As already mentioned, stigma and confidentiality issues potentially limit uptake of HIV programme services by healthcare staff, who may fear discrimination at work if they access HIV services at their own facility.
Testing: The first and greatest hurdle may be accessing HIV testing services. While these must be made available on site for staff, as the TTR survey demonstrated, most do not make use of their onsite services.18
However, “in individual interviews we found the idea of annual HIV testing surprisingly acceptable. 75% say they would be very willing to have annual HIV testing, even if this was not linked to any extra HIV care. And only 5% here say they would not be at all willing, regardless of extra care provided,” said Dr Corbett. But in focus-group discussions, there was “a lot of concern about the need for absolute confidence that could not be provided by your own workplace colleagues.”
When given a choice about how they would like to be tested each year, almost half said that a self-testing option (either making self-testing available in private or at home for all staff) would be either their most or second most preferred option. Hiring an independent VCT provider to visit and provide testing each year was the next preferred option, though a high percentage also say they would prefer an HIV test to be part of their routine health check.
This final observation is especially worth noting because of field reports described below, that show uptake of testing increases when it is provided within the context of comprehensive care at staff clinics.
The TTR survey noted that many healthcare workers had secretly tested themselves - and this was something that some members of our advisory panel remarked upon.
“Health care providers (and other hospital/clinic employees) are stealing HIV rapid tests from the workplace to enable self-testing. This has become such common practice, that institutions have taken to locking up HIV tests so they cannot even be obtained easily by doctors who want to test their patients! This rather than recognising that healthcare workers, like patients, do not want to utilise the available VCT services due to stigma and fears of lack of confidentiality, and identifying an alternative,” Dr Krista Dong told HATIP.
One alternative is to buy finger prick HIV test kits from private pharmacies. In some settings, these are widely available at a cost ranging from US $2 to $10 per test. However, the process of asking for the kit may be a disincentive to some healthcare workers, and there is a clear need to provide more support and counselling to healthcare workers who chose this option. Other alternatives are needed to make HIV testing more widely available, and linked to services for healthcare workers.
ART and HIV care: The TTR survey also investigated how participants thought they might prefer to receive ART and other HIV treatment services - with somewhat counter-intuitive results.
Several models of HIV service delivery were considered, and participants ranked them in the following order:
- Priority service at their own ART facility
- From a staff clinic providing ART within the context of comprehensive care
- Free medical insurance (and presumably making their own arrangements for care)
- Priority access to another nearby ART clinic
- A free arrangement with a private doctor
- Separate ‘Wellness’ clinics for health workers in larger cities
- Mobile clinics
- Consultation by phone (with drugs sent to them)
According to the full report, “Secrecy about one’s status does not appear to be problematic by the stage of seeking ART, and focus groups support a preference for being cared for by people who know you and so will give good service. There was little evidence of stigmatization of co-workers attending ART clinics, with supportive opinions more commonly expressed.”
But these results have to be interpreted with caution because the majority of participants in the study are presumably not HIV-positive themselves. In addition, there are several other reasons to be somewhat circumspect about the findings. One is that when participants were asked to rate what qualities would be important to them in an ART service, the highest percentage chose “confidentiality” as the most or second most important feature to them - which would seem difficult if they were receiving treatment along with other patients at their own ART clinic. Another problem is that it is difficult to judge the uptake of ART services at these facilities in the survey since the HIV prevalence of the cohort is unknown - but as Dr Corbett said, it seems rather low at the facilities in the survey.
So it may be better to look at these findings in light of the evidence coming from practice in the field, keeping in mind that there are no comparative data. Some of the field evidence suggests that the findings are not entirely off the mark - but what may actually be needed is a range of options for accessing care - though the uptake of services clearly seem to be enhanced when provided in the context of comprehensive health services rather than at a dedicated ART clinic.19,20
Uebel et al. report on three programmes in southern Africa:21
McCord Hospital in Durban provides health care for staff free of charge at the staff clinic. All aspects of HIV care (including testing, CD4 monitoring and ART) are integrated with other comprehensive services provided at the staff clinic, including acute conditions and chronic conditions, such as TB. It is confidential for staff because it is separate from the general ART clinic.
Before institution of the programme, few staff (6 to 11 per year) were accessing VCT, but increasing numbers of staff have been accessing VCT every year since the programme started. There has been a great improvement in the morale and some staff members on ART have now disclosed their status to encourage others to undergo testing or start receiving treatment.
The programme also provides support groups for nurses to cope with the burden of providing care for dying patients, particularly adolescents and children.
Mseleni Hospital, a government-supported facility in a remote rural part of KwaZulu-Natal, also provides care, including HIV care and ART, for staff through the staff clinic, though some staff have chosen to obtain medical care through local private practitioners. Here, as well, staff have become increasingly willing to disclose their status to colleagues. However, uptake among non-caregiving staff (groundkeepers etc.) is still limited.
Tshedisa Institute in Gaborone, Botswana is a privately-funded ‘Wellness’ clinic offering comprehensive holistic care to healthcare providers that is within walking distance of the Princess Marina Hospital. Tshedisa means “to rejuvenate or give life” in Setswana. The programme focuses on healthcare workers with HIV as well as those who are affected by caring for people with HIV and who are experiencing stress, compassion fatigue, and burn-out. It “offers holistic health services, including one-on-one counselling, support groups, creative arts therapy (e.g. dance, yoga, visual arts, poetry, and creative writing), comprehensive HIV/AIDS testing and treatment, general medical check-ups, and a quiet garden for staff to enjoy,” according to Uebel et al. They also offer courses on stress management and cognitive behavioural therapy. Group counselling is also available for healthcare workers.
In a little over a year since opening, 204 healthcare workers have come in for HIV testing, 12% were found to be HIV-positive and 17 have started receiving ART.
Other wellness centres have been set up in Swaziland, Lesotho, Zambia (linked to the support groups mentioned earlier) and now Malawi. According to Tesfamicael Ghebrehiwet, of the International Council of Nurses, speaking at a session in Mexico City, these have been established in order to provide dedicated health services including HIV, TB, prevention, treatment and care; PEP; stress management; occupational safety training; capacity building; for healthcare workers and their families - all within the context of comprehensive care.
In Lesotho, these opened in November 2007 and have already reached more than 1300 healthcare workers with services and training. Training includes courses in stress management, behaviour change, PEP, WHO’s Integrated Management of Adolescent and Adult Illnesses and so on. They also provide ART, nurse counselling and wellness checks.
In Swaziland, a wellness clinic was set up in 2006 in the city of Manzini. According to presentations at the International AIDS Conference in Mexico, it focuses on offering healthcare providers comprehensive health services with counselling, HIV testing and other laboratory services, ART, TB and malaria clinics. Other services include skills building training, stress management, care and support programmes and recreation.
According to Ghebrehiwet, 6225 healthcare workers have been reached (77% of the total health workforce) and HIV testing and counselling has increased among health workers.
Wellness Centres have been heavily promoted, however, in a more recent report, researchers from the Swaziland Nursing Association and the Southern African Human Capacity Development Coalition conducted a survey that suggested that Wellness Centres may not meet every healthcare worker’s needs.22 The survey included 35 nurses, 50% of whom said that if they knew a colleague who was HIV-positive, they would advise her to go to another public or private facility for care. Twenty-five percent of them suggested that they get care at their own clinic, while only 20% of them recommended the Wellness Centre.
“Many said that there would be very few places where she would not know some of the health workers. This was echoed by many of those who advised her to stay at her local clinic, as there was really no place she could go for complete anonymity. This perceived lack of privacy was a pervasive theme, in part due to the fact that Swazi health workers are members of a small community with shared training and work environments in a small country,” the researchers noted.
The Wellness Centres may still be stigmatised, especially if the "well" never use them. Notably, participants in the survey felt that HIV services should be offered within the context of comprehensive services, and said that services were also needed for diabetes, hypertension and safe motherhood, along with counselling about HIV and stress.
These findings were shared with key stakeholders, and since that time 12 additional ‘Wellness Corners’ have been set up in facilities in the country, serviced by mobile services from the Manzini clinic.
The paper identified five key lessons learned:
- More needs to be done to address the unique aspects of HIV stigma among healthcare staff.
“A range of services needs to be provided, as no single facility or programme will be acceptable to all health workers. In Swaziland, the stand-alone Comprehensive Wellness Center should continue but should work with other providers to harmonize marketing and identify gaps in services. Health workers need a range of options in order to feel comfortable seeking HIV care.”
- Peer support groups should be considered to address the emotional and financial stresses health workers face.
- In order to be utilised and acceptable, services for health workers must be comprehensive and accessible.
- Data on health workers’ service use from all of these programmes should be monitored regularly (preserving confidentiality) to help to identify unmet needs.
While there may not be one ‘right’ way for health systems to begin to offer HIV services to their healthcare workers, it is important that programmes begin to be put in place. According to Uebel et al., formal policies must be put in place regarding the management of HIV/AIDS among staff in the workplace.23 The authors note that TB management continues to be a challenge, because treatment is generally only provided by separate TB clinics. However, health systems can reduce the burden of TB among their staff by offering IPT, improving TB infection control, and TB screening and diagnostic services. “Programmes to provide HIV care and treatment for healthcare workers are an urgent necessity,” Uebel et al. wrote. They recommend that health departments and hospitals perform anonymous surveys to assess the needs for care and treatment among their own staff, and then put in place a programme that is “convenient, holistic and integrated into one clinic”.