Paradox of HIV stigma in an integrated chronic disease care in rural South Africa: Viewpoints of service users and providers

Background An integrated chronic disease management (ICDM) model was introduced by the National Department of Health in South Africa to tackle the dual burden of HIV/AIDS and non-communicable diseases. One of the aims of the ICDM model is to reduce HIV-related stigma. This paper describes the viewpoints of service users and providers on HIV stigma in an ICDM model in rural South Africa. Materials and methods A content analysis of HIV stigmatisation in seven primary health care (PHC) facilities and their catchment communities was conducted in 2013 in the rural Agincourt sub-district, South Africa. Eight Focus Group Discussions were used to obtain data from 61 purposively selected participants who were 18 years and above. Seven In-Depth Interviews were conducted with the nurses-in-charge of the facilities. The transcripts were inductively analysed using MAXQDA 2018 qualitative software. Results The emerging themes were HIV stigma, HIV testing and reproductive health-related concerns. Both service providers and users perceived implementation of the ICDM model may have led to reduced HIV stigma in the facilities. On the other hand, service users and providers thought HIV stigma increased in the communities because community members thought that home-based carers visited the homes of People living with HIV. Service users thought that routine HIV testing, intended for pregnant women, was linked with unwanted pregnancies among adolescents who wanted to use contraceptives but refused to take an HIV test as a precondition for receiving contraceptives. Conclusions Although the ICDM model was perceived to have contributed to reducing HIV stigma in the health facilities, it was linked with stigma in the communities. This has implications for practice in the community component of the ICDM model in the study setting and elsewhere in South Africa.


INTRODUCTION
Chronic diseases are diseases (e.g. hypertension, diabetes and HIV) that require regular and ongoing, usually for a long time contact with health facilities. Since June 2011, the National Department of Health has been testing the integrated chronic disease management (ICDM) model of care in all the clinics Bushbuckridge sub-district. The aim of this model is to improve health outcomes of patients with chronic diseases and improve service delivery in health facilities. We invite you to describe your experiences with the quality of care in the clinics with respect to the topics below. You are not expected to name the chronic disease for which you are being managed in the clinic.
Topics for the discussion 1) General satisfaction with the quality of the integrated chronic disease care  In general, could you tell us how satisfied or dissatisfied you are with the integrated chronic disease care in the health facility you attend? o Prompt participants to explain the reason for their satisfaction or dissatisfaction  All of you have been receiving treatment in the clinics for at least two years. Have you noticed any changes in the way services for chronic diseases have been combined? o Prompt participants to discuss any positive or negative changes in the combined/integrated chronic disease services in the clinics since June 2011  How perfect are these services?
o o Probe participants to ascertain their reasons for agreeing or disagreeing with the above question.

16) Attendance and examination
 How well do the nurses attend to you in the consultation room? o Probe participants to ascertain their reasons for agreeing or disagreeing with the above question.  Do the nurses do physical examination of your body in the consultation room?
o Probe participants to ascertain their reasons for agreeing or disagreeing with the above question.

17) What would you like us to tell the National Department of Health concerning your individual needs, circumstances and challenges?
SUMMARY  In order to be sure that we did not miss anything, the moderator will summarise the topics for the discussion.  Is the summary accurate? Was anything left out?

INTRODUCTION
-Introduce members of the team -The aim of this discussion is to understand patient experiences with the quality of care for chronic diseases in the primary health facilities and to know why the participants failed to come for clinic appointment for at least one month after the appointment given to them by the nurses -We would like to get a very good understanding of your experiences in the clinics, some of which you may not have been able to discuss with us during interviews in the clinic last year. -This discussion will contribute in understanding how services for chronic diseases are organized in the health facilities -This study has the support of the Bushbuckridge Department of Health and Wits University 2. ACTIVITIES -Eleven topics around quality of chronic disease care in the clinic will be discussed today -Participation in this discussion will be free, fair, equal and in relaxed environment -A report of this discussion will be sent to you -There will be no mention of your names in the report or any other document(s) -You will not be identified as a participant in this discussion -Refreshments will be provided in the meetings -You are free to leave the study at any time -We would like to know if there are suggested modifications to this programme 3. WRITTEN INFORMED CONSENT -Written informed consent, signed by participants, study investigator or senior qualitative field worker is obtained

INTRODUCTION
Chronic diseases are diseases (e.g. hypertension, diabetes and HIV) that require regular and ongoing, usually for a long time contact with health facilities. Since June 2011, the National Department of Health has been testing the integrated chronic disease management (ICDM) model of care in all the clinics Bushbuckridge sub-district. The aim of this model is to improve health outcomes of patients with chronic diseases and improve service delivery in health facilities.
We invite you to describe your experiences with the quality of care in the clinics with respect to the topics below. You are not expected to name the chronic disease for which you are being managed in the clinic. Topics for the discussion 1) General satisfaction with the quality of the integrated chronic disease care  In general, could you tell us how satisfied or dissatisfied you are with the integrated chronic disease care in the health facility you attend? o Prompt participants to explain the reason for their satisfaction or dissatisfaction  All of you have been receiving treatment in the clinics for at least two years. Have you noticed any changes in the way services for chronic diseases have been combined? o Prompt participants to discuss any positive or negative changes in the combined/integrated chronic disease services in the clinics since June 2011  How perfect are these services?
o o Probe participants to describe specific instances of competence or incompetence of the nurses

5) Communication
 Tell us whether the nurses explain to you reason(s) for doing physical examination or requesting laboratory tests o Invite participants to describe such experiences  Do the nurses sometimes ignore what you tell them?
o Probe participants to provide illustrations with specific instances 6) Financial aspect of accessing care  Do have to pay fees to access services in the clinics? o Invite participants to illustrate specific instances when fees were paid  Are you able to afford the cost of transportation to the clinic? o Invite participants to describe distances between their homes and the clinic, and how much they have to pay for transport 7) Waiting time before seeing nurses and time spent with nurses in the consultation room  How long do you wait to see the nurses before they attend to you? o Probe participants to describe their experiences with waiting time  Do the nurses hurry too much when they attend to you in the consultation room?
o Probe participants to describe their experiences 8) Accessibility of the integrated chronic disease services  How hard or easy is it for you to access services in the clinic? o Invite participates to describe their experiences  Describe your experiences in having access to a doctor or a specialist

15) Prepacking of medicines
 Do the nurses pack your medicines the day before your clinic appointment? o Probe participants to ascertain their reasons for agreeing or disagreeing with the above question.

16) Attendance and examination
 How well do the nurses attend to you in the consultation room? o Probe participants to ascertain their reasons for agreeing or disagreeing with the above question.  Do the nurses do physical examination of your body in the consultation room?
o Probe participants to ascertain their reasons for agreeing or disagreeing with the above question.

17) What would you like us to tell the National Department of Health concerning your individual needs, circumstances and challenges?
SUMMARY  In order to be sure that we did not miss anything, the moderator will summarise the topics for the discussion.  Is the summary accurate? Was anything left out?