Households, fluidity, and HIV service delivery in Zambia and South Africa – an exploratory analysis of longitudinal qualitative data from the HPTN 071 (PopART) trial
Date
2018
Journal Title
Journal ISSN
Volume Title
Publisher
Wiley Open Access
Abstract
Introduction: Population distributions, family and household compositions, and people’s sense of belonging and social stability
in southern Africa have been shaped by tumultuous, continuing large-scale historical disruptions. As a result, many people
experience high levels of geographic and social fluidity, which intersect with individual and population-level migration patterns.
We describe the complexities of household fluidity and HIV service access in South Africa and Zambia to explore implications
for health systems and service delivery in contexts of high household fluidity.
Methods: HPTN 071 (PopART) is a three-arm cluster randomized controlled trial implemented in 21 peri-urban study communities
in Zambia and South Africa between 2013 and 2018. A qualitative cohort nested in the trial included 148 purposively
sampled households. Data collection was informed by ethnographic and participatory research principles. The analysis
process was reflexive and findings are descriptive narrative summaries of emergent ideas.
Results: Households in southern Africa are extremely fluid, with people having a tenuous sense of security in their social networks.
This fluidity intersects with high individual and population mobility. To characterize fluidity, we describe thematic patterns
of household membership and residence. We also identify reasons people give for moving around and shifting social ties,
including economic survival, fostering interpersonal relationships, participating in cultural, traditional, religious, or familial gatherings,
being institutionalized, and maintaining patterns of substance use. High fluidity disrupted HIV service access for some
participants. Despite these challenges, many participants were able to regularly access HIV testing services and participants
living with HIV were especially resourceful in maintaining continuity of antiretroviral therapy (ART). We identify three key features
of health service interactions that facilitated care continuity: disclosure to family members, understanding attitudes
among health services staff including flexibility to accommodate clients’ transient pressures, and participants’ agency in ARTrelated
decisions.
Conclusions: Choices made to manage one’s experiential sense of household fluidity are intentional responses to livelihood
and social support constraints. To enhance retention in care for people living with HIV, policy makers and service providers
should focus on creating responsive, flexible health service delivery systems designed to accommodate many shifts in client
circumstances.
Description
CITATION: Hoddinott, G., et al. 2018. Households, fluidity, and HIV service delivery in Zambia and South Africa – an exploratory analysis of longitudinal qualitative data from the HPTN 071 (PopART) trial. Journal of the International AIDS Society, 21(4):e25135, doi:10.1002/jia2.25135.
The original publication is available at https://onlinelibrary.wiley.com
The original publication is available at https://onlinelibrary.wiley.com
Keywords
Antiretroviral therapy, Antiretroviral agents -- Southern Africa, HIV-positive persons -- Care, PopART, HPTN 071, Household fluidity -- Zambia -- South Africa, Migration -- Health aspects -- Southern Africa, HIV-infections -- Treatment
Citation
Hoddinott, G., et al. 2018. Households, fluidity, and HIV service delivery in Zambia and South Africa – an exploratory analysis of longitudinal qualitative data from the HPTN 071 (PopART) trial. Journal of the International AIDS Society, 21(4):e25135, doi:10.1002/jia2.25135