Client profile
Family planning clients were an average of 26 years old and mostly married (88%); outpatient clients were an average of 28 years and less than three-quarters were married (70%). Clients waiting to start ART were the oldest with an average of 30 years; they had been living with HIV for an average of 2.7 years and two-thirds (66%) were married.
Delivery of HTS within Family Planning and Outpatient Services
According to client exit interviews, nearly all clients had been tested for HIV previously (Figure 1). Eleven percent of FP clients and 9% of OPD clients were tested on the day of the observation. Over half of clients reported being tested in the last six months (58% FP, 54% OPD); about one-third reported being tested more than six months ago (29% FP, 33% OPD). A very small number of clients reported never having received testing (1% FP, 4% OPD).
Figure 1. Time since last HIV test, by client type, from client exit interviews
The reasons most clients did not get tested on the day of the interview included: already knowing their status (41% FP, 37% OPD), visiting the facility for some other purpose (39% FP, 39% OPD), and providers not offering the test (32% FP, 34% OPD) (data not shown).
Data on the delivery of HTS from both client exit interviews and observations are reported in Table 2. The intention of reporting both sets of results is to illustrate the relative frequency with which clients receive services rather than to directly compare the two. Just over one-third of family planning (38%) and outpatient (35%) clients knew that testing was available at the facility on the day of the interview. (This information was not available from observation data as RAs did not ask clients questions during the observations.) In the exit interviews, about one-third (34%) of FP clients and one-quarter (25%) of OPD clients reported that the provider mentioned getting tested for HIV on the day of the interview; however, according to observations of provider-client interactions, providers mentioned HIV testing much less.
Table 2: HTS received, by client type, as reported in exit interviews and observed
|
Family Planning %
|
Outpatient %
|
Exit
(n=1349)
|
Obs.
(n=1343)
|
Exit
(n=1322)
|
Obs.
(n=1314)
|
Knew HTS available
|
37.8
|
NA
|
34.7
|
NA
|
Provider mentioned HIV testing today
|
34.1
|
12.0
|
25.4
|
9.2
|
Knew HTS available
|
37.8
|
NA
|
34.7
|
NA
|
Counseled on HIV prevention*
|
21.9
|
19.3
|
14.1
|
8.7
|
Received condoms
|
2.3
|
1.3
|
1.4
|
0.2
|
Obs.: Client-provider observations
NA: Data not available
*For exit interviews, HIV prevention counseling was measured by clients saying if the provider “mentioned ways of preventing HIV infection.” In the observations, HIV prevention counseling was counted if the provider mentioned any of the following: condoms as prevention, benefit of knowing status, couples testing, the HIV test process, or HIV disclosure.
|
HIV prevention counseling was infrequently provided to both FP and OPD clients. Only 22% of FP clients and 14% of OPD clients said their providers gave them prevention messages. (Table 2) Similarly, low proportions of clients received these messages during observed consultations. (Table 2) Furthermore, over 50% of those who reported having been counseled on HIV prevention could not provide any details on the content of the counseling (data not shown) including information on abstinence, having only one partner, using condoms and avoiding needles as methods to prevent HIV. Most facilities were observed to have condoms available during observations; however, a small number of facilities (2 of 18) had condoms available during fewer than 20% of the observations. Very few clients from either service reported receiving condoms at the facility.
Among the 270 clients who were tested for HIV on the day of the interview, 56% of clients exiting both family planning and outpatient services said they had received counseling on ways to prevent HIV transmission, such as condom use and monogamy (data not shown). Among the 64 family planning clients whose HIV testing was observed for this study, approximately half were counseled on the benefits of knowing their status and on couples testing. (Table 3) A greater proportion (70%) had the testing process explained to them and 75% were observed to give their consent for the test.
Table 3. Frequency of components of HIV counseling according to Minimum Package guidelines, among family planning clients* whose test process was observed
|
Family planning %
(n= 64)
|
Provider tells client benefit of knowing status
|
54.7
|
Provider tells client about couples testing
|
51.6
|
Provider explains HIV test process
|
70.3
|
Provider gets client’s consent for test
|
75.0
|
* This table reflects data from family planning clients only because we observed only 9HIV tests among outpatient clients.
Key informants shared information on the approach they take in offering HIV testing. Providers commonly described making decisions as to which clients to offer HIV testing based on a clients’ appearance and clinical symptoms; specifically, those who presented with signs and symptoms of HIV or other STIs, new mothers, those with opportunistic infections, or those who generally appeared weak were mentioned as groups to whom HIV testing was offered. As one outpatient provider noted,
“I will just look at the patient’s condition and suspect the patient is having HIV or I have treated this patient for a long time, but they are not responding so I just send the client for DTC.” [NOTE: diagnostic testing and counseling, or DTC, targets clients with HIV-related signs and symptoms].”
– Provider, Family Planning department
Some providers reported that risk of HIV was not readily identifiable. One FP provider stated that, “…when it comes to HIV, it doesn’t have the boundaries, anyone can have it." However, more key informants identified particular social characteristics as important for determining risk. Across providers and managers in both FP and OPD services, respondents identified young, sexually active, single women; fishermen; truck drivers’ wives; commercial sex workers; and IV drug users as high-risk groups.
Interviews also illuminated service delivery challenges that could limit integration of HTS into the two services. An inconsistent supply of test kits was a commonly cited limitation to the provision of HTS during FP and OPD services. For 38% of family planning visits and 45% of outpatient visits observed, RAs documented that HIV test kits were not available for the client (data not shown). This resulted in facilities having to refer clients to other facilities. In addition, family planning providers and managers reported a lack of basic family planning commodities, including injectable contraceptive and long-acting methods, as a regular and persistent problem at the facility level.
“…Now we are facing shortage of test kits. They (clients) are not being tested, they are being referred to another facility unless [except for] the one you really, really want to do, but those who are coming for voluntary testing we are not doing.”
– Provider, Outpatient Department
Pre-ART
Client exit interviews, observations and key informant interviews, show similar patterns of inconsistent provision of the full range of pre-ART services (See Table 4). During the visit on the day of the exit interview, the most commonly received service was the receipt of co-trimoxazole, an antibiotic given prophylactically to HIV-positive individuals to prevent common infections. Nutrition, HIV prevention, and family planning were the next most commonly received services, with approximately one-third of providers discussing appetite with clients and nearly half discussing family planning and HIV protection for partners. Rates of TB prevention counseling (10%), testing for cervical cancer (5%), and TB testing (3%) on the day of the interview were particularly low. However, nearly half (47%) of pre-ART clients reported that a provider in the facility had mentioned tuberculosis prevention since the client learned their HIV status. Among women who self-reported having a cough for at least 3 weeks or who had been coughing up blood, only 38% had been tested for TB at the facility since learning their status. (Data not shown). Aside from the receipt of co-trimoxazole, which in some cases was dispensed from a pharmacy and not during the observed provider examination, results from the observations of client-provider interactions regarding the services received were fairly similar to those reported by clients.
Table 4. Services received by pre-ART clients, self-reported and in observations, by timing of receipt
|
Exit Interviews (n-586)
|
Observations (n=589)
|
Counseling/Service topic
|
% ever received
|
% received today
|
% received today
|
Infectious disease
|
Co-trimoxazole provided
|
97.8
|
93.0
|
53.5
|
|
Genital pain/discomfort discussed
|
40.4
|
13.8
|
7.8
|
|
Malaria prevention (bed nets, insect spray)
|
63.5
|
10.6
|
9.0
|
|
TB prevention discussed
|
47.4
|
9.6
|
9.0
|
|
Cervical cancer screening
|
26.6
|
4.6
|
1.7
|
|
Malaria medicine provided
|
24.9
|
4.3
|
1.7
|
|
TB test
|
21.2
|
3.2
|
4.2
|
|
STI test
|
20.8
|
1.7
|
0.2
|
|
Vaccination provided
|
7.0
|
0.2
|
0
|
Nutrition
|
Appetite discussed
|
58.0
|
30.9
|
29.0
|
|
Nutritional supplements/vitamins provided
|
39.6
|
15.4
|
11.0
|
|
Food assistance programs discussed
|
16.6
|
5.0
|
4.8
|
HIV prevention
|
Protecting sexual partner from HIV discussed
|
90.4
|
42.8
|
49.9
|
|
Partner testing mentioned
|
88.1
|
36.7
|
21.7
|
Pregnancy
|
Family planning discussed
|
79.4
|
41.8
|
52.1
|
|
Safe pregnancy discussed
|
72.0
|
17.6
|
5.4
|
|
Pregnancy desire discussed
|
46.6
|
17.4
|
12.1
|
|
FP method provided
|
57.2
|
9.9
|
2.0
|
Psycho-social
|
Disclosing status discussed
|
67.4
|
17.1
|
34.1
|
|
Joining HIV support group discussed
|
56.1
|
14.7
|
28.7
|
Sanitation
|
Safe drinking water education
|
74.4
|
17.6
|
13.4
|
|
Hand-washing education
|
68.9
|
13.3
|
7.0
|
Key informants were asked to explain how they decided which services a pre-ART client should receive. Some respondents recognized the need to provide services universally. One provider in a CCC stated: “If a client comes here I have to screen for TB because I have checklist for checking…they come in I have to go through the TB tool, STI tool, all those…" Many other providers and managers, however, described how clients presenting with opportunistic infections or signs and symptoms of HIV, clients who are pregnant, and clients who have TB or a low CD4 count, are given priority in the form of being seen immediately or given more time with a provider. Respondents also discussed tailoring services they provided to CCC clients according to social characteristics, allowing them to broaden the services delivered to clients. Clients perceived to be part of high-risk populations, such as commercial sex workers, drug users, men who have sex with men, alcoholics, and selected occupational groups such as long-distance truck drivers or fisherman, often received different services.
Health system factors facilitating Minimum Package rollout
County and national key informants expressed positive attitudes towards the provision of integrated services conducive to the provision of the Minimum Package. These participants described multiple benefits of integration including: time savings for clients and providers, the opportunity to capture more clients, increased client satisfaction, and elimination of the need for clients to wait in more than one line. A few respondents also stated that integrated services would increase client compliance and save resources.
"That (integration) is the only way to go if you are to catch up with HIV…you have to have an interest in family planning which is very key especially now that we want to do elimination of mother to child transmission… that is the only way we should go...shuffling patients from left to right they even get lost for follow up… so we have to integrate our services under one roof.”
- County level health official
Respondents also positively described the support they received from the county and national level government and external partners in the form of trainings and supportive supervision to increase provider capacity to deliver integrated services, technical input to help identify and make improvements to address facility weaknesses, and assistance with organizing community outreach activities. Assistance from external partners to hire additional staff, make infrastructure improvements and procurement were additional areas of support cited.
“There have been a lot of trainings, especially to the health care givers, and much of it is towards HTS…our counselors and nurses have been empowered so much. There is adherence training…there is [sic] people living positively training, there is disclosure training…There is a way of giving out benefits of carrying out HTS, so they have also been empowered with that technique. These ones actually enhance our uptake on providing HTS.”
- Provider, Outpatient Department
Health system constraints impeding Minimum Package rollout
Results from key informant interviews provide insight into the health systems-level factors that impede effective delivery of integrated services. At the most basic level, knowledge of the Minimum Package was far from universal, even in the integrated facilities. Only 24 of 64 facility-level managers had heard of these service delivery guidelines before the interview. Among all respondents, county- and national-level managers were more apt to be aware of the Minimum Package compared to managers and providers working in health facilities.
Key informants also shared information about weaknesses in the health system that constrained implementation of the Minimum Package more generally. The vast majority of key informants at all levels spontaneously mentioned that staff shortages were a systemic problem at the facility level. One national-level key informant stated:
“I think resource allocation…especially the staff [is a key challenge], when you look at the shortage they have, there is shortage across board and every cadre, for clinical officers…we need 5,700 more…in nurses they are talking about another 10,000…The issue of shortage is very critical so for integration we really need to look at the human resource aspect."
– National Level Official
Key informants reported that staff shortages often left providers overburdened with clients and resulted in the need to prioritize certain clients for HTS.
"Specifically,…HTS is for all clients, but due to the fact that you know there is problem with the manpower, the staffs are few, I think what we normally do here is to request patients who have major presentation of HIV/AIDS to go for, we provide those clients, we also ask those who are high risk--the commercial sex workers, people with multiple partners, STIs and rape cases those kind of patients we normally ask them to go for VCT."
- Manager, Outpatient department
Other staffing issues included situations where one staff member had responsibility for all clinical services, as one CCC manager stated, “I am the one doing the pharmacy, I am the one doing the blood, I am the one…you know, you do everything.” Additionally, the overall lack of supervision or support for providers and managers was commonly cited.
“When staff are over worked then they look for shortcuts or when nobody gives you a pat on your back for job well done then short cuts are taken to make sure that the queue of clients is short, you evade some things to favor yourself… you say, what the hell, I will not take temperature or height or weight. That is human…but, it can be controlled and it’s only that they don’t want to support us (providers). That is why some of these things will go on for years and years."
– Provider, CCC department, Kisumu County
Inadequate staff training was raised by key informants at every level of the health system and in each type of service explored in the study. Insufficient resources allocated to health facility staff development led to providers not receiving in-service training for some services they were expected to deliver.
"I have not received any family planning training [since college] 15 years ago so what I have learnt in family planning is my own initiative. I read books and the family planning packages book on my own to be able to provide family planning services to the clients."
– Provider, Family Planning department
Health facilities were found to frequently rely on volunteers for the provision of services, especially for HTS. Reliance on unpaid workers is a severe challenge to the sustained provision of health services, particularly given the lack of incentives for volunteers to work on a regular basis.
Key informants reported that the limitations described above were key contributors to longer client wait times that obstructed the provision of integrated services. This point was reinforced by exit interviews, with about one-third of family planning and pre-ART clients and half of outpatients saying that the wait time to see the provider was too long.
Key informants also reported a general lack of privacy and inadequate infrastructure in facilities that made it difficult for health facility staff to deliver services and for clients to receive high-quality care. This was especially true regarding space for HIV counseling and the provision of sexual reproductive health services such as cervical cancer screening or IUD insertion. Key informants reported that there is often only one room for multiple clients, creating challenges for maintaining privacy and confidentiality.
"In this facility… there is no privacy because it is one room where the clinicians and the counselor sit. So, sometimes a clinician has a client that needs to be examined on the couch and that couch is next to where the counselor sits…and so there is lack of privacy because the counselor plus her client will be hearing what I am telling the patient I am examining. At the same time, we will be able to hear what the counselor and the client are talking about. So…that will also hinder the HTS."
– Provider, Outpatient department, Kisumu County
Key informants also noted demand-side challenges specific to the provision of HIV-related services. Specifically, many described lack of attendance for pre-ART services as strongly linked to the stigma associated with seeking care from a facility offering HIV services.
"The largest challenge is stigma. Some new clients aren't comfortable with sitting in the area that is known as the CCC client area. Clients don’t want to be seen coming to the clinic."
– Provider, CCC department, Nairobi County
Work with in-country stakeholders
Stakeholders acknowledged that the health system weaknesses identified in the study were factors preventing delivery of the Minimum Package, and they offered alternative perspectives on many of the issues highlighted by study results. For example, stakeholders discussed how issues related to commodities, such as a lack of HIV test kits, required attention in addition to supply. They suggested a focus on identifying root causes of test kit stock-outs, such as theft, under-reporting of testing or inaccurate recordkeeping, and limitations in forecasting made by providers at the facility and county levels. Issues related to training could be partially addressed with improved tracking of the training needs and capacity of staff.