient who comes into the consulting room, should be provided with HIV counselling, if the patient agrees (PHC nurse) | Targeted testing | 1-2a: By their clinical pictures, physical things…another one maybe by the signs/symptoms that they are mentioning …especially when they have STIs, I encourage them to go. (PHC nurse) 1-2b: Well from our wing it’s mostly initiated based on symptom, so 99% of patients who come in will have features of something that could possibly be immunodeficiency then we’d like to test you for HIV”. (Hospital doctor) |
| | HTS lower priority compared to patient’s reason for visiting clinic | 2–2: You keep thinking that now if this patient goes there he’s going to spend 15 minutes then maybe I’ll also send him to X-ray that’s another 15–30…then you say no no….this one[HIV testing] can wait. (Hospital nurse) |
Cognitive participation | |
All staff categories support HTS | 3-1a:I think we are all for it you know, because the doctors even do come here to ask where the counsellors are if a patient goes back to the doctor without being tested. They show concern. To me it looks like we are all for the idea that people should test”. (Hospital nurse) 3-1b: As I told you, we do assess patients and the we offer, if the patient agrees we send them to the counsellors and they test and counsel them” (CHC nurse) | Clinicians (doctors & nurses) felt that HTS was not their work. | 3-2a: I think doctors & nurses’ involvement would be a good thing but due to the workload we are not able to do it personally. We have a lot of patients who are waiting for us and we do have counsellors who are employed to do the HIV testing…” (PHC nurse) 3-2b: We don’t keep patients who have come to test to ourselves because we have work to do. The counsellors are there for testing and if we take the patients they will have nothing to do”. (PHC nurse) |
Lay counsellors skilled & confident in providing the service | 4-1a: I’ve been trained to do it, but I didn’t go for update” (PHC counsellor). 4-2b: I know how to do my work. Patients sometimes don’t want counselling, but I tell them that I have to do everything accordingly…” (CHC counsellor) | Clinicians lack HTS training | 4-2a: As I’ve told you, we have counsellors who are doing that and most of the time now our registered nurses they are not yet trained for doing HTS… (CHC nurse) 4-2b: Like now he was forcing me to do the testing. I told him that we don’t do the testing because I never went for even in-service training so I won’t do it…and he was so … (Hospital nurse) |
Collective action |
Set HTS targets | 6 − 1: You have 60 patients that you need to consult and then this particular patient takes almost 45 minutes to an hour of your time. SO there is resistance, that’s why they gave us targets to say if you don’t want to test all of them, test at least 5 per day”. (PHC nurse) | Low compensation of counsellors for the work. | “Thing is we counsellors in the hospital we are called “volunteers”, so you can’t cover a volunteer. We are doing this because … I love what I am doing but I won’t stay in this profession for long, I am still looking for greener pastures”. (Hospital counsellor) |
HTS equipment always available | 7 − 1: We always have test kits. Every Monday the nurse orders test kits for us. We have everything except the working space.” (Hospital counsellor) | Limited working time of counsellors | 7 − 2: We knock off at 2 and you find that people come to the clinic to test knowing that the clinic closes at 4 pm. When they get here they are told that the counsellors have left…” (CHC counsellor) |
| | Limited HTS work space | 8 − 2: We don’t have enough working spaces. We only have 1 room to test the patients and there is always a queue that side”. (Hospital nurse) |
| | Long queues & huge work load | 9-2a: Ja, PICT [HTS] is part of our task, but we are not implementing it. I mean firstly because of the duration of counselling, and because of the volume of the patients in the clinic”. (PHC nurse) 9-2b: Remember you can get 5 or 10 patients at a time, isn’t it? Now there’s 1 counsellor, they can only see 1 patient at a time, then the patients get irritated” (Hospital doctor) |
Reflexive monitoring |
Emphasis on need to test all patients to prevent stigma & discrimination | 10 − 1: It is easier to get people to agree when they see that everyone is going, it is not just me who’s being picked saying no you must come and also this picking…obviously it’s stigmatizing so the person will wonder, why me, (Hospital doctor). | | |
Need to increase awareness at waiting area | 11 − 1: The discrepancy is that there are various health talks on different days. If we could include PICT [HTS] daily in our health talks and say when you go in there know this…”(PHC nurse) | | |
Despite understanding of, and stated agreement with, the HTS policy and policy justification there was lack of coherence with implementation. The lack of coherence was illustrated by clinicians reporting actual practices of offering HIV testing based on suspicion of HIV. Specifically, the presence of chronic illness, wasting, or sexually transmitted diseases was what prompted most clinicians to recommend testing.
“By their clinical pictures, physical things…another one maybe by the signs/symptoms that they are mentioning …especially when they have STIs, I encourage them to go [for an HIV test].” (nurse)
“Well from our wing it’s mostly initiated based on symptom, so 99% of patients who come in will have features of something that could possibly be immunodeficiency then we’d like to test you for HIV.” (doctor)
Cognitive participation
The level of commitment to provider-initiated HIV testing differed between clinicians (doctors and nurses) and counsellors. Clinicians stated that they did not see it as their duty and to perform HTS. In addition, several nurses stated that they lacked the counselling skills needed to engage patients with HTS. Clinicians (both doctors & nurses) stated they were comfortable with recommending HIV testing, but not with being involved in providing the actual test. In contrast, HTS counsellors described full participation in the promotion and delivery of HTS.
“I think doctors & nurses’ involvement would be a good thing but due to the workload we are not able to do it personally. We have a lot of patients who are waiting for us and we do have counsellors who are employed to do the HIV testing…” (nurse) (Table 2)
“I know how to do my work [HIV counselling and testing]. Patients sometimes don’t want counselling, but I tell them that I have to do everything accordingly…” (lay counsellor) (Table 2).
Collective Action
There was a common practice of role division among healthcare providers in the provision of HTS. HIV testing was mainly recommended by the clinicians for delivery by lay counsellors. While this approach allowed for a degree of skill specialization, HTS services broke down when counsellors were not available due to the limited working hours of lay counsellors in the facility. When lay counsellors were unavailable, HTS was not provided. Clinicians resisted providing HTS, indicating that they considered it unfair that they should be expected to provide it and stating that the task of HTS should fall on others’ shoulders. This suggested a lack of full engagement in collective action.
“As I told you, we do assess patients and then we offer [HTS], if the patient agrees we send them to the counsellors and they test and counsel them.” (nurse)
“We knock off at 2 and you find that people come to the clinic to test knowing that the clinic closes at 4 pm. When they get here they are told that the counsellors have left…” (counsellor) (Table 2).
An additional barrier to a team-based approach was the substantial difference in status of the nurses and doctors compared to lay counsellors. Lay counsellors received small stipends, limited training, and were not embraced as part of the clinical team, often being left out of facility meetings including those regarding HTS: “If I were to tell you… actually they don’t value us, they don’t count us. We don’t have a say that is why we end up not knowing where we stand, because we don’t have a say” (lay counsellor).
“We counsellors in the hospital we are called “volunteers”, so you can’t cover [no employee benefits] a volunteer. We are doing this because I love what I am doing but I won’t stay in this profession for long, I am still looking for greener pastures”. (lay counsellor)
This further challenged creating a team dedicated to a collective goal.
Lay counsellors also described lacking the needed resources to perform HTS – suggesting lack of full support from clinic management. A major missing resource was private space to provide HTS.
“We always have test kits. Every Monday the nurse orders test kits for us. We have everything except the working space.” (lay counsellor)
“We don’t have enough working spaces. We only have one room to test the patients and there is always a queue that side”. (nurse)
Reflexive Monitoring
Some health workers emphasized the value of offering HIV testing to all clients, suggesting it should be considered similar to checking vital signs. One clinician further mentioned that offering an HIV test to everyone may reduce the stigma of HIV testing.
“It is easier to get people to agree when they see that everyone is going, it is not just me who’s being picked saying no you must come and also this picking…obviously it’s stigmatizing so the person will wonder, why me.” (doctor) (Table 2).
However, when compared to other practises embedded in routine practice, HIV testing was perceived to have challenges that made it a lower priority. A doctor narrated this as follows: “You keep thinking that now if this patient goes there he’s going to spend 15 minutes then maybe I’ll also send him to X-ray that’s another 15–30…then you say no no…. this one [HIV testing] can wait”. This illustrates the gap in reflexive monitoring, that despite identifying gaps in delivery, clinicians were not motivated to change the current approach to HTS.