The perceptions and experiences of HIV testing service counsellors with providing HIV counselling and testing at three community sites in South Africa

Pretorius, Zuzelle
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Introduction HIV Testing Services (HTS) represents a critical entry point for reducing HIV risk through personalised counselling and testing (Colpin, 2006, Denison et al., 2008; Fonner, 2014). Despite the significant uptake of HTS since 2010, personal risk perception among South Africans remains low, with individuals continuing to engage in risky sexual behaviour (Statistics South Africa, 2017). This raises concerns about the quality and effectiveness of HTS in reducing HIV risk among HTS clients. In seeking to understand how best to strengthen HTS, lay counsellors who work at the forefront of HTS provision are primary targets for inquiry. This study sought to explore the experiences and perceptions of community-based HTS lay counsellors of providing HTS, the strategies they use to reduce HIV risk among diverse clients, and their perceptions of HTS training and supervision. Methods Qualitative semi-structured interviews were conducted with 12 community-based HTS counsellors at three government-accredited HTS sites in Gauteng and North West provinces. Ethical clearance was obtained in April 2015 and the interviews were conducted from July- October 2015. Interviews were audio-recorded, professionally transcribed, and coded using MaxQDA. Inductive and deductive thematic analysis was used to meet the study objectives. Results The HTS lay counsellors came from diverse personal and educational backgrounds. Their HTS training was not standardised, differing in scope, depth, and duration. Their sector influenced their scope of practice, remuneration and relationship with the Department of Health. HTS Counsellors tended to follow a client-centred approach to HIV counselling; balancing general HIV education with more tailored prevention counselling. Gender norms appeared to influence risk-reduction counselling, in which counsellors advised men to use condoms and women to be faithful to their partners. Counsellors resisted the notion of differential risk among HTS clients, and offered generic, simplified prevention messages tailored to clients‘ age and gender. Counsellors seldom explored known risk factors for HIV infection, such as alcohol and drug abuse, anal sex, and gender-based violence with clients. They prioritised post-test counselling for HIV-positive clients and tended to neglect post-test counselling for HIV-negative clients. . Counsellors recommended regular in-service training, enhanced supervision and debriefing, and formal recognition of the field through establishing standardised guidelines, career paths and a professional body. Discussion This study confirms previous research on the sub-optimal quality of risk-reduction counselling, which varies between sites and counsellors. Although HTS counsellors follow the nationally prescribed, client-centred approach, there is limited evidence that this approach effectively reduces HIV risk (Peltzer et al., 2013). In contrast, theory-based approaches, such as Motivational Behavioural Interviewing, which has effectively reduced unprotected sex, alcohol use before sex, number of sexual partners, and transactional sex among high risk groups globally and in South Africa (Petersen et al., 2014, Simbayi et al., 2004).were largely absent in HTS programmes covered in this study. The HTS lay counsellors in this study are among those who have contributed significantly to the rapid scale up of HTS in South Africa. However, they identified structural challenges detrimental to their work performance and motivation. HTS counsellors are not formally recognised or included within national human resources for health plans, and their job profiles and remuneration are not standardised. The inconsistent management and unfair treatment described by counsellors in this study has been reported across the country (Medecins Sans Frontieres, 2015). Conclusions The major recommendations that emerged from this study include the need for the government to create a supportive legal and policy framework to guide the integration of HTS counsellors into the formal health care system. This could happen by establishing a professional body for HTS counsellors and updating the minimum standards for HTS. Quality could be improved by training counsellors on use of individual and social theories of behaviour change (Petersen et al., 2014) and standardising HTS training curricula at national levels. Strengthening HTS vsupervision to ensure quality HTS counselling and testing nationally is also needed. Overall, this study confirmed that further research is needed to improve the quality of risk reduction interventions in HTS and develop a coherent framework for the integration of lay counsellors into the South African health and social service sectors.
A research report submitted to the Faculty of Health Sciences (School of Public Health), University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master in Public Health in the field of Social and Behaviour Change Communication 4 June 2019, Johannesburg
Pretorius, Zuzelle Changuion (2019) Perceptions and experiences of HIV testing service counsellors with providing HIV counselling and testing at three community-based sites in South Africa, University of the Witwatersrand, Johannesburg, <>