Factors influencing uptake of HIV care and treatment among children in South Africa - a qualitative study of caregivers and clinic staff.

Despite antiretroviral therapy rollout in South Africa, fewer children than expected are accessing HIV care services. Our objectives were to describe barriers and facilitators of uptake of HIV care among children. Our study involved six private-sector clinics which provide HIV care free-of-charge in and around Gauteng province, South Africa. In-depth interviews were conducted in July 2008 with 21 caregivers of HIV-infected children attending these clinics, 21 clinic staff members and three lead members of staff from affiliated care centres. Many children were only tested for HIV after being recurrently unwell. The main facility-related barriers reported were long queues, negative staff attitudes, missed testing opportunities at healthcare facilities and provider difficulties with paediatric counselling and venesection. Caregivers reported lack of money for transport, food and treatments for opportunistic infections, poor access to welfare grants and lack of coordination amongst multiple caregivers. Misperceptions about HIV, maternal guilt and fear of negative repercussions from disclosure were common. Reported facilitators included measures implemented by clinics to help with transport, support from family and day-care centres/orphanages, and seeing children's health improve on treatment. Participants felt that better public knowledge about HIV would facilitate uptake. Poverty and the implications of children's HIV infection for their families underlie many of these factors. Some staff-related and practical issues may be addressed by improved training and simple measures employed at clinics. However, changing caregiver attitudes may require interventions at both individual and societal levels. Healthcare providers should actively promote HIV testing and care-seeking for children.

Evaluation of antiretroviral therapy (ART)-related counselling in a workplace-based ART implementation programme, South Africa.

Counselling about antiretroviral therapy (ART) is thought important to prepare patients for treatment and enhance adherence. A workplace-based HIV care programme in South Africa instituted a three-step ART counselling protocol with guidelines prompting issues to be covered at each step. We carried out an early evaluation of ART counselling to determine whether patients understood key information about ART, and the perceptions that patients and health care professionals (HCP) had of the process. Among 40 patients (median time on ART 83 days), over 90% answered 6/7 HIV/ART knowledge-related questions correctly. 95% thought counselling sessions were good. 93% thought ongoing counselling was important. Recommendations included the need for continuing education about HIV/ART, being respectful, promoting HIV testing and addressing the issues of infected partners and stigma. 24 participating HCP identified additional training needs including counselling of family and friends, family planning, sexually transmitted infections and running support groups. 90% of HCP thought that counselling guidelines were helpful. The programme appears to be preparing patients well for ART. Counselling should be offered at every clinic visit. Counselling guidelines were a valuable tool and may be useful elsewhere. The evaluation helped to assess the quality of the programme and to suggest areas for improvement.