Antiretroviral therapy adherence counselling practice in primary healthcare facilities in the City of Tshwane, Gauteng, South Africa

Abstract

South Africa’s growing HIV treatment programme is integrated into primary healthcare services, thus improving access for people living with HIV. However, there are mounting concerns regarding adherence, as less than half of clients are retained on antiretroviral therapy (ART) 60 months after initiation. Adherence counselling is one of five key strategies in the Adherence Guidelines for HIV, TB and NCDs: Policy and service delivery guidelines for linkage to care, adherence to treatment and retention in care, which were developed in 2016 to standardise and improve adherence approaches. While client perspectives on factors affecting adherence have been well-researched, there is limited literature on practice among professional nurses implementing nurse-initiated management of antiretroviral therapy (NIMART). Moreover, little is known about the factors affecting quality service provision, particularly from the perspective of healthcare providers implementing NIMART. Consequently, this study aimed to explore ART adherence counselling practice by professional nurses in five primary healthcare clinics in the City of Tshwane. Study objectives included discussing the context of ART adherence counselling practice, describing ART adherence counselling practice from the perspective of the professional nurses, analysing the reported adherence counselling practice in relation to the national Adherence Guidelines, and discussing factors that influence the professional nurses’ provision of ART adherence counselling. Methods The study employed a qualitative research approach, applying a cross-sectional exploratory design. Five primary healthcare clinics located in the City of Tshwane in Gauteng province, South Africa, were selected, with two in suburban areas, two in townships, and one in the inner city. In-depth interviews were conducted with 10 professional nurses at these facilities (two at each facility), who were purposively sampled based on experience and availability. The in-depth interviews were transcribed and a codebook developed through deductive and inductive coding of data, which was applied to facilitate thematic analysis. This data was compared to the Adherence Guidelines’ fast-track initiation counselling using a table with section headings to assess similarities and differences. Results Due to perceived lay counsellor unavailability or inadequate capacity, the professional nurses reported that they provide adherence counselling themselves, consisting of education on HIV, ART and the treatment process; addressing side effects; medication scheduling; and reminders. They employ simple, appropriate language and supportive attitudes to build client rapport. In addition, they address behaviours (substance use, traditional and alternative medication use, iv

and diet) which can affect adherence, explaining how these behaviours may affect treatment efficacy and viral load through drug interactions and hindering absorption of the antiretrovirals (ARVs). While messaging is largely didactic, the professional nurses support clients to adopt their guidance related to these behaviours, including facilitating disclosure through re-testing with clients’ partners. In the absence of official job aids, they create their own analogies using everyday examples and props to explain complex concepts such as viral suppression. The professional nurses’ adherence counselling practice is comparable to that outlined in the Adherence Guidelines, particularly in terms of messaging, counselling methods, roles, and parameters (frequency, time, and duration). While the professional nurses are confident in their ability to provide counselling following NIMART training, supportive interventions are appreciated, including additional human resources provided by District Support Partners and collaboration with service providers such as Ward-based Primary Healthcare Outreach Teams (WBOTs). System-related improvement measures yield mixed results: integration of HIV care into clinic services and rotation of nurses through various service areas has reduced stigma, but hinders continuity of care. Similarly, the appointment system helps manage workload, but can discourage client access. On the other hand, staff shortages, unrealistic daily consultation targets, and clients’ clinic preferences limit the professional nurses’ time to provide adherence counselling and compromise quality of care. Health facility location affects the feasibility of adherence interventions such as support groups, as well as the extent of assistance from other government and community-based service providers. Client understanding and cooperation are important, with the professional nurses acknowledging the powerful influence of social, economic, and cultural factors, which can undermine adherence. Discussion and recommendations While the professional nurses reported that their adherence counselling practice does address social, economic, and cultural factors relevant to their clients’ context, messaging related to the direct effect of specific behaviours on treatment efficacy and viral load go beyond findings in existing literature. This indicates a need to specify and standardise core adherence counselling messaging. Measures to improve HIV care such as system adaptations and support structures, and better use of existing resources such as lay counsellors and WBOTs, can contribute towards improving professional nurses’ adherence counselling practice. However, it is important to ensure that these adaptations do not inadvertently undermine adherence behaviour. The differences identified between reported practice by the professional nurses and the Adherence Guidelines – in terms of messaging, counselling methods, roles, and parameters – can play a valuable role in the revision of the guidelines and preparation for national rollout Conclusion As the number of people on ART in South Africa grows, nurses will likely continue to be the main providers of clinical HIV services, including adherence interventions. By exploring adherence counselling practice by professional nurses in primary healthcare settings, this study hopes to provide insight into areas of strength as well as those requiring improvement, particularly in light of the future implementation of the Adherence Guidelines to build on and enhance efforts to promote client adherence and retention in care.