Recommendations from HIV testing and service counsellors in the community
South Africa faces the largest burden of HIV globally with approximately 7.8 million people living with HIV1. Diseases, such as HIV, TB and malaria, are reliant of large-scale prevention and treatment programmes. Community-based HIV Testing and Service (HTS) Counsellors, frequently considered under the umbrella of Community Healthcare Workers (CHWs), play a substantial role in South Africa’s health system. Since the 1930s, CHWs broadly have supported health in communities. With the onset of the HIV epidemic in the late 1990s, communitybased HTS counsellors emerged as a new cadre of CHWs.
Today it is estimated that over 70,000 lay health workers, representing CHWs and community-based HTS counsellors, have supported community-based health efforts across South Africa. The National HIV Testing Service Policy describes community based HTS counsellors as multifaceted, strategic actors in reaching South Africa’s most vulnerable with HIV related health services including HIV testing and linkage to care. South Africa’s health workforce is notoriously unevenly distributed across rural and urban areas and public and private sectors (8) thus positioning HTS counsellors in a strategic space to reach those most vulnerable and thus further progress towards 95-95-95 targets*.
While the country’s antiretroviral therapy (ART) programme is the largest in the world, with over 5 million adults receiving treatment in 2020, the most recent UNAIDS Global AIDS Update highlights a 10-year steady decline in the number of people living with HIV on treatment. As cautioned in the report, ‘Efforts to support people on treatment to maintain treatment and achieve durable viral suppression are critical to improving health outcomes, maximizing the preventive benefits of treatment and preventing the re-emergence of drugresistant strains of HIV’. A decline in retention to treatment poses a critical threat towards reaching the second 95 in South Africa. One reason for this steady decline in retention to treatment is the lack of trust between clients and facility-based healthcare workers.
Top five recommendations for gaining and sustaining trust
Trust in HIV Testing and Service
Trust between health care workers and clients is consistently associated with improved access and uptake of health services, improved patient satisfaction increased adherence and retention to care, and even improved health outcomes. Trust in health care has also been seen as advantageous within the space of HIV-related health services.
In a context of continued HIV stigma and discrimination, trust is particularly vital to a client’s perception and experiences of continued quality, dignified care. Trust between healthcare workers and clients can impact whether a client will test for HIV, how they will react to their status, and whether they will continue accessing care.
Although trust appears as unequivocally beneficial to health, health system constraints such as high patient volumes, inadequate staffing, and insufficient resources can act as structural barriers to promoting a trusting relationship between a client and a health care worker. For the purposes of this article, the authors (some of whom are HTS counsellors), explored issues around trust and HTS counselling.
As noted by the authors, having the additional time and energy to foster trust can be just ‘a luxury add on’ when many South African facility-based health workers contend with an overburdened, under resourced and understaffed health system. In acknowledging these structural barriers, CHAPS’ experienced community-based HTS counsellors and programme managers offered several recommendations for how facility- based health care workers can promote trust with their clients to achieve greater progress towards 95-95-95 goals in South Africa. The recommendations were a result of five informal, opened ended interviews with CHAPS HTS counsellors and programme managers. Based on analysis and discussion about these interview findings, the authors identified five key recommendations for gaining trust within the HIV care cascade model.
Definition of trust
“to believe that someone or something is reliable, good, honest, effective, ect.: to have confidence in (someone or something)”.
It takes courage to get tested for HIV
Clients can delay testing for HIV or seeking care for fear of nondignfied communication and stigmatization. Drawing on our extensive experience within HIV testing, we highlight that supportive, encouraging, welcoming and honest communication with clients can substantially assist in building trust between health care workers and clients. It is important to recognise that testing for HIV is a challenging and potentially life altering decision. Adopting a humanising approach to HIV testing and care through open communication about the client’s concerns can significantly bridge the gap between clients and health-care workers.
Always Remember Introductions
Introductions are an essential part of forming good first impressions, establishing credibility, putting clients at ease, and establishing patientclient trust. Building rapport through casual conversation prior to clinical procedures creates a psychologically safe environment. HIV prevention and treatment clinical work involves asking intimate questions about a client’s health, sexual history, and body. Through establishing a relationship through conversation, we can improve the quality of health outcomes through making the client feel seen and establishing pathways for open communication.
Concerns around confidentiality adversely impact trust between clients and health care providers. HIV status confidentiality is a well described concern among both individuals who seek community-based and health facility testing and treatment services. Even a seemingly harmless instruction such as informing a client to enter a designated room to receive ART could compromise a client’s
view of confidentiality. To avoid threats to a client’s privacy, assure them of their status confidentiality during every consultation with a client. Additionally, inform clients that there might be times when other health care workers need to be informed of their status in order to provide further care. Open, transparent communication can foster dialogue that allays client’s apprehension.
The Importance of Pre-test Counselling
Pre-test counselling is essential and provides an opportunity for health care workers to educate the client on HIV, outline treatment options, acknowledge and debunk HIV-related myths, and remind the client that HIV is a treatable condition. Myths surrounding ART side effects and drug efficacy can delay initiation to treatment and hinder adherence. By offering time to the client to debunk these myths, dispel misconceptions, and inform them of scientifically proven treatment options, trust between the health care worker and client can grow. Additionally, the likelihood of retention in care is strengthened.
Recognise Client Obstacles
HIV services within South Africa face challenges related to access and retention due to highly mobile populations, socioeconomic constraints, including lack of money for transportation fare to the health facility, lack of social support, HIV stigma, adverse effects of medication, and medication fatigue33. Some of the barriers faced by clients could be resolved through support of social grants or social workers, or additional counselling; however, to first identify these barriers to care, open communication between a health care provider and clients is essential. Open, and non-judgemental communication about adherence will foster trust, open spaces for improving care and build relationships for collaborative solutions in healthcare.
Trust is vital to the health system, and it cannot be overlooked within the context of the HIV care cascade. For South Africa to reach 95-95-95 targets and reverse the current downward tread of care retention, one solution could lie in fostering trust between a health care worker and their client.
Nursing Matters December 2021