Department of Paediatrics and Child Health

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Browsing Department of Paediatrics and Child Health by browse.metadata.advisor "Burger, Ronelle"

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    The contribution of a community based HIV Counseling and Testing (HCT) initiative in working towards increasing access to HIV counseling and testing in Cape Town, South Africa
    (Stellenbosch : Stellenbosch University, 2018-03) Meehan, Sue-Ann; Beyers, Nulda; Burger, Ronelle; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health.
    ENGLISH ABSTRACT: HIV testing services (HTS) play an important role in South Africa’s response to the HIV epidemic and within the UNAIDS ‘90-90-90’ strategy. Reaching the first ‘90’, diagnosing 90% of individuals unaware of their HIV-positive status is vital for reaching the overall target. It is not possible for public health facilities to reach this target alone, as not all populations access health facilities optimally. Community-based testing services, provided outside of public health facilities are necessary for expanding access to HIV testing and must be explored. There is limited understanding of what constitutes access to community-based HTS. This dissertation used a framework to measure access along three dimensions, availability, affordability and acceptability, in order to determine access of a Community-Based HIV Counseling and Testing (CB-HCT) initiative, comprising mobile and stand-alone services. This dissertation includes six research studies, all of which were conducted within communities situated in the Cape Metro district of the Western Cape Province, South Africa between 2008 and 2015. I used a mixed-methods approach, and included quantitative and qualitative studies as well as a cost-analysis. Participants self-initiated an HIV test at either a mobile or a stand-alone service at a CB-HCT initiative or a public health facility. Mobile services consisted of tents and a mobile van set up at busy spots within the community. Stand-alone centers were fixed sites, not attached to a health facility. Consistently across studies (chapters 2, 4, 7), there was a higher proportion of males amongst the users at mobile (40% to 55%) compared to stand-alone and public health facilities (25% to 27%). As HIV test uptake in public health facilities is low for men, this finding infers that mobile HTS can meet the health seeking needs, regarding HIV testing, of men. Consistently across studies (chapters 2,3,4,5), the majority of users walked to HTS, irrespective of which service they accessed, indicating the importance of providing a geographically accessible service that allows individuals to test in close proximity to where they are. Mobile was also able to provide an immediate opportunity to test for those walking past and not considering an HIV test at that time, highlighting the key role that opportunity to test plays in access. Service providers can create opportunities and play a direct role in making HTS available. As most users walked to HTS, they incurred little or no direct costs. HTS were affordable in our setting. Providing services in close proximity to users will increase the affordability of HTS for the user and enable access (chapters 2 and 4). The largest difference pertaining to user acceptability was waiting times, which were significantly shorter at mobile compared to stand-alone and public health facilities (chapters 2, 3, 4, 5), making mobile a viable option for reaching populations who do not want to wait in long queues. Reports of healthcare worker demeanour varied. Users at mobile and stand-alone consistently reported favourable staff attitudes, while users at public health facilities had mixed reports. The cost to implement mobile and stand-alone services is important when considering scale-up of services. Overall, mobile cost less than stand-alone ($77 764 and $96 616 respectively)-(chapter 7). The mean cost per person tested for HIV at mobile was lower than at stand-alone because of the higher numbers of users testing at mobile, making it a viable service to scale-up. However, the mean cost of diagnosing and linking an HIV-infected person to HIV care was higher at mobile compared to stand-alone. HIV testing service is associated with linkage to care, users diagnosed at stand-alone were significantly more likely to link to care compared to those diagnosed at mobile (chapter 6). Evidenced-based linkage to care interventions will be essential prior to scaling up mobile services. This dissertation provides important insight into the availability, affordability and acceptability of mobile and stand-alone HTS (CB-HCT initiative) as well as considerations for scale-up. The operational nature of this dissertation (studies are based on the operations of the CB-HCT initiative) is able to provide evidence-based lessons learnt for program implementation to make services accessible. Considering the user perspective when aiming to increase access to HIVtesting is vitally important as users have differing needs (pertaining to availability, affordability and acceptability). Tailoring HTS in line with these needs is critical if we are to build a more user responsive health system. The practical application of the findings make this a meaningful dissertation.