Facilitators & Barriers to Implementing Provider-Initiated HIV Counselling and Testing at the Clinic-Level in Ekurhuleni District, South Africa

Abstract

BackgroundHIV testing is the entry point into the HIV care continuum, and critical for HIV epidemic control. Facility-based HIV testing services (HTS) reach individuals who are already seeking clinical care and engaging with the medical care system. For this reason, individuals diagnosed with HIV during facility-based HIV testing are more likely to continue into HIV care. Efforts have been increasingly made to increase facility-based HIV testing services (HTS), including introducing provider-initiated counselling & testing (PICT), but this strategy remains under-utilized. We aimed to identify key constraints to normalization of PICT implementation in 10 Ekurhuleni District healthcare facilities in South Africa. MethodsIn-depth interviews were conducted with 40 healthcare workers (28 clinicians and 12 lay counsellors). Health care workers were purposefully selected to participate in the interviews, stratified by health facility and work category. Interviews were audio-recorded, transcribed, and translated for analysis. Thematic analysis was guided by the normalisation process theory (NPT). NPT theory explains how practices are routinely embedded within organisational contexts. We used NVivo 10 software for qualitative data management. ResultsBoth clinicians and lay counsellors exhibited clear understanding of the PICT policy – acknowledging its purpose and value. Key barriers to normalisation of PICT among clinicians understanding that HIV testing needs to be offered to all clients yet reporting actual practices of offering HIV testing based on suspicion of HIV. Additionally, clinicians perceived PICT as incongruent with their clinical roles and perceived it to be lay counsellors’ responsibility. The main facilitator was participation of all healthcare workers, specifically the presence of lay counsellors, although they also faced barriers such as a lack of workspace and under-appreciation. ConclusionsUse of NPT helped identify barriers which prevent normalization of PICT and its integration into the routine patient care. These barriers can be modified by low-cost interventions that promotes congruence of PICT to the roles of clinicians and integrate the role of lay counsellors within the patient flow in the facility.