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Bridging the gap between VCT and HIV/AIDS treatment uptake: perspectives from a mining-sector workplace in South Africa Anil Bhagwanjee , Inge Petersen , Olagoke Akintola & Gavin George Published online: 11 Nov 2009.

To cite this article: Anil Bhagwanjee , Inge Petersen , Olagoke Akintola & Gavin George (2008) Bridging the gap between VCT and HIV/AIDS treatment uptake: perspectives from a mining-sector workplace in South Africa, African Journal of AIDS Research, 7:3, 271-279, DOI: 10.2989/AJAR.2008.7.3.4.651 To link to this article: http://dx.doi.org/10.2989/AJAR.2008.7.3.4.651

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African Journal of AIDS Research 2008, 7(3): 271–279 Printed in South Africa — All rights reserved

AJAR

ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/AJAR.2008.7.3.4.651

Bridging the gap between VCT and HIV/AIDS treatment uptake: perspectives from a mining-sector workplace in South Africa Anil Bhagwanjee1*, Inge Petersen1, Olagoke Akintola1 and Gavin George2 School of Psychology, Howard College, University of KwaZulu-Natal, Private Bag X54001, Durban, South Africa Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Private Bag X54001, Durban, South Africa * Corresponding author, e-mail: [email protected]

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This qualitative study sought to understand users’ perceptions of the voluntary counselling and testing (VCT) and HIV-treatment services offered by a mining company in South Africa, with the intention of making recommendations to improve the rates of uptake. A purposive sample of 75 employees was interviewed and three focus groups were conducted with VCT users as well as with HIV-positive employees currently enrolled in the company’s treatment programme. The relatively high uptake of VCT at the workplace appeared to be a function of the convenience afforded by rapid testing and the on-site nature of the company’s annual campaign, the group nature of the campaign, and increased HIV awareness facilitated by pre-test counselling. Notwithstanding this, the study revealed barriers to uptake of VCT in the workplace, including: perceived violations of confidentiality by healthcare staff and doubts about the voluntary basis of HIV testing; organisational factors, including the visible group nature of the VCT campaign; and fear of a HIV-positive result and discrimination in that event. In contrast to VCT uptake, there was a relatively low rate of enrolment in the treatment programme: a significant proportion of HIV-positive employees identified in the VCT campaign did not present to the company’s clinic for treatment. Impediments to treatment uptake included fears of being identified in the workplace as HIV-positive, which arose from perceived confidentiality violations on the part of the healthcare staff as well as organisational factors they believed allowed easy identification of the programme’s users; limited time to attend the clinic; poor quality of post-test counselling and follow-up; difficulties in coping with the diagnosis; and traditional explanatory models of illness, which precluded medical care. A combination of the current annual, opt-in VCT campaign and a provider-initiated opt-out approach to VCT should be carefully considered in order to bridge the gap between the current levels of VCT and HIV-treatment uptake by employees at the company. Keywords: company programmes, mining industry, prevention and control, private sector, programme planning and management, qualitative research, workplace

Introduction Voluntary counselling and testing (VCT) is understood to be an integral component of HIV-prevention programmes in South Africa (Kalichman & Simbayi, 2003) as well as in many other low- to middle-income countries with high HIV prevalence (Coovadia, 2000). While serving as a crucial precursor to HIV-treatment interventions for those individuals who are infected, VCT also serves as an entry point for helping uninfected individuals maintain their HIV-negative status. Recent evidence indicates that people who know their serostatus will reduce their risks or take measures to protect their sexual partners from infection (Coates, Richter & Caceres, 2008). Thus, VCT should be conceptualised along a continuum of HIV prevention and care, rather than merely as a means of screening for treatment. Thus, increasing the number of people who know their HIV status and providing counselling to assist both high- and low-risk groups are priorities for HIV-prevention efforts in southern Africa. The attractiveness of VCT as an intervention strategy is further enhanced because it is one of the

most cost-effective and economically viable strategies in response to HIV in Africa (Corbett, Dauya, Matambo, Cheung, Makamure, Bassett et al., 2006). The workplace is regarded as a favourable setting for the provision of VCT to reach men and women of reproductive age. In southern Africa, the mining and trucking sectors are particularly adversely affected by HIV, due in large part to the nature of the work, which demands that employees are away from their spouses/partners for long periods. This predisposes these employees to higher-risk sexual behaviour and, consequently, HIV infection (Weston, Churchyard, Mametja, McIntyre & Randera, 2007). In a survey of the HIV/AIDS programmes offered by 52 South African companies, Connelly & Rosen (2006) found that close to 50% of the companies offered VCT, particularly those in the mining and financial business sectors. Given that a provider-initiated opt-out approach to VCT can only be implemented by those companies who have clinic facilities and who regularly send their staff for medical screening, the most popular model for workplace VCT provision is the opt-in model where employees choose whether or not to

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participate in a VCT campaign. Connelly & Rosen (2006) reported that 75% of the companies surveyed made antiretroviral treatment (ART) available to their employees: 8 of 12 mining companies provided ART, primarily through the employer-provider model, with 90% of staff having access to company-sponsored HIV-treatment programmes. Despite the provision of VCT and HIV-treatment services, that same study reported that the rates of VCT and ART uptake were relatively poor across the companies surveyed. Comparative analyses of the effectiveness and efficacy of the different models of HIV-related care and treatment implemented by corporate entities is bedevilled by the fact that statistics on VCT uptake and HIV-treatment enrolment and adherence rates are rarely communicated by the providers or purchasers of these services. This is due to the confidential nature of these services and general reluctance to reveal the full extent of the burden of disease facing a company, since this could have negative ramifications for the investors, board, management and employees of the company (George, 2006). Notwithstanding this, a common challenge faced by private-sector workplace health-management programmes in southern Africa is the relatively low uptake of available VCT services, and the late uptake of HIV-related treatment services, in that employees often present for treatment in advanced stages of illness. Thus, despite sophisticated programme designs and substantive financial investments, many companies are not experiencing the anticipated gains from investing in VCT and treatment services (George, 2006). The empirical literature reveals a range of barriers to workplace VCT uptake (e.g. Ginwalla, Grant, Day, Dlova, MacIntyre, Baggaley & Churchyard, 2002) and workplace treatment enrolment (e.g. Charalambous, Grant, Day, Rothwell, Chaisson, Hayes & Churchyard, 2004), yet few studies have investigated workplace VCT uptake and treatment enrolment holistically along a single continuum (e.g. Day, Miyamura, Grant, Leeuw, Munsamy, Baggaley & Churchyard, 2003). This is despite evidence suggesting that knowledge of treatment availability after an HIV-positive test result is one of the primary reasons for VCT uptake (Feeley, Collier, Richards, Van der Borght & De Wit, 2007) — and despite increasing evidence concerning the importance of ART in reducing the chances of HIV transmission (Padian, Buve, Balkus, Serwadda & Cates, 2008). Set in one of the larger sites of a mining company in South Africa, the purpose of the present study was to develop an understanding of the issues and concerns facing employees with respect to the uptake of both VCT and HIV-treatment services offered by the company, with the intention of making recommendations to improve service delivery, and also to add to the body of evidence pertaining to the factors that impact on both VCT and treatment uptake within workplace settings. Methods Study site and context The study was conducted at one of the sites of a large mining company located in South Africa. At the time of the study, the employee population at the site comprised

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approximately 951 permanent employees, 250 temporary employees, and almost 1 600 contract workers. Over the previous eight years, the company, with the support of organised labour, had developed an integrated strategy for HIV/AIDS management across all their mining sites, which included policy, prevention and treatment initiatives. A full-time HIV/AIDS programme coordinator, backed by a team of two wellness coordinators, managed the HIV/ AIDS programme at the study site. The programme was supported by clinical staff, trade-union shop stewards, peer educators and management, who were all represented on the company’s HIV/AIDS task team. In terms of the mining company’s policy, VCT was available to permanent and temporary employees, contractors and their spouses/life partners, with treatment being effected through clinics based at the mining sites. The VCT programme at the study site took the form of annual VCT campaigns, which were outsourced during 2006 and 2007 to a local service provider from a neighbouring town. Unlike many other workplace VCT programmes — where all employees are encouraged to present themselves at a central venue — this company’s VCT service was taken to employees in their work units. Typically, pre-test counselling took the form of a group presentation, with HIV testing and post-test counselling being provided individually to those who chose to proceed with testing. A saliva-based rapid screening was conducted, followed by a confirmatory ELISA blood test for those who tested HIV-positive. Test results were presented immediately, backed by post-test counselling for both HIV-positive and HIV-negative individuals. HIV-positive employees were referred to the site’s company clinic for treatment. With regard to treatment, the mining site utilises the employer-provider model (see Connelly & Rosen, 2006), comprising a mixed model of internally financed and delivered HIV-related treatment and care supported by a closed medical aid scheme. The site clinic was staffed by a doctor and two full-time nurses. The clinic provides comprehensive medical services, including routine medical screening for all permanent employees. Thus, treatment for all HIV-positive individuals was delivered through this clinic, except that a separate funding arrangement pertained to contractor workers, as it was managed by an external service provider. While the mine clinic was tasked with HIV-related treatment delivery, both employees and contractors were free to also seek treatment through community service providers; this made case management difficult, especially in the cases of contractor workers who had varying contract lengths and thus periodically moved off to other sites. The 2007 VCT campaign at the mining company achieved an exceptional average uptake of 86% (83% of permanent and temporary employees and 90% of contractors had participated); this was in line with the previous year’s performance of 84% average VCT uptake. An enduring challenge, however, was a 5-year pattern showing that employees tended to enroll in the treatment programme only when they were in an advanced stage of illness. An average of 20% of employees who tested HIV-positive during the VCT campaigns over that period had not registered with the company-sponsored treatment programme. This rate

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resembles established trends in the private sector in South Africa (George, 2006). Sample A total of 75 participants were interviewed for the study. To begin, this comprised a non-probability sample of 42 employees from a cross section of job grades and occupational departments who volunteered to be interviewed during the August–September 2007 VCT campaign. Subsequently, a clinical cohort of mine employees receiving HIV-related treatment at the site’s company clinic was recruited and invited to participate in the individual interviews, with a total of 33 interviews conducted between October 2007 and February 2008. In addition, three focus groups were conducted with volunteers also participating in the VCT campaign in order to triangulate data sources. Data collection The fieldwork was conducted by a research team that was independent of the VCT service provider. A semi-structured interview schedule and focus group guide covered a range of issues, including individuals’ attitudes to HIV testing and treatment, attitudes toward the company’s VCT campaign and treatment services, reasons for testing for HIV, perceived benefits and barriers to using VCT or treatment services, and perceived quality of the VCT and treatment services. The interviews and focus group discussions were variously conducted in eight local languages by trained interviewers. Interviews were digitally recorded with permission of the respondents. The interviews in English were transcribed verbatim; the non-English interviews were translated into English and transcribed, with back-translation checks being applied by independent bilingual speakers. A workshop was held with mine stakeholders, where the preliminary results of the study were presented and validated through intensive discussion. Standard protocols were followed in securing ethical approval for the study from the University of KwaZulu-Natal, and in obtaining permission and informed consent from all relevant mine stakeholders as well as from all research participants. Data analysis Framework analysis (Ritchie & Spencer, 1994) was used to analyse the qualitative data. Although framework analysis was developed for qualitative data in applied policy research, it can be usefully applied to other contexts since it provides a systematic structure for analysis, allowing for a-priori and emergent codes to be used in the process. NVivo7 software for qualitative data analysis was used to apply the a-priori thematic framework from the interview schedule as well as to code new emergent themes. NVivo7 enables easy storage of and access to the raw data of interviews and discussions. Results In keeping with the aims of the study, the main findings from the analysis of the qualitative data are organised into two sections, namely VCT uptake and treatment uptake.

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VCT uptake The results in this section elucidate the employees’ attitudes towards VCT in general, and the factors they perceived as motivating or inhibiting employees’ uptake of VCT at the mine, including positive and negative aspects of the site-based VCT campaign. The participants’ attitudes towards an alternative provider-initiated model of VCT are presented, as well as a perceived need for family involvement in HIV testing. Employees’ attitudes towards VCT Most participants expressed a positive attitude towards VCT, with knowing one’s HIV status regarded as important in trying to stop the epidemic from spreading, as reflected in the following excerpt: ‘Yes, I think it is important because if people know that they are HIV-positive within three months they might stop spreading the disease, and they might have one partner, and also do it [sex] safely, and this is very, very important.’ Notwithstanding a generally positive attitude, a minority of participants still did not want to know their HIV status for fear of having to deal with the consequences: ‘…I don’t want to do the test because sometimes I might be [HIV-]positive and this is going to frustrate me and I will have a problem.’ Aspects of the site-based VCT campaign which motivated VCT uptake The participants identified several helpful aspects of the site-based campaign’s opt-in approach to organising VCT. Especially motivating for the participants were the use of an external service provider, the annual and routine groupbased nature of the campaign, the pre-test counselling sessions, and the convenience of having VCT available at the worksite. The use of an external service provider afforded users some level of confidentiality: ‘Ja. I don’t have a problem with them…the people come from outside, they don’t know me…I won’t see them again until maybe if they come again next year, I’ll see them again…. So it’s a good thing they bring people from outside….’ The annual and routine group-based nature of the VCT campaign appeared to play an important role in motivating people to test for HIV. Some participants indicated that they thought that testing was compulsory, while others felt that people would start to ask questions if they did not test, and yet others felt persuaded to test because everyone else was testing: ‘We do talk about this thing…[if you] say — Hey I am not going there — Hey…[they] look at you in another way…— Why does this person not want to go? It’s better you go, even if you don’t trust yourself, so that people don’t keep looking at you and thinking — Why does this person not want to go?’ ‘Because four or five do it, man, so the other three, four, say okay, let me also do it, you see, because it’s like…in a group structure, so you have to do it, you see? …Because if you are alone, you

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say ah…no, no, no, but in a group…you see that guy is tested, okay, I can go and test also….’ Pre-test counselling sessions emerged as useful in prompting employees to reflect on their risk behaviours and for creating awareness of the importance of knowing one’s HIV status for the benefit of their families: ‘…The [pre-test] counselling was good; it helped me a lot in deciding to go for a test…. I felt like I can handle it even though I didn’t know what to expect; I realised this is not about me, [it] is about people who live around me as well, my family at home.’ Running the campaign annually served to normalise VCT and increase employees’ self-efficacy with respect to HIV testing, as suggested by the following excerpt from a respondent who tested every year: ‘After 2002 I decided to start going for tests, so I can know my status; after getting that information I started going every year.’ An on-site-campaign rendered HIV testing more convenient and thus easier to undertake: ‘Yes, because since we are working we don’t have enough time to go to health centres for testing. So I think it is wise if they keep coming to us.’ Other factors motivating VCT uptake Participants mentioned other reasons for testing, which were not directly related to the company’s VCT campaign; these included compulsory testing for insurance purposes, personal illness or illness in the family, and having witnessed friends or relatives suffer with the disease. Also, the advent of VCT in the workplace appeared to have encouraged some employees to reflect on their risk behaviours and motivated them to test for HIV: ‘Yes, since I had my last child, I had affairs with four different people. I got worried when I heard the information [at pre-test counselling] and this made me come for testing every time.’ Aspects of the site-based VCT campaign which impeded VCT uptake Despite the campaign’s positive influences on HIV-testing uptake, the participants also expressed a range of concerns about the site’s VCT campaign. These included scepticism about the service provider’s ability to maintain users’ confidentiality, distrust regarding the company’s true motives for conducting the VCT campaign, and apprehension arising from the possibility of identifying colleagues who tested HIV-positive because of structural factors related to the way in which post-test counselling was conducted. Even though the use of an external service provider was considered helpful in assuring confidentiality, some participants were not convinced that the service provider did maintain confidentiality: ‘But my concern is the confidentiality part of VCT. They say that the results are confidential, but it’s worrying me. In the testing there are only two people, the counselor and the patient, but next time you hear people talking about the status of another person when he passes by…one day I was just with some guys at the shopping mall. When I

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was standing there I overheard them saying that — Do you see that guy who is passing there, he is HIV-positive. You wonder how they got the information because none of them works at the wellness programme. This shows that people who are testing us talk to others.’ This concern was accompanied by skepticism about the true aims of the company’s programme, with some participants believing that it was implemented to identify employees who were HIV-positive, so that they could be retrenched: ‘The company is looking to increase productivity… they want you to test so that they will be able to find other workers…the kind of forms they use for people to go for VCT — they even ask for the names, and this could discriminate. Based on that you can be distinguished because it could lead to that person.’ Another concern about the manner in which the VCT campaign was conducted related to the on-site nature of the campaign, which allowed employees to tell if a colleague had tested HIV-positive on the basis of the amount of time s/he had spent in the post-test counselling session, as well as the individual’s visible emotional response: ‘The problem is when we do the testing there are people who take long and there are those who take a short time. Those who take long are suspected of being infected and they took long because the VCT counsellors are trying to console them. And you can see those people who take long…are so stressed and no longer the same as before.’ Other factors inhibiting VCT uptake Fear of testing positive, denial, and anxiety arising from the possibility of being stigmatised by colleagues and community members also emerged as barriers to testing. A few participants indicated that they had not tested for fear of being HIV-positive: ‘I was scared, because I was thinking I might be having it, but I knew it wasn’t because of sex because I know what kind of a person I am; but I was scared because we work in the mines where we touch blood when we are injured.’ Additionally, denial affected some older employees and caused them not to test, as they perceived themselves to be invulnerable to HIV, viewing it as a problem for younger people: ‘Because what we are saying is, the youngsters are the ones who are, you know like, going to the pub, having more than one partner…[but] let’s say, my colleague here, he will say, errh…if he goes out and he meets another old lady, he will say — No, I know this old lady is not running around and, you know, like having a lot of boyfriends, so she is automatically negative, so I can sleep without a condom with this woman — that’s actually what I pick up amongst you know [the older men]…but the youngsters… AIDS and testing are for them.’ Notwithstanding the efforts of a cadre of peer educators and mine management’s obvious support for HIV testing in the workplace, the participants expressed concern about stigma and discriminatory treatment emanating from

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colleagues at work or from community members, which seemed to affect employees’ uptake of VCT: ‘…People don’t go for the test because of the stigma. The confidential part of it is important. Sometimes maybe people you work with will start discriminating against you because they know your status.’ ‘If people would know my status and if I go to their house and they give me a coffee, when I go they will break that cup. I am telling you the truth; especially here in our community…most people have been treated like that.’ Employees’ attitudes to provider-initiated VCT The majority of participants supported provider-initiated HIV testing among the workforce but stressed the need for it to be voluntary and for counselling to be provided. These participants suggested that integrating VCT into the general health service would increase VCT uptake because people would be less easily identified as HIV infected, and this might assist to normalise the disease: ‘Yes, I support that [provider-initiated VCT], because people think AIDS is more dangerous compared to other diseases…if it was treated normal like high blood pressure it [is] going to be better.’ Some suggested that integrating VCT and treatment for HIV and AIDS into general healthcare provision would facilitate access to treatment: ‘I think people who do not know their status are the ones who do not want to go for testing because they always think…how are they going to get it [their treatment] and who are they going to find there. Because you find that treatment is only on a specific day of the week and people are afraid to come forth and say today I must collect my medicine. It will help if it’s integrated, because we can assume that everybody came for his or her own problems and not specifically for HIV/AIDS.’ Employees’ need for family-based VCT and treatment services Several participants supported the idea of extending the company’s VCT and treatment programme to family members, given the probability that partners would also be infected if an employee were HIV-positive. However, while most permanent employees lived with their families in neighbouring ‘labour-supply’ communities, many contract workers occupied on-site company housing and were less likely to be living with their spouses and children, making family-based VCT and HIV-related treatment services difficult or more impractical for this group: ‘The programme should also involve people at home, the wife and kids. Because if you are positive the chances are there that your wife is also positive. So, I think the testing and medication programme should also cover those at home if they do not want to use the government programme.’ Some suggested that it might be easier if partners tested together: ‘Because you see, if I tested positive…we must hear it together, otherwise maybe I won’t have the guts to

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tell her. She [also] thought she won’t have the guts to tell me about her status, so that’s why we decided to go to test together.’ Treatment uptake Perceived violations of patient confidentiality Problems with the uptake of HIV-related treatment services provided at the mine appeared underpinned mainly by perceptions of confidentiality violations by the doctors and clinic staff. To exacerbate this, having specific clinic days for HIV patients and logistical difficulties in collecting medication privately allegedly made it easy to identify patients: ‘I think they are afraid that the public might notice them and that they have this problem, because people who have this problem are consulting a specific doctor. What can be done there is that they must be referred to any doctor available, not to a specified doctor. Most of us know them [the doctors] because we visit them regularly for different reasons. So we end up knowing that on this day a particular doctor deals with these kinds of people.’ Even if treatment was sought outside the company, in the local town, the ability of healthcare personnel to uphold users’ confidentiality still remained a concern: ‘The treatment — I can also go take it somewhere else, although it’s available here. I’d rather go to the doctor here in town, but it’s the same doctors coming to the mine…you see because we are a small community. If you do something tonight, I hear about it tomorrow…that guy did that. So what about my status, what will keep that a secret if the other stories come out like that?’ Difficulty in coming to terms with the diagnosis Despite the availability of free treatment provided by the company, many participants who had tested positive during the VCT campaign did not register for the company’s HIV-treatment programme. Difficulty in coming to terms with an HIV-positive diagnosis emerged as one reason for this, with some participants expressing doubt about the accuracy of the HIV test, choosing to repeat the test outside the mine setting: ‘I don’t want to accept that [the diagnosis], because others tell you that you are negative and others say that you are positive. So I still want to go and test somewhere else. It’s just my feeling right now, even though I know that what happened has happened.’ Others had difficulty with coming to terms with their diagnosis because it served as a reminder of their illness; thus they were reluctant to take up treatment: ‘I think that is because whenever they think of going for treatment they get reminded that they are sick. Think of a person who has killed someone and buried him secretly. Whenever you go past the area where you buried the person unknown to other people, other people will not feel stressed about the fact that someone has been buried there because they don’t know. Only the person who has killed and buried the person secretly will be the one suffering

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emotionally. It is just the same situation with those who have tested positive.’ This point was demonstrated in telephonic follow-up interviews with people who had refused to take up treatment after testing positive. Many had told the wellness team to stop calling them because they were trying to forget about the disease and that phoning them only served as a reminder that they were ill. Perceived poor quality of pre- and post-test counselling Pre- and post-test counselling is critical in preparing and assisting people to come to terms with an HIV-positive diagnosis as well as promoting treatment uptake. Both the location and limited time allotted for VCT services emerged as factors that impeded the quality of pre- and post-test counselling provided during the VCT campaign. In this regard, employees were given a short time to attend VCT and then had to return to work immediately thereafter. Moreover, cramped conditions at the mining site limited the physical space available for private HIV testing and post-test counselling. Thus, the burden of post-test counselling essentially fell on the clinical staff, as it occurred only when HIV-positive employees physically presented themselves at the clinic to register for treatment. One patient who had tested HIV-positive commented: ‘But the thing is after testing they just send you to the clinic without follow-ups as to whether you do go there or not…they should try and find out where you are staying in order to pay you a visit and ask how you are doing, because testing and leaving a person to himself is not enough…those people who are positive should not be ignored…they should also be given contact numbers just in case they don’t feel well.’ Notably, once a person exited the VCT set-up, it was difficult to initiate follow-up, either at the mine or at the person’s home, for fear of violating his or her confidentiality and exposing the individual’s HIV status. Other factors that made follow-up difficult included logistical ones (e.g. employees working underground were not allowed to have cell phones with them) and the mobility of contractor workers. Belief in traditional explanatory models of illness Another set of impediments to HIV-treatment uptake related to religious and traditional beliefs about using Western medicine; many of the participants, and some of their spouses, had visited a traditional healer for diagnosis and treatment of their condition: ‘Our people don’t believe much in tablets, more especially the followers of the ZCC [Zion Christian Church]. They believe in their own ways of dealing with sickness. It similarly applies to the people who believe in traditional medicine. It depends much on what one believes in.’ ‘There is one [traditional medicine] that I am taking. I don’t think it is dangerous to use it [traditional medicine], because I did not grow up taking tablets and I do not believe much in them.’

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Discussion Appraisal of the existing VCT and ART services The VCT campaign at the study site resulted in 86% uptake for 2007, which is remarkably higher than that obtained in many other South African companies (Connelly & Rosen, 2006). This success can be attributed to a number of factors, as revealed in the qualitative data. First, the on-site campaign and the use of rapid-testing made it convenient and easy for employees to participate in the programme. Likewise, other studies have suggested that on-site VCT facilities serve as a draw for programme uptake (e.g. Corbett et al., 2006). Furthermore, lack of accessibility and the need for individuals to return for their HIV-test result have been previously cited as limitations of VCT campaigns in workplace settings (e.g. Day et al., 2003). Second, the group nature of the VCT campaign appeared to harness peer influences that encouraged many employees to test for HIV. The responses suggest an element of coercion in this, however, with some participants indicating that they felt obliged to test because their colleagues were doing so or out of fear for what their colleagues would think if they did not test. While the ethics of such an approach is questionable, in that the individual’s freedom of choice is compromised by the need to conform to structurally induced social pressure — the group process, as well as the routine nature of the annual campaign, seemed to have helped normalise HIV testing at the mining site. The success of such an approach reinforces the notion that HIV-prevention campaigns in African contexts need to pay more attention to the role of group processes in facilitating health-enhancing social norms (Petersen, Mason, Bhana, Bell & McKay, 2006) given the dominance of communal value systems that are at odds with an exclusive focus on individual behavioural choices (Airhihenbuwa & Obregon, 2000). Third, the pre-test counselling information provided by the campaign emerged as useful for employees to consider the benefits of HIV testing. In a study of another mining community in South Africa, Charalambous et al. (2004) also found that pre-test counselling information on the importance of HIV testing helped improved VCT uptake. Notwithstanding the overall success of the annual workplace VCT campaign, several concerns emerged to help explain the non-uptake of VCT by 14% of the employees. A key concern among respondents was a perceived lack of confidentiality on the part of the mining company as well as the counsellors conducting the VCT programme. The visible on-site nature of the campaign purportedly undermined the possibility of keeping employees’ HIV-test results confidential. Underpinning this concern was a fear of stigmatisation and discrimination by colleagues, management or community members in the event of testing HIV-positive. These findings mirror those of several other studies within workplace, public-health and community settings (e.g. Ginwalla et al., 2002; Day et al., 2003; Wolff, Nyanzi, Katongole, Ssesanga, Ruberantwari & Whitwirth, 2005; Okonkwo, Reich, Alabi, Umeike & Nachman, 2007). A preference to take an HIV test with one’s partner also emerged as a reason for not using the company’s VCT

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services, similar to the findings of Feeley et al. (2007) in Rwanda. Given that HIV transmission is a dyadic event, VCT for couples is emerging as a key strategy for reducing HIV transmission in Africa. VCT for couples was shown to be effective in reducing HIV transmission, sexually transmitted diseases and unintended pregnancies in couples in both Zambia and Rwanda (Coates et al., 2008). The findings suggest the need for a range of practical interventions aimed at increasing participation in the company-sponsored VCT campaign, most notably efforts to assure confidentiality. Given the excellent platform that has been achieved with regard to the rate of VCT uptake at the study site, much is to be gained from additional efforts to reach the more than 10% of employees who annually have not participated in the VCT campaign since these individuals could constitute a higher-risk group in terms of their HIV status and risk behaviour. Despite that, an increase in VCT uptake alone may not narrow the significant gap between the number of employees who know their HIV-positive status and those who have enrolled in the company’s treatment programme. The ‘reason for being’ of workplace VCT/ART programmes is largely to reduce the financial burden of HIV infection to the company by keeping HIV-negative employees negative and HIV-positive employees healthy through the provision of treatment (Brink & Pienaar, 2007). ART is increasingly recognised as important to preventing HIV transmission as it reduces a person’s infectiousness (Padian et al., 2008). Reasons given for low uptake of the company-sponsored treatment programme include difficulty in coming to terms with the diagnosis, reticence to commit to lifelong treatment, and structural factors, such as exclusive clinic days for the treatment of HIV-positive employees. In addition, traditional explanatory models of illness were also cited as a reason for reluctant uptake of the treatment services. In addition, while the pre- and post-test counselling provided by the VCT service should assist employees to adjust to an HIV-positive diagnosis, the quality of this service was hampered by a number of logistical and practical problems that were a product of the on-site nature of the VCT campaign. A fundamental concern was employees’ fear of a lack of confidentiality on the part of the healthcare personnel at the company’s clinic. Healthcare personnel who worked for the company at the study site in fact lived in the same community as their patients and thus could be linked to the same social networks wherein they might reveal an individual patient’s HIV status. Provider-initiated opt-out VCT as an alternative model The provider-initiated opt-out model of VCT was supported by participants in this study who perceived it as possibly narrowing the gap between VCT uptake and treatment uptake. In effect, that model provides the opportunity for continuity of care by the same healthcare facility, from the moment of receiving one’s HIV-test result to being counselled about treatment options, to receiving HIV treatment and follow-up care. The provider-initiated opt-out model was suggested by the World Health Organization (WHO) (2003) as an alternate approach to the customary opt-in model, which

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places the burden of choice squarely with the individual, who must choose (typically in the face of a persuasive message campaign) whether or not s/he wants to know his/her HIV status and consequently whether to participate in VCT. As has been suggested previously, the group nature of the campaign under investigation raises questions about whether or not the decision to test for HIV was in fact located at the level of the individual. The WHO argues that, especially in contexts where the epidemic threatens national development and security, there is a need to move away from the opt-in model of HIV counselling and testing in favour of the opt-out approach, whereby a healthcare worker routinely recommends and conducts HIV testing for anyone who visits a healthcare facility, such that it effectively becomes “a standard component of care” (WHO, 2007, p. 19). This service operates on the principle that, after being fully informed and given pre-test counselling, clients must choose whether or not they want the HIV test, or opt-out of knowing their results. The provider-initiated opt-out model of VCT potentially presents a context in which users could get improved preand post-test counselling in a safe environment. Adequate pre- and post-test counselling requires expertise and time. This is especially true if a culture-centred approach is introduced, as it requires that traditional explanatory models of illness are explored and incorporated into the treatment plan through a process of ‘illness negotiation’ (cf. Katon & Kleinman, 1980). That approach could help assuage the socio-cultural impediments to HIV testing, such as emerged in this study and that have been widely reported in the literature (e.g. Charalambous et al., 2004; Okonkwo et al., 2007). However, a culture-centred approach has implications for the resourcing and organisation of health services, as the services must ensure that more time, expertise and personnel are provided for counselling, and that healthcare personnel are trained and orientated towards delivering this approach, despite the historically biomedical focus of their training. Greater spousal/partner involvement could also be facilitated by making regular medical check-ups available to partners of employees as well as allowing them to access the provider-initiated opt-out VCT services. This would help to ameliorate disclosure problems as well as increase partner and family support for employees’ treatment uptake and adherence, as supported by the findings of other studies (e.g. Feeley et al., 2007). This method is arguably superior to the company’s current approach to reach spouses and partners, which is to offer campaign-based opt-in VCT services at a community level in the hope of reaching the partners/spouses of the employees. Moreover, with the provider-initiated opt-out model, VCT-service-users testing HIV-positive would not have to secondarily decide to seek out treatment as they would already be patients in the healthcare system. Integrating VCT into the existing compulsory, annual medical check-up and healthcare provision at the mine could also potentially lessen employees’ fears of being identified as HIV-positive in the workplace, as people would be less easily identified as receiving treatment for HIV specifically. As indicated by some participants, this approach would also help

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de-stigmatise and normalise the disease since patients with HIV would be identified and treated in much the same way as patients with other chronic illnesses. Provider-initiated opt-out VCT has been supported by the results of other workplace studies; for instance, Day et al. (2003) have shown that the integration of VCT services into an occupational health centre was more favoured by employees because they perceived greater anonymity. From a company perspective, this model has also been associated with a decrease in overall healthcare costs (Forsythe, Arthur, Ngatia, Mutemi, Odhiambo & Gilks, 2002). Impediments to the success of the provider-initiated opt-out model include reservations about confidentiality on the part of healthcare personnel, which emerged as a central concern in this study. Rennie & Behets (2006) maintain that this model is problematic in situations where discrimination and stigma are still attached to HIV, and they raise concerns about implementing this model in low- to middle-income countries since it presupposes knowledge or awareness of HIV and AIDS by patients attending a clinic or other health facility. The unequal power relations that characterise the patient-healthcare-provider relationship, and which can result in a patient feeling obliged to agree to the healthcare worker’s suggestion to undergo HIV testing, is also an ongoing concern (Rennie & Behets, 2006). Caution has also been advised with regard to resources, in that a sufficient complement of staff, with adequate time and energy to ensure high quality counselling, need to be available (Charalambous, Innes, Muirhead, Kumaranayake, Fielding, Pemba et al., 2007). Recommendations In the context of high participation rates in the mining company’s on-site opt-in VCT campaign, the implementation of a provider-initiated opt-out model of VCT at the study site needs to be approached with caution: it is unclear what effect this approach would have on the exceptional rates of VCT uptake achieved after years of effort by all stakeholders. However, the relatively low rate of HIV-treatment uptake at the study site demands that the company take steps to close the gap between the numbers of employees using VCT and those on treatment if the full benefits of the companysponsored programme are to be harnessed. In doing so, a complex set of choices needs to be negotiated with all stakeholders concerned. Adopting and evaluating a combination of opt-in and provider-initiated opt-out VCT approaches, whereby the company’s clinicbased treatment services are added as a final step in the opt-in VCT campaign for employees who test HIV-positive, may assist in lessening some of the barriers to treatment uptake identified in this study. This would also obviate the problem of HIV-positive employees having to make the additional decision to attend the company’s clinic for treatment, since the treatment services would be integrated as a final step in the VCT programme. This would also afford opportunities to improve the quality of post-test counselling, which was found to be a shortcoming in this study, and provide the opportunity for the inclusion of culture-centred healthcare.

Bhagwanjee, Petersen, Akintola and George

Acknowledgements — We acknowledge the financial support of Merck & Co., Inc. and the assistance and cooperation afforded to us by the mining company and the study participants.

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AIDS treatment uptake: perspectives from a mining-sector workplace in South Africa.

This qualitative study sought to understand users' perceptions of the voluntary counselling and testing (VCT) and HIV-treatment services offered by a ...
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