3.1 Health Care Provider characteristics
A total of 24 interviews were conducted; 12 Healthcare providers and 12 adult participants. The sample of healthcare providers included 1 registered nurse, 9 professional nurses and 2 doctors across three hospitals and seven clinics. With regards to gender, the HCPs comprised of eleven females and one male as shown in Fig. 2.
All HCPs had spent at least two years in their profession and in providing treatment and care to PLWH and/or chronic conditions. We asked the providers to detail the types of chronic conditions that they commonly attended to among PLWH. All HCPs cited hypertension and/or diabetes as the most prevalent chronic condition to affect adults diagnosed with HIV. Of the twelve HCPs interviewed, all mentioned that most of their HIV positive adult patients had hypertension while only 6 mentioned that both hypertension and diabetes were prevalent among adults living with HIV. The distribution of the interviews conducted with healthcare providers is as shown Fig. 2.
3.2 Characteristics of patient participants
Of the 12 HIV positive participants, 10 were diagnosed with hypertension and two with diabetes. All were on ART.
Table 1
Characteristics of adults living with HIV Comorbidity (Hypertension & Diabetes)
AGE
|
Frequency (N)
|
Percentage (%)
|
30–35
|
2
|
16.66
|
36–40
|
2
|
16.66
|
41–45
|
1
|
8.33
|
46–50
|
4
|
33.33
|
51–55
|
2
|
16.66
|
56–60
|
1
|
8.33
|
SEX
|
|
|
Female
|
11
|
91.66
|
Male
|
1
|
8.33
|
MARITAL STATUS
|
|
|
Single
|
7
|
58.33
|
Married
|
3
|
25
|
Divorced/Separated
|
2
|
16.66
|
LEVEL OF EDUCATION
|
|
|
Primary
|
3
|
25
|
Secondary
|
8
|
66.6
|
Matric
|
1
|
8.33
|
EMPLOYMENT STATUS
|
|
|
Employed
|
6
|
50
|
Unemployed
|
6
|
50
|
The majority (33%) of the participants were aged between 46–50, mostly female (92%) and almost 60% reported that they were single. In terms of socio-economic status, more than two-thirds had received secondary education. There was an equal balance between the number of participants that were employed and those that were not employed.
3.3. Improved operational efficiency and quality of care
Overall, the healthcare providers cited three main challenges pertaining to providing efficient and quality care to patients living with the comorbidity of HIV and hypertension or diabetes under the ICDM model.
Under-resourced facilities
Most healthcare providers reported that their health facilities were under-resourced in terms of staff capacity. The nurses cited being frequently overwhelmed with the patient flow. Some said that they sometimes do not take their lunch breaks or reduce them to 15 minutes. Others reported that they took their lunch while consulting with patients. The fatigue resulting from missing lunch breaks and/or the workload placed on providers to attend to as many patients seems costly for holistic patient care. One nurse shared the following experience:
“Sometimes the facility itself would be packed, so meaning that you don’t really have enough time to spend with one patient, you have to rush the queue…another thing sometimes we have problems with shortage of drugs especially chronic medication like for hypertension and diabetes”, professional nurse, EC.
The patient participants echoed that the lack of staffing in healthcare facilities was responsible for the many notable inefficiencies such as the slow delivery of services. One patient said: “To us it seems as though they are just slow, but they are not slow it’s just that they are short staffed”, P2 GP.
In the nurse’s shared experience, concern was raised over the lack of on time delivery of chronic medications, particularly in the rural areas. This hinders efforts to achieving improved operational efficiency because it means patients may need to return on a different date to receive their medication; which could be one of the reasons health facilities and healthcare providers become overworked on specific days. The issue of delayed delivery of medication further risks patients defaulting from treatment.
Lack of training and guidance on chronic care delivery
Two major concerns were raised by healthcare providers with regards to receiving adequate training on delivery the ICDM model. Firstly, and because of the previous point of under resourced facilities, some healthcare providers reported that they are too overworked to find time to attend training and when they do attend, they are not as focused during lessons because they are exhausted. For example, one healthcare provider said:
“To be honest with you nurses don’t always have the time for refresher courses because most of the time hospitals and clinics are short-staffed”, professional nurse, EC
In the second account, healthcare providers who had moved between facilities or different departments reported that they had some experience with providing treatment and care for HIV, hypertension and diabetes, respectively. However, they did not receive training on dealing with HIV chronic comorbidities. One nurse summarized her experience as follows:
“Let me be honest with you, when I was working at XXX clinic I had just come from working in a hospital, so at the hospital I was working at medical and didn’t know much about what is going on in the primary health care and I did not get training like specific to co-morbidities…I was just thrown in the deep end”, professional/triage nurse, EC.
Unclear guideline on chronic care integration
The lack of training was reflected in the accounts of several other healthcare providers. There seemed to be different interpretations and methods of implementation of the ICDM model. Some nurses reported that they provided holistic treatment for all chronic conditions including HIV, hypertension and/or diabetes. For example, a patient with HIV and hypertension has one file, one appointment card and can receive their chronic medication from the same nurse or during the same clinic visit. However, there were reports of patients having different clinic dates for HIV and hypertension or diabetes. A doctor in one of the hospitals said:
“Somehow chronic care is not yet too much integrated in the government sector because I remember asking another patient why she had another date for another treatment…you find one condition is handled by the other and one also handled by the other”, Dr, EC.
Interestingly, when the adult participants were asked about their experiences of receiving integrated chronic care and the quality of the care provided. We found that patients were happy with the attitude of healthcare workers in providing treatment and care. “Every time when I come here, they don’t just give me my medication and say here is your medication go, they will ask me this and that; how are the pills treating you, how does your body feel and so on”, P4 GP. However, we found that routine testing for high blood pressure was provided but not for diabetes. With the exception of one patient (who was pregnant at the time of interview), most reported receiving their HIV and chronic care treatment from one nurse within the same facility. However, some patients raised concerns about the separation of ques for patients receiving HIV treatment and those receiving care for other conditions and the slow delivery of services. “I had a problem with the way the queues are formed. People with HIV had their own line and other people who came to the clinic for different issues had their own lines…that puzzled me a lot”, P10 EC.
3.3. Individual Responsibility
We explored providers and patients perspectives of the role of patients to adhere to treatment and ensure adequate management of their conditions. HCPs mentioned that the self-management of diseases was difficult for patients and evident in the rate of default from HIV treatment and, subsequently, from other chronic medication as well. The HCPs elaborated on a number of reasons and experiences that cause patients to discontinue treatment, which we have organised under sub-themes. These themes include: non-disclosure; polypharmacy, poor knowledge of treatments; constant movement of patients and lastly, socio-economic issues.
Non-disclosure
Most HCPs mentioned that most of their patients defaulted because of non-disclosure of their HIV status to either their partners, family, peers and/or employers. All agreed that HIV was the most difficult to disclose compared to other chronic conditions such as hypertension or diabetes. However, even after disclosure of HIV status, some HCPs were to the view that most of their patients found it difficult disclosing that their other chronic conditions because it was too many illnesses for anyone to understand. One of nurses said:
“People don’t want to disclose, I think it is because of the stigma or whatever…they will even tell you that even the family haven’t accepted that they are HIV positive and now there is hypertension or diabetes so sometimes it’s difficult…they are even too scared to disclose the status to their partners, parents and when not disclosing their status obviously adherence is going to fall”, registered nurse, GP.
There were different accounts from the patient participants. Some agreed with the healthcare providers that it was much easier to inform people that you are hypertensive or diabetic as opposed to telling them about your HIV status. Others related their non-disclosure as a fear of discrimination, stigma or judgement. Two of the participants shared their experiences as follows: “…. you know I was once employed as a house helper and my employer found me taking my pills and she fired me from work just for that… and I have worked for them for many years but I was fired for that…Now it is many of us at work who are taking medications and we all know each other’s clinic appointment dates but our employers are not aware of that. So when one goes for their clinic appointment you just tell them about the high blood condition but not the HIV one”, P5 GP.
“Well yes people do gossip about me because I lost weight, my body was not like this… many are not aware of my high blood pressure condition but they are aware of the HIV one because I am losing weight… the discrimination that I am receiving is mainly because of the HIV but not the high blood”, P4 GP.
Polypharmacy
Polypharmacy refers to the use of multiple medications, which is common for persons living with comorbidities. The healthcare providers mentioned that another leading cause for treatment default was because PLWH and additional chronic conditions were subjected to taking different medications, sometimes taking a number of pills at a single or different times. They reported that this often lead to treatment fatigue or patients weighing which of the treatments; between HIV or hypertension; they thought was more important or had the least side effects.
“I think pill burden is a problem for patients…for hypertension it depends how your high blood is elevated, for example I can start you on one drug or two or three drugs…so the fact that you have three drugs on top of the ARV drug…now taking four tablets in a day it’s a lot for them. So you find that some of them take the HIV drug only and say no the hypertension one I will see”, professional nurse, GP.
Indeed, some patients reported treatment fatigue. One of the patients cited the following: “They are five…I take two for HIV and three for high blood…hey it is very hard…they are a lot and stressful to take…worse when I hear or see other people that taking 1 pill for HIV and probably less for chronic…it worries me a lot, I just wonder what is so unique about my illnesses”, P8 EC.
Poor knowledge of treatments
We found that participants had poor knowledge of their HIV and chronic medication, with most being unable to name the medications that they using aside from saying it is for HIV and hypertension/diabetes. In the healthcare worker’s account: “Most of the time patients don’t even know the names of the tablets that they are taking”, professional nurse, EC. This corroborated the experiences of the patient participant with one saying: “I don’t know their name, I just drink pills”, P9 EC.
Relocation of patients
Healthcare providers raised concern over the constant movement of patients from one geographical area to the next. Reasons for the relocation can be alluded to fear of stigma in the area where they receive their medication and pull factors that lead them to seek better economic opportunities. The problem however arises where patients that intend to relocate do not request their local clinic to provide them with transfer letters in order to allow the next clinic to know the client’s medical history.
Our clients are moving a lot, today they will be here the next day they are in KZN…we tell clients that when they leave they should come and we give them a transfer letter but some do not follow that…usually what they do is that when they come to an institution they will say that it is my first time because client knows that she is supposed to be bringing a transfer letter”, professional nurse, EC. .
Socio-economic issues
Individual responsibility is difficult to achieve, especially, for patients with a low socio-economic status. In most of the PHC included in this study, the patients were unemployed and experienced several financial challenges that affected access to health facilities, food security and their ability to take treatment accordingly. One healthcare provider reported that:
“Some patients will tell you that I don’t have food at home and don’t even have money to go fetch that treatment at the hospital so mostly its social factors”, Dr, EC.
Similarly, the patient participant agreed that unemployment was one of the factors that made the self-management of chronic conditions difficult. One participant went on to say:
“I am unemployed so the problem is that I am not working. For someone to be living with these conditions and on the other hand not working it is a problem obviously… because even those pills you cannot just drink them when you have not yet eaten, you must eat before you can be able to drink pills…you must eat fruits and other things; all those things require money because even with this condition, we hear from doctors or nurse’s advices that it is very important that we always eat lots of fruits and that is money”, P4 GP.
3.4. Activated and Informed population
HCPs were asked about their role in ensuring patients with HIV comorbidities were informed and supported about the prevention and management of chronic comorbidities. Providers reported that support and information was provided through different structures. These include community healthcare workers and social workers who provide health talks and support through platforms such as WhatsApp and adherence clubs. They mentioned that these support initiatives were implemented by organisations not affiliated to the clinics; often non-governmental organisations under donor funding.
However, we found a different perspective from the patient participants. Most reported an unavailability of social workers or support groups that provide information and/or support to patients living with HIV Chronic comorbidities. Others reported having not received sufficient information about managing their conditions from healthcare providers as well. For example, two of the participants mentioned the following:
“We just get our medication and go home…we do not have support programmes that help us to cope with mental and stress of having these conditions”, P9 EC.
“I did not get much information about HIV and ways of preventing vulnerability from other chronic diseases, the information I got was very vague…they only said when you diagnosed with HIV it’s easy to get other diseases but that time didn’t have diabetes or know it existed”, P7 EC.