Counselling and testing for HIV/AIDS among TB patients in the Free ...

Counselling and 

testing for HIV/AIDS 

among TB patients 

in the Free State 

Fact-finding research to inform intervention 

Christo Heunis 

Michelle Engelbrecht 

Gladys Kigozi 

Anja Pienaar 

Dingie van Rensburg

Counselling and 

testing for HIV/AIDS 

among TB patients 

in the Free State 

Fact-finding research to inform intervention 

Christo Heunis 

Michelle Engelbrecht 

Gladys Kigozi 

Anja Pienaar 

Dingie van Rensburg

© Centre for Health Systems Research & Development 2009 

Published by the Centre for Health Systems Research & Development 

University of the Free State 

PO Box 339 

Bloemfontein 

9300 

ISBN 978-0-86886-778-5 

Electronic version available at: www.ufs.ac.za/tbhctreport 

Acknowledgements 

The following institutions and persons are gratefully acknowledged for: 

Funding and support 

Department for International Development (DfID, UK); National Research Foundation (NRF); University of the Free 

State (UFS); American International Health Alliance (AIHA) funded by Centers for Disease Control and Prevention 

(CDC, USA) through the US President’s Emergency Plan for AIDS Relief (PEPFAR); State University of New York 

(SUNY) Downstate Medical Center 

Authorisation and support of the project 

Free State Department of Health (FSDoH), FSDoH TB Control Programme, 

FSDoH HIV&AIDS/STI/CDC Programme 

Participation in interviews 

TB patients, lay counsellors, DOT supporters, nurses, doctors, facility and line managers 

Project and financial management 

Prof Dingie van Rensburg, Francois Steyn, Belinda Jacobs 

Domain experts 

Profs Helen Schneider, Herman Meulemans, Yvonne Botma, Drs David Coetzee, 

Henriëtte van den Berg, Perpetual Chikobvu 

Fieldwork management 

Dr Michelle Engelbrecht, Prof Christo Heunis, Hlengiwe Hlophe, Gladys Kigozi, Mosilo Machere, 

Anja Pienaar, Leona Smith 

Translation/interviews with community health workers 

Nomfazwe Thomas, Palesa Tlali, Jo-Ann Sejanamane 

Interviews with TB patients 

Teboho Kele, Mosele Khateane, Moeketsi Koalane, Dinah Masindwa, Dimakatso Masiteng, 

Ragel Modise, Patrick Mofokeng, Dineo Mutlanyane, Ishmael Ponoane, Rose Ramathe, 

Alphonsina Ramolahlehi, Hilda van Wyk 

Data gathering for TB-HIV information system appraisal 

Leona Smith 

Data capturing and information management 

Hannes van Biljon, Gerhardus Drinkrow, Jana Els, Willemien Heunis, Nomfazwe Thomas, Palesa Tlali 

Secretary 

Heila Oelofse, Bridget Smit 

Report technical layout and cover design 

Liezel Meintjes

Abbreviations 

AIDS 

Acquired immunodeficiency syndrome 

ART 

Antiretroviral treatment/therapy 

ARVs 

Antiretroviral drugs 

CCMT Comprehensive Care, Management and Treatment 

CHWs Community health workers 

CPT 

Cotrimoxazole preventive therapy 

DOT 

Directly observed treatment (TB) 

DOTS Directly observed treatment strategy (TB) 

DTC 

Diagnostic testing and counselling (HIV) 

FHI 

Family Health International 

FSDoH Free State Department of Health 

HAST HIV&AIDS/STI/TB 

HBCs High-burden countries (TB) 

HCT 

HIV counselling and testing 

HTC 

HIV testing and counselling 

HIV 

Human immunodeficiency virus 

IEC 

Information, education, communication 

IPT 

Isoniazid preventive therapy 

ISDS 

Initiative for Sub-district Support 

MDR 

Multi-drug resistant (TB) 

MDGs Millennium Development Goals 

NDoH National Department of Health (RSA) 

NGO Non-governmental organisation 

NSP HIV & AIDS and STI National Strategic Plan, 2007-2011 

NTCP National Tuberculosis Control Programme 

PALSA Plus Practical Approach to Lung Health and HIV/AIDS in South Africa 

PHC 

Primary health care 

PHWs Professional health workers 

PICT 

Provider-initiated counselling and testing (HIV) 

PITC 

Provider-initiated testing and counselling (HIV) 

PLWHA People living with HIV/AIDS 

PMTCT Prevention of mother-to-child transmission (HIV) 

PN 

Professional nurse 

R&D 

Research and Development 

ss+ 

Sputum smear – positive 

ss- 

Sputum smear – negative 

TB 

Tuberculosis 

UNAIDS Joint United Nations Programme on HIV/AIDS 

VCT 

Voluntary counselling and testing (HIV) 

VCCT Voluntary confidential counselling and testing (HIV) 

WHO World Health Organization 

XDR 

Extensively drug resistant (TB)

Executive summary 

Introduction and background (Section A) 

TB patients’ uptake of HIV counselling and testing 

(HCT) is affected by a wide variety of health systems/ 

services-related and patient/community-related factors. 

This research set out to explain comparatively low rates 

of HCT among TB patients in Lejweleputswa and Thabo 

Mofutsanyana Districts in the Free State Province. By 

interviewing patients, community health workers, front-line 

providers and health managers this “fact-finding” research 

sought to identify and illuminate barriers to and facilitators 

of uptake of HCT by TB patients. 

TB-HIV/AIDS co-epidemic (Section B) 

The rapid rise in HIV infection in sub-Saharan Africa in 

the past two decades has caused serious problems in TB 

control and has been accompanied by an up to fourfold 

increase in the number of TB cases registered by national 

TB control programmes. The epidemic of HIV-associated 

TB continues to grow and drive global incidence rates 

upwards. Antiretroviral treatment (ART) provision is still 

very limited and there is not yet a successful strategy to 

reduce TB incidence in high HIV-prevalence countries. 

Policy review (Section C) 

A range of international and national policies call for 

(i) integration of TB and HIV services and (ii) increased 

HCT among clients suspected for or diagnosed with TB. 

The WHO (2004) recommends that TB and HIV disease 

control programmes should incorporate testing, diagnosing, 

treatment and care for both diseases. The South African 

NSP, 2007-2011 and TB Strategic Plan, 2007-2011, echo 

these recommendations. Although the policy shift from 

voluntary counselling and testing (VCT) to providerinitiated 

testing and counselling (PITC) has also evoked 

critical reactions, it is widely advocated especially in the 

case of TB patients. The policies are clear and the challenge 

now is to put PITC for TB patients into effect. 

HIV counselling and testing (HCT) of TB patients 

(Section D) 

Universally, since 2003 there has been a threefold increase 

in both HIV testing of TB patients and detection of TB-HIV 

co-infection. However, total coverage of HIV testing and 

counselling is still very low. In 2006, globally only about 

12% and nationally only 22% of TB patients were tested for 

HIV. In 2007, the corresponding figures for Lejweleputswa 

and Thabo Mofutsanyana were respectively 32.4% and 

37.9%. The provincial HIV testing rate among TB patients 

was 43.1%. 

Fact finding: TB patients (Section E) 

As with the other interest groups surveyed in the factfinding 

research, the objective was to identify perceived 

facilitators of and barriers to uptake of HCT by TB 

patients (n=600). The research identified self-reported 

indecisiveness about undertaking HCT as an important 

deterring factor to uptake of HIV testing by TB patients. 

Fear of stigmatisation and HIV-positivity was also 

observed to demotivate HCT uptake. Patients were also 

discouraged from taking up HCT due to first wanting to 

deal with the burden of TB. The major health systemsrelated 

factor dissuading patients from accessing HCT was 

that patients reportedly had not been advised to do so at 

the TB treatment facility. Overall, uptake of HCT among 

TB patients was motivated especially by the provision 

of information on the link between TB and HIV. The TB 

patient respondents also indicated a need for both facility 

and community-based support systems to aid their HCT 

decision-making process. 

Fact finding: community health workers (CHWs) 

(Section F) 

Given the dire shortage of qualified health professionals 

in South Africa, public health services rely on CHWs 

in their response to the TB and HIV/AIDS epidemics. 

Especially since the commencement of ART rollout in 

2004, the reliance on CHWs has increased and they 

have also become more multi-skilled. The interviewed 

CHWs (total, n=97) included lay counsellors and directly 

observed treatment (DOT) supporters. Analysis shows 

that the CHWs perceived TB patients’ fear of HIV and/ 

or TB-HIV, as well as their fear of stigmatisation should 

they test HIV-positive, to be the most important barriers 

to HCT uptake. Hence, the most often voiced suggestion 

to facilitate HCT among TB patients was that the patients 

should be continuously encouraged and motivated. 

Essentially, this means that health workers should engage 

with patients about their fear of HIV-positivity, TB-HIV coinfection 

and death. TB patients should thus be informed 

(especially by doctors and nurses) of the preventive and 

prognostic advantages of early HIV/AIDS diagnosis. 

Fact finding: professional health workers (PHWs) 

(Section G) 

In PITC, the onus is on PHWs to offer HCT to all TB 

patients. If the patient refuses HCT, the PHW has numerous 

opportunities during the course of TB treatment to reemphasise 

the importance of and re-offer HCT. A total of 

81 PHWs including clinic and hospital managers, and nurses 

and doctors working in the TB and HIV&AIDS programmes, 

were interviewed. The PHW survey highlighted numerous

factors that hinder patients from going for HCT: human 

resource shortages, lack of relevant training, inadequate 

space, and extended waiting times. Also, patients’ fear of 

the stigmatisation that is perceived to accompany an HIVpositive 

diagnosis was emphasised by nurses as a barrier 

to uptake of HIV testing. Of particular concern was nurses’ 

view that patients often do not trust lay counsellors and 

prefer to be counselled by nurses. On the positive side, 

by far most responses suggested that PHC facilities and 

nurses played an important role in encouraging TB patients 

to access HCT. This survice was available weekdays at all 

fixed clinics and hospitals. Reportedly, the majority of TB 

patients were referred for HCT, generally at diagnosis of 

TB. A key strategy to motivate all TB patients to go for 

HCT was to re-offer this service at each visit. 

Fact finding: programme line managers (Section H) 

Given their control of managerial resources such as budgets, 

personnel and support services, public health managers 

exert substantial bureaucratic power in the introduction 

of new policies. There is, however, a lack of literature on 

TB and HIV/AIDS line managers’ views on new policies 

for integration of these programmes and introduction of 

PITC. Again this interest group was asked to identify and 

explain perceived barriers to and facilitators of uptake of 

HCT by TB patients. Summarily, and in order of importance, 

the main factors thought to hinder TB patients from going 

for HCT were fear of stigmatisation, lack of infrastructure 

and the unavailability and high workload of health care 

workers. The three most important factors thought to 

facilitate uptake of HCT were clarification and assignment 

of specific roles and/or task shifting, improved training, and 

improved counselling. 

Fact finding: TB-HIV information system (Section I) 

Despite investments and efforts in the Free State to improve 

the IT used to gather TB and HIV&AIDS programme data, 

the fact finding research found 21% inconsistency between 

facility and province-based data for the same patient in 

respect of seven indicators/data items. Nevertheless, half 

of the TB coordinating nurses interviewed (n=20) did not 

perceive the TB-HIV information system to be problematic. 

The remaining half pointed especially to problems related 

to staff shortages, lack of training, “too many forms”, and 

the difficulty to keep track of patients. The main suggested 

improvements to the TB-HIV information system was to 

(i) increase TB staff, (ii) provide improved/more TB-HIVrelated 

IEC to patients and communities, and (iii) have a 

single/integrated information system for both the TB and 

the HIV&AIDS programmes. 

Fact finding: district feedback workshops (Section J) 

Attendees at the five district-level feedback workshops held 

after the fact-finding research was completed responded 

favourably to the study and its findings, and all expressed 

an interest in having interventions piloted in their districts. 

The main suggestions for improving TB patients’ uptake 

of HCT included: appointment of additional staff; training 

of staff on the integrated management of patients with 

TB and HIV/AIDS; ensuring that a comprehensive TB-HIV/ 

AIDS service is provided at all facilities; provision of health 

education focusing on the link between TB and HIV/AIDS 

to all TB patients; actively practice PITC for TB patients; 

support from managers for health care workers; and 

collaboration between facilities and their communities on 

TB-HIV/AIDS-related activities. 

Conclusions and way forward 

In light of the fact-finding results, the current study 

recommends the following towards scale-up of HCT and 

PITC among TB patients: 

• Intensify dissemination of information on the link 

between TB and HIV. 

• Motivate and support patients in the HCT decisionmaking 

process. 

• Especially target males, patients newly diagnosed with 

TB, employed and married patients. 

• Improve counsellors’ training and skills and manage, 

support and monitor their work. 

• Encourage disclosure of HIV status by TB-HIV coinfected 

patients and involve them in motivating other 

TB patients to test for HIV in order to reap the same 

benefits from integrated care, treatment and support. 

The fact-finding research results have been presented 

to and become part of the contemplations of a steering 

group which will develop, implement and evaluate the 

impact of a multifaceted intervention (Part II of the overall 

project) suitable for the conditions in the Free State, but 

also with wider application potential. This group includes 

domain experts, the collaborating FSDOH provincial and 

district-level TB and HIV&AIDS programme managers, as 

well as the CHSR&D researchers responsible for this factfinding 

research.

CONTENTS 

Section A Introduction and background 

A1 Introduction........................................................................................................................................................................................................................1 

A2 Fact-finding design and methods...........................................................................................................................................................................1 

A3 Study areas: Lejweleputswa and Thabo Mofutsanyana..............................................................................................................................1 

A3.1 Population and age distribution..............................................................................................................................................................................2 

A3.2 Poverty..................................................................................................................................................................................................................................3 

A3.3 Per capita expenditure on PHC.............................................................................................................................................................................3 

A3.4 Nurse workload ..............................................................................................................................................................................................................3 

A3.5 Clinic supervision............................................................................................................................................................................................................3 

A3.6 PHC service utilisation.................................................................................................................................................................................................3 

A4 Summary characterisation of study areas.........................................................................................................................................................4 

Section B TB-HIV/AIDS co-epidemic 

B1 Introduction........................................................................................................................................................................................................................4 

B2 TB-HIV/AIDS: global......................................................................................................................................................................................................4 

B3 TB-HIV/AIDS: South Africa .......................................................................................................................................................................................5 

B4 Discussion and conclusion.........................................................................................................................................................................................6 

Section C Policy review 

C1 Introduction........................................................................................................................................................................................................................6 

C2 International policies .....................................................................................................................................................................................................6 

C2.1 WHO interim policy on collaborative TB/HIV activities........................................................................................................................6 

C2.2 WHO/UNAIDS guidance on provider-initiated HIV testing and counselling (PITC)..........................................................7 

C3 National policies..............................................................................................................................................................................................................7 

C3.1 Operational Plan for CCMT.....................................................................................................................................................................................7 

C3.2 National Tuberculosis Control Programme Practical Guidelines.........................................................................................................8 

C3.3 National HIV and AIDS and STI Strategic Plan for South Africa (NSP), 2007-2011...............................................................8 

C3.4 Tuberculosis Strategic Plan for South Africa, 2007-2011.........................................................................................................................8 

C4 Discussion and conclusion.........................................................................................................................................................................................8 

Section D HIV counselling and testing (HCT) of TB patients 

D1 Introduction........................................................................................................................................................................................................................8 

D2 HCT among TB patients – Global.........................................................................................................................................................................8 

D3 HCT among TB patients – South Africa............................................................................................................................................................9 

D4 HCT among TB patients – Free State.................................................................................................................................................................9 

D5 Factors associated with TB patients’ uptake/non-uptake of HCT.......................................................................................................9 

D6 Discussion and conclusion......................................................................................................................................................................................11 

Section E Fact finding: TB patients 

E1 Introduction ...................................................................................................................................................................................................................11 

E2 Aim and objectives .....................................................................................................................................................................................................12 

E3 Methods and sampling..............................................................................................................................................................................................12 

E3.1 Population ........................................................................................................................................................................................................................12 

E3.2 Fieldwork..........................................................................................................................................................................................................................12 

E3.3 Instrument and data collection............................................................................................................................................................................12 

E3.4 Data analysis ...................................................................................................................................................................................................................12 

E4 Findings ..............................................................................................................................................................................................................................13 

E4.1 Sample description......................................................................................................................................................................................................13 

E4.2 Patient category, type of TB, sexual activity, self-reported HIV testing..........................................................................................14 

E4.3 Patients’ knowledge about TB and HIV...........................................................................................................................................................14 

E4.4 Patients’ perception of AIDS as a community problem.........................................................................................................................15 

E4.5 Patients’ knowing/not knowing someone living with HIV.....................................................................................................................15 

E4.6 Patients’ self-perceived risk for HIV...................................................................................................................................................................16

E4.7 Patients’ HIV testing and sexual risk-reduction practices......................................................................................................................16 

E4.8 Patients’ experience of HCT and counsellors of different types......................................................................................................17 

E4.9 Association of patient characteristics with self-reported HIV testing...........................................................................................19 

E4.10 Patients’ suggestions of how health care workers can encourage uptake of HCT ...............................................................19 

E4.11 Patients’ suggestions of how others can encourage uptake of HCT.............................................................................................20 

E4.12 Patients’ suggestions of factors that discourage uptake of HCT ......................................................................................................20 

E4.13 Predictors of HIV testing.........................................................................................................................................................................................21 

E5 Discussion and conclusion......................................................................................................................................................................................21 

Section F Fact finding: community health workers (CHWs) 

F1 Introduction.....................................................................................................................................................................................................................23 

F2 Methods and sample..................................................................................................................................................................................................24 

F3 Findings ..............................................................................................................................................................................................................................25 

F3.1 CHWs’ views on barriers to HCT uptake by TB patients ...................................................................................................................25 

F3.2. CHWs’ views on facilitators of HCT uptake by TB patients...............................................................................................................26 

F4 Discussion and conclusion......................................................................................................................................................................................27 

Section G Fact finding: professional health workers (PHWs) 

G1 Introduction.....................................................................................................................................................................................................................27 

G2 Methods and sample..................................................................................................................................................................................................28 

G2.1 Sampling of facilities and respondents.............................................................................................................................................................28 

G2.2 Instrument........................................................................................................................................................................................................................28 

G2.3 Data gathering and analysis....................................................................................................................................................................................28 

G3 Findings ..............................................................................................................................................................................................................................28 

G3.1 PHWs’ views on human resources for HCT...............................................................................................................................................28 

G3.2 PHWs’ views on operating hours ......................................................................................................................................................................29 

G3.3 PHWs’ views on space and location.................................................................................................................................................................29 

G3.4 PHWs’ views on waiting times.............................................................................................................................................................................29 

G3.5 Nurses’ views on patients’ satisfaction with lay counsellors................................................................................................................30 

G3.6 PHWs’ views on problems experienced with HIV counselling.........................................................................................................30 

G3.7 PHWs’ views on factors discouraging and encouraging uptake of HCT.....................................................................................31 

G4 Discussion and conclusion......................................................................................................................................................................................33 

Section H Fact finding: programme line managers 

H1 Introduction.....................................................................................................................................................................................................................33 

H2 Methods and sample..................................................................................................................................................................................................33 

H3 Findings ..............................................................................................................................................................................................................................34 

H3.1 Line managers’ views on the barriers to uptake of HCT by TB patients ....................................................................................34 

H3.2 Line managers’ views on the facilitators of uptake of HCT by TB patients................................................................................35 

H4 Discussion and conclusion......................................................................................................................................................................................37 

Section I Fact finding: TB-HIV/AIDS information system 

I1 Introduction.....................................................................................................................................................................................................................37 

I2 Methods and sample..................................................................................................................................................................................................38 

I3 Findings ..............................................................................................................................................................................................................................38 

I3.1 Inconsistencies between facility-based and provincial-level data......................................................................................................38 

I3.2 TB coordinating nurses’ views on problems with TB-HIV/AIDS information system...........................................................39 

I3.3 TB coordinating nurses’ suggestions on how to improve TB-HIV/AIDS information system 

in respect of management of TB patients......................................................................................................................................................39 

I3.4 TB coordinating nurses’ suggestions on how to improve TB-HIV/AIDS information system 

in respect of management of TB/HIV patients............................................................................................................................................39 

I3.5 TB coordinating nurses’ indication of usefulness of TB-HIV/AIDS information system.......................................................39 

I4 Discussion and conclusion......................................................................................................................................................................................39 

Section J Fact finding: district feedback workshops 

J1 Introduction.....................................................................................................................................................................................................................40 

J2 How to improve TB patients’ uptake of HCT: health care facilities ................................................................................................40 

J2.1 Hospitals ...........................................................................................................................................................................................................................40

J2.2 Fixed clinics......................................................................................................................................................................................................................40 

J2.3 Mobile clinics ..................................................................................................................................................................................................................41 

J3 How to improve TB patients’ uptake of HCT: managers......................................................................................................................41 

J3.1 Provincial and national managers........................................................................................................................................................................41 

J3.2 District and subdistrict managers.......................................................................................................................................................................41 

J3.3 Facility managers ..........................................................................................................................................................................................................41 

J4 How to improve TB patients’ uptake of HCT: health care workers...............................................................................................41 

J4.1 Nurses................................................................................................................................................................................................................................41 

J4.2 Community health workers...................................................................................................................................................................................41 

J5 How to improve TB patients’ uptake of HCT: communities...............................................................................................................41 

J6 How to improve TB-HIV/AIDS: information system ...............................................................................................................................42 

J7 Discussion and conclusion......................................................................................................................................................................................42 

Section K Recommendations and way forward 

REFERENCES .......................................................................................................................................43 

List of tables 

Table A1 Population by age group (years) – districts, Free State (2001).......................................................................................................2 

Table A2 Population change – Lejweleputswa, Free State (1996-2001)........................................................................................................3 

Table A3 Summary characteristics – districts.................................................................................................................................................................4 

Table C1 WHO-recommended collaborative TB/HIV activities .........................................................................................................................7 

Table D1 Factors associated with uptake/non-uptake of HIV testing – global (1995-2008)...........................................................10 

Table E1 TB patient sample – districts, total ...............................................................................................................................................................13 

Table E2 Patients’ occupations – districts, total..........................................................................................................................................................13 

Table E3 Patient category, type of TB, sexual activity, HIV testing – districts, total ................................................................................14 

Table E4 Patient sex, whether informed about TB-HIV by HIV testing – districts ................................................................................15 

Table E5 TB patient category, whether informed about TB-HIV by HIV testing – districts.............................................................15 

Table E6 Patients’ perception of AIDS as a community problem – districts.............................................................................................15 

Table E7 Patients’ knowing/not knowing someone with HIV – districts.....................................................................................................15 

Table E8 Patients’ HIV testing and sexual risk-reduction practices – districts, total..............................................................................16 

Table E9 Patients’ estimation of time spent in HCT process – districts, total..........................................................................................19 

Table E10 Patient characteristics by self-reported HIV testing – districts ...................................................................................................19 

Table E11 Logistic regression models of variables associated with HIV testing – total ........................................................................21 

Table F1 CHW sample: training, other responsibilities, work hours, number of patients – districts...........................................25 

Table F2 CHWs’ suggestions of main barriers to uptake of HCT by TB patients – total.................................................................26 

Table F3 CHWs’ suggestions of main facilitators of uptake of HCT by TB patients – total............................................................26 

Table G1 Facilities sampled for PHW survey – district, total..............................................................................................................................28 

Table G2 PHW sample per district and facility type – district, total ..............................................................................................................28 

Table G3 Nurses’ TB and HIV-related training – district, total............................................................................................................................29 

Table G4 Times HCT is offered at fixed clinics – district, total.........................................................................................................................29 

Table G5 Time patients spend waiting for HCT at clinics – district, total...................................................................................................30 

Table G6 Nurses’ views whether lay counsellors are capable of counselling – district, total...........................................................30 

Table G7 PHWs’ ideas re. factors discouraging uptake of HCT by TB patients – district, total......................................................31 

Table G8 PHWs’ ideas re. factors encouraging uptake of HCT by TB patients – district, total......................................................32 

Table G9 PHWs’ suggested strategies to encourage HCT uptake at clinics – district, total ............................................................32 

Table H1 Line managers’ ideas re. patient-related barriers to HCT uptake – total..............................................................................34 

Table H2 Line managers’ ideas re. health service-related barriers to HCT uptake – total...............................................................34 

Table H3 Line managers’ ideas re. health service-related facilitating factors – total..............................................................................35 

Table H4 Line managers’ ideas re. health care worker-related facilitators – total..................................................................................36 

Table I1 TB coordinating nurses’ ideas to improve information system to manage TB patients (n=17) – total................39 

Table I2 TB coordinating nurses’ ideas to improve information system to manage TB/HIV patients (n=19) – total......39 

Table I3 TB nurses’ ideas to improve user-friendliness of the information system for nurses (n=20) – total ....................39 

Table I4 TB nurses’ indication of ways in which TB-HIV/AIDS data is used for planning (n=28) – total ...............................39

List of figures 

Figure A1 Districts and selected subdistricts – Free State......................................................................................................................2 

Figure A2 Population density – districts, Free State, South Africa (2007) ....................................................................................2 

Figure A3 Poverty rate – districts, Free State, South Africa (2005) .................................................................................................3 

Figure A4 Per capita expenditure on PHC – districts, Free State, South Africa (2006/7) ...................................................3 

Figure A5 Nurse clinical workload – districts, Free State, South Africa (2006/7) ....................................................................3 

Figure A6 Clinic supervision rate – districts, Free State, South Africa (2006/7) .......................................................................3 

Figure A7 PHC utilisation rate – districts, Free State, South Africa (2006/7) .............................................................................4 

Figure B1 HIV prevalence estimates – South Africa (1990-2006) ...................................................................................................5 

Figure B2 Estimated incidence of TB – 22 HBCs, Africa, Global (2006) .......................................................................................5 

Figure B3 HIV prevalence in incident TB cases – 22 HBCs, Africa, Global (2006) ..................................................................5 

Figure B4 HIV prevalence estimates – provinces (2005-2007) .........................................................................................................5 

Figure B5 HIV testing of antenatal clients – districts, Free State, South Africa (2006/7) .....................................................6 

Figure B6 HIV prevalence: antenatal clients – districts, Free State, South Africa (2006/7) .................................................6 

Figure B7 Smear conversion rate – districts, Free State, South Africa (2006) ...........................................................................6 

Figure B8 TB cure rate – districts, Free State, South Africa (2005) .................................................................................................6 

Figure D1 TB patients tested for HIV – WHO region (2006) ............................................................................................................9 

Figure D2 TB patients tested for HIV and testing HIV-positive – 8 HBCs (2005) ..................................................................9 

Figure D3 TB patients undergoing HCT and testing HIV-positive/negative – districts, Free State (2007) .................9 

Figure D4 TB patients HIV counselled and tested – districts, Free State (2007) .....................................................................9 

Figure D5 TB patients testing HIV-positive/negative – districts, Free State (2007) .................................................................9 

Figure E1 Patients agreeing: “a person with HIV always shows symptoms” – districts.............................................................14 

Figure E2 Patients agreeing: “there is a relationship between TB and HIV ” – districts............................................................14 

Figure E3 Patients’ knowledge about TB-HIV link by sex – districts...............................................................................................14 

Figure E4 Patients’ knowledge about TB-HIV link by HIV testing – districts .............................................................................15 

Figure E5 Patients’ concern about acquiring HIV – districts...............................................................................................................16 

Figure E6 Patients’ concern about already having HIV – districts....................................................................................................16 

Figure E7 Patients’ concern about infecting others if they have HIV – districts......................................................................16 

Figure E8 Patients’ indication of provider type: pre-test counselling – districts.......................................................................17 

Figure E9 Patients’ indication of provider type: post-test counselling – districts.....................................................................17 

Figure E10 Patients indication of location of pre-test counselling – districts...............................................................................17 

Figure E11 Patients’ indication of location of post-test counselling – districts............................................................................17 

Figure E12 Patients’ indication of consent to HIV testing – districts ................................................................................................17 

Figure E13 Patients’ indication of types of counselling received – districts...................................................................................17 

Figure E14 Patients’ indication of characteristics of actual counsellor – districts.......................................................................18 

Figure E15 Preference for nurse – patients counselled by lay counsellor – districts..............................................................18 

Figure E16 Preference for lay counsellor – patients counselled by nurse – districts..............................................................18 

Figure E17 Whether patients would refer others to where HCT received – districts.........................................................18 

Figure E18 Patients’ reasons for referral of others to facility where HCT received – districts.........................................18 

Figure E19 Patients’ ideas how health workers can encourage uptake of HCT – districts.................................................20 

Figure E20 Patients’ ideas how others can encourage uptake of HCT – districts....................................................................20 

Figure E21 Patients’ reasons for non-uptake of HCT – districts.........................................................................................................20 

Figure F1 Availability of CHWs – five African countries (2003/4).................................................................................................23 

Figure F2 CHW sample – districts ...................................................................................................................................................................25 

Figure I1 Inconsistency between facility and provincial information (%) (n=2 800 entries) – total..........................38 

Figure I2 Number of inconsistencies per file (%) (n=2 800 data entries) – total ...............................................................38 

Figure I3 TB coordinating nurses’ problems with information system (n=20) – total ......................................................39

Section A 

Introduction and background 

In 1680, Bunyan (1900: 129) described tuberculosis (TB) 

as: “The Captain of all these men of death.” 

In 2005, Cameron (2005: 9) described Acquired 

Immunodeficiency Syndrome (AIDS) as: “An accumulation 

of rare afflictions of the human body ... running unbridled 

through the body ... portending a lingering death.” 

A1. Introduction 

TB is a leading cause of death among human 

immunodeficiency virus (HIV)-infected Africans. TB-HIV 

co-infected persons can benefit from cotrimoxazole 

preventive therapy (CPT) and antiretroviral treatment 

(ART). Therefore, international and national policies 

emphasize the importance of offering HIV counselling 

and testing (HCT) to TB patients and the provision of HIV 

care and treatment to those patients who are found to be 

dually infected. HCT should be a routine part of the scope 

of TB control, more so in high HIV prevalence countries 

like South Africa. 

The many compelling reasons to test (TB) patients for 

HIV include (FHI 2001): 

• TB is one of the rare infectious diseases that is fuelled 

by the HIV epidemic and does not remain confined to 

HIV-infected individuals. 

• TB is one of the first opportunistic infections to appear 

in PLWHA and may be the first sign of HIV infection. 

• HCT helps to alleviate the anxiety of TB patients 

(many are aware of the link between TB and HIV) and 

motivates HIV-negative patients to adopt life-saving 

skills. 

• HCT makes it possible for HIV-positive persons to 

plan for the future and alter their behaviour to protect 

others. 

• HIV education at TB service points, aimed at filling gaps 

in knowledge and dispelling misunderstandings, can 

also reduce stigma and discrimination. 

• Providing appropriate HIV care will boost the credibility 

of health care workers working in TB programmes. 

However, TB patients’ uptake of HCT is affected by a 

variety of health systems/services-related and patient/ 

community-related factors. This research set out to explain 

comparatively low rates of HCT among TB patients in 

Lejweleputswa and Thabo Mofutsanyana Districts in the 

Free State Province. By interviewing health managers, 

front-line providers and TB patients, the “fact-finding” 

research sought to identify and illuminate barriers to and 

facilitators of uptake of HCT by TB patients. 

The overall project entails two parts: 

• Fact-finding research (Part I). 

• Development, implementation and evaluation of a 

multifaceted intervention (Part II). 

The overall R&D project aims to increase the uptake of 

HCT among TB patients by devising an evidence-based 

multifaceted intervention with positive health system 

and patient-effects. The planned intervention should be 

appropriate for local circumstances, and also have wider 

application potential. 

The overall project was authorised by the Free State 

Department of Health (FSDoH) (28 August 2006, 26 July 

2007) and is conducted in collaboration with managers 

and staff of the provincial and district TB Control and 

HIV&AIDS/STI/CDC Programmes. Ethical clearance for 

the research was obtained from the Ethics Committee of 

the Faculty of the Humanities, University of the Free State 

(12 February 2007). 

A2. Fact-finding design and 

methods 

Over the period September 2007 to March 2008, crosssectional 

data gathering for the fact-finding research 

entailed: 

• Interviews with patients (n=600) attending TB 

services at fixed primary health care (PHC) clinics (Cf 

Section E). 

• Group interviews with community health workers 

(CHWs) including lay counsellors (n=40) and directlyobserved 

treatment (DOT) supporters (n=57) (Cf 

Section F). 

• Interviews with professional health workers (PHWs) 

including facility managers and nursing and medical staff 

working in the TB, HIV&AIDS and VCT programmes 

at mobile and fixed clinics and district and regional 

hospitals (n=81) (Cf Section G). 

• Interviews with subdistrict, district, provincial and 

national TB, HIV&AIDS and VCT programme line 

managers (n=13) (Cf Section H). 

• Rapid assessment of the TB-HIV information system 

over the period November-December, 2007 (n=20 

facilities) (Cf Section I). 

• Group discussions towards identifying solutions to 

HCT uptake by TB patients at district-level feedback 

workshops (n=5 workshops) (Cf Section J). 

A3. Study areas: Lejweleputswa and 

Thabo Mofutsanyana 

The five health districts/district municipalities of the 

Free State are indicated in Figure A1. All five subdistricts 

in Lejweleputswa District (Masilonyana, Thokologo, 

Section a • Introduction and Background 1

Tswelopele, Matjhabeng, and Nala) and all five subdistricts 

in Thabo Mofutsanyana (Dihlabeng, Maluti-a-Phofung, 

Setsoto, Nketoana, and Phumelela) were involved in the 

group interviews with CHWs and individual interviews 

with facility managers and PHWs. 

The patient survey was limited to and representative of TB 

patients in the subdistricts Matjhabeng (large town/urban) 

and Masilonyana (small town/rural) in Lejweleputswa and 

Maluti-a-Phofung (large town/urban) and Nketoana (small 

town/rural) in Thabo Mofutsanyana. 

Figure A1. 

Districts and selected subdistricts – Free State 

Lejweleputswa 

1 

Xhariep 

2 

3 

Motheo 

4 

5 6 

Fezile Dabi 

7 

8 

10 

9 


1. Thokologo 2. Tswelopele 3. Nala 

4. Matjhabeng 5. Masilonyana 6. Setsoto 

7. Nketoana 8. Dihlabeng 9. Phumelela 

10. Maluti-a-Phofung 

As shown in par. D4, during 2007, Lejweleputswa and 

Thabo Mofutsanyana Districts recorded relatively low HIV 

testing rates among TB patients, in both cases lower than 

the mean rate for the province. However, significant sociodemographic 

differences occur between the two districts 

and should be taken into account when interpreting the 

fact-finding data. The following background information 

about Lejweleputswa and Thabo Mofutsanyana (relative 

to statistics for the Free State Province and South Africa 

at large) are derived from: 

• Health Situation Analysis of Thabo Mofutsanyana District 

Municipality (Initiative for Sub-District Support [ISDS] 

2004). 

• Population Census 2001 (Statistics South Africa 2006). 

• District Health Barometer 2006/07 (Barron et al 2007). 

A3.1 Population and age distribution 

After the Northern Cape, the Free State has the lowest 

population density among South Africa’s nine provinces. 

In 2007, Lejweleputswa and Thabo Mofutsanyana 

respectively had populations of 758 097 and 767 862. 

Figure A2 indicates higher overall population density in 

Lejweleputswa than in Thabo Mofutsanyana. 

Figure A2. 

Population density – districts, Free State, South Africa 

(2007) 

4.3 4.5 

2.5 

Lejweleputswa Thabo Mofutsanyana Free State South Africa 

Source: Barron et al (2007). 

Number of people per km 2 

In 2001, Lejweleputswa had proportionally more middle/ 

working-aged people, while Thabo Mofutsanyana’s 

population included proportionally more children, 

teenagers and elderly (Table A1). In Thabo Mofutsanyana 

a larger proportion of the population fell in the age group 

5-19 years, while in Lejweleputswa a larger proportion 

were in the age group 20-49 years. 

Table A1. 

Population by age group (years) – districts, Free State 

(2001) 

Thabo 

Lejweleputswa 

Age 

Mofutsanyana 

Free State 

n % n % n % 

0-4 62 791 9.6 71 450 9.8 

5-9 63 348 9.6 81 347 11.2 830 229 30.7 

10-14 70 585 10.7 91 146 13.6 

15-19 70 067 10.7 91 220 12.6 

20-24 59 741 9.1 69 547 9.6 

25-29 55 791 8.5 58 304 8.0 

30-34 53 330 8.1 50 157 6.9 

35-39 54 196 9.2 45 529 6.3 

40-44 46 565 7.1 38 090 5.3 

1 742 128 64.4 

45-49 36 011 5.5 32 266 4.4 

50-54 25 797 3.9 25 617 3.5 

55-59 17 996 2.7 18 604 2.6 

60-64 14 175 2.2 15 843 2.2 

65-69 10 976 1.7 13 311 1.8 

70-74 6 837 1.0 10 079 1.4 

75-79 3 986 0.6 5 491 0.8 134 418 4.9 

80-84 3 013 0.5 4 868 0.6 

85+ 1 806 0.3 3 068 0.4 

Total 657 012 100.0 725 939 100.0 2 706 775 100.0 

Source: Statistics South Africa (2006). 

Lejweleputswa District includes a number of large gold 

mines. Traditionally, mining has been fundamental to the 

economy of the province (Akinbohun 2005: 12; Marais 

2006: 63). However, since the mid-1990s significant 

down-scaling of mining operations and accompanying 

extensive retrenchments have ignited and propelled 

high unemployment and poverty figures in many once 

prosperous mining environments: “Simultaneously, and 

almost concurrently with the economic demise of the 

Goldfields, HIV prevalence rates ... have soared to new heights” 

(Pelser & Redelinghuys 2006: 29-30). This has resulted in 

a substantial decline in population in Lejweleputswa and 

especially in Matjhabeng (Table A2), i.e. the subdistrict 

which contributes most to the district’s economy. 

3.5 

2 Counselling and testing for HIV/AIDS among TB patients in the Free State

Table A2. 

Population change – Lejweleputswa, Free State 

(1996-2001) 

Subdistrict 1996 2001 

Annual growth/ 

decline (%) 

Masilonyana 65 862 64 411 -0.44 

Thokologo 25 140 32 452 5.24 

Tswelopele 51 644 53 713 0.79 

Matjhabeng 476 764 408 171 -3.06 

Nala 81 089 98 260 3.92 

Lejweleputswa 700 499 657 007 -1.27 

Free State 2 633 503 2 706 771 0.6 

Source: Marais (2008). 

A3.4 Nurse workload 

Compared with an average South African professional 

nurse (PN) clinical workload of 26.9 patients per day in 

2006/7, nurses in the Free State (36.3 patients) and both 

the study districts had substantially higher patient loads 

(Figure A5). PNs in Thabo Mofutsanyana consulted almost 

40 and their counterparts in Lejweleputswa almost 38 

patients per day. 

Figure A5. 

Nurse clinical workload – districts, Free State, South 

Africa (2006/7) 

A3.2 Poverty 

37.7 

39.2 

36.3 

26.9 

In 2005, the poverty rate in Thabo Mofutsanyana was 

substantially higher than that of the Free State and South 

Africa (Figure A3). However, despite the demise of the 

gold mining industry and economic decline of 3% per 

annum between 1996 and 2004 in Lejweleputswa (Marais 

2008: 7), the poverty rate was substantially lower than 

the corresponding rates for the province and the country. 

These data characterise Thabo Mofutsanyana as the 

poorer of the two study areas. 

Figure A3. Poverty rate – districts, Free State, South Africa (2005) 

60.9 

43.2 

48 

47.2 



% households spending

Figure A7. 

1.5 

PHC utilisation rate – districts, Free State, South Africa 

(2006/7) 

2.4 



2.0 

Mean annual number of visits to PHC facilities per person 

A4. Summary characterisation of 

study areas 

The above information allows for the following summary 

characterisation of the two study areas, as compared with 

each other, the Free State, and South Africa (Table A3): 

Table A3. 

Summary characteristics – districts 

Lejweleputswa 

Lower rate of poverty than 

Thabo Mofutsanyana, Free 

State, South Africa 

Lower per capita expenditure 

on PHC than Thabo 

Mofutsanyana, Free State, South 

Africa 

Higher nurse clinical workload 

than Free State, South Africa 

Lower clinical supervision rate 

than Thabo Mofutsanyana, Free 


Lower PHC utilisation rate 

than Thabo Mofutsanyana, Free 



2.2 

Higher rate of poverty than 

Lejweleputswa, Free State, South 

Africa 

Lower per capita expenditure on 

PHC than Free State, South Africa 

Higher nurse clinical workload than 


Africa 

Higher clinical supervision rate than 


Africa 

Higher PHC utilisation rate than 


Africa 

Section B 

TB-HIV/AIDS co-epidemic 

“There has been no other single disease which has been so 

prevalent and widespread over such an extensive period in 

time [as TB]” (Metcalf 1991: 1). 

“HIV/AIDS is recognized as the modern world’s greatest 

pandemic” (Harries & Dye 2006: 418). 

B1. Introduction 

HIV infection leads to progressive immunodeficiency and 

increased susceptibility to infections, including TB. As HIV 

infection progresses, the immune system is less able to 

prevent the growth and local spread of TB. HIV/AIDS 

fuels the TB epidemic in several ways (World Health 

Organization [WHO] 2001: 12; National Department of 

Health [NDoH] 2004: 54): 

• HIV promotes progression to active TB disease both 

in people with recently acquired and those with latent 

TB infection. 

• HIV increases the rate of recurrent TB, which may be 

due to either endogenous reactivation or exogenous 

re-infection. 

• In the absence of HIV infection, only about 10% of 

people infected with passive TB fall ill with TB during 

their lifetime. In people who are co-infected with HIV 

and TB, about 50% will develop active TB disease at 

some stage. 

• Increased TB disease in people living with HIV/AIDS 

(PLWHA) amplifies the risk of TB transmission to the 

general community. 

HIV has been described as the greatest risk factor for TB 

ever known. This section presents an overview of the TB- 

HIV/AIDS epidemic globally, in South Africa and in the 

Free State. 

B2. TB-HIV/AIDS: global 

While the global percentage of PLWHA has stabilised 

since 2000, the overall number of PLWHA has increased 

due to the ongoing number of new infections each year 

as well as the beneficial effects of more widely available 

ART. Sub-Saharan Africa remains the most heavily affected 

region of the world, accounting for 67% of all PLWHA 

and for 72% of global AIDS deaths in 2007 (Joint United 

Nations Programme on HIV/AIDS [UNAIDS] 2008: 5). 

Global incidence of TB has increased over the past ten 

years, killing approximately 2 million people annually 

(WHO 2005; 2007a; 2008). After HIV/AIDS, TB is the 

second most common cause of death from infectious 

disease in the world. Countries in sub-Saharan Africa have 

the highest TB incidence rates, primarily because of the 

HIV epidemic (Buvé et al 2003; Churchyard 2005; El-Sony 

2006; Mwinga et al 2008). 

As far back as 1988, WHO (1988: 12) warned that the 

spread of HIV was likely to worsen TB morbidity, and 

would reduce or even cancel progress made in TB control. 

By 1993, globally, around 7% of all annual deaths were 

attributed to TB. WHO consequently declared TB a global 

emergency (Redelinghuys & Van Rensburg 2004: 252). 

The global burden of TB in 2006 is starkly described in the 

following key points of the 2008 Global Tuberculosis Control 

Report (WHO 2008: 3): 

• An estimated 14.4 million prevalent cases of TB. 

• An estimated 9.2 million new cases of TB (139 per 

100 000 population), including 4.1 million new smearpositive 

cases (44% of total) and 0.7 million HIVpositive 

TB cases (8% of total). 


• Respectively, India, China, Indonesia, South Africa 

and Nigeria ranked first to fifth in terms of absolute 

numbers of TB cases. 

Sub-Saharan African countries fall far short of WHO’s 

targets for TB case detection and treatment, which, in turn, 

make the achievement of the Millennium Development 

Goals (MDGs) for TB – to ensure that the incidence 

of TB will fall by 2015 and to halve the prevalence of TB 

and the annual number of TB-attributable deaths between 

1990 and 2015 – unlikely (Harries & Dye 2006: 415). 

However, integration and large-scale expansion of HIV 

and TB control programmes, with universal access to HIV 

diagnosis, ART and opportunistic infection prophylaxis, 

have the potential to improve TB control and outcomes 

(Churchyard & Corbett 2005: 451). 

B3. TB-HIV/AIDS: South Africa 

Although HIV prevalence data collected from antenatal 

clinic surveillance in South Africa suggest that HIV infection 

levels might be levelling off (Figure B1), with prevalence 

among pregnant women at 28.0% in 2007, South Africa 

remains the country with the largest absolute number of 

HIV infections in the world (UNAIDS/WHO 2007: 16; 

NDoH 2007: 2). 

Figure B1. HIV prevalence estimates – South Africa (1990-2006) 

0.7 1.7 2.2 

4 

7.6 10.4 14.2 17 22.8 22.4 24.5 24.8 26.5 27.9 29.5 30.2 29.1 28 

1990 '91 '92 '93 '94 '95 '96 '97 '98 '99 2000 '01 '02 '03 '04 '05 '06 '07 

Source: NDoH (2008). 

% HIV prevalence 

The past decade has seen a rapid increase in TB in parallel 

to the increase in the estimated prevalence of HIV in the 

adult population in South Africa. As a result, the NDoH 

declared TB a crisis in the country (Dong et al 2007: S49). 

South Africa is one of the 22 high-burden countries (HBCs) 

that account for about 80% of new TB cases globally each 

year (Dye et al 2003). Not only does the country have the 

highest number of PLWHA, but also by far the highest TB 

incidence among the 22 HBCs (Figure B2). 

Figure B2. 

940 

Estimated incidence of TB – 22 HBCs, Africa, Global 

(2006) 

While South Africa is home to only 0.7% of the world’s 

population, the country accounts for 28% of the global 

number of HIV-positive TB cases and for 33% of HIVpositive 

cases in the WHO African Region. Next to Kenya, 

South Africa also recorded the highest HIV prevalence in 

incident TB cases in 2006 (Figure B3). The South African 

prevalence rate was twice as high as the corresponding 

rate in Africa and more than four times as high as HIV 

prevalence in incident TB cases worldwide. 

Figure B3. 

1.2 0.3 0.6 

44 

9.6 

HIV prevalence in incident TB cases – 22 HBCs, Africa, 

Global (2006) 

0 

6.3 0.3 0.1 

9.2 3.8 5 

52 

43 

30 

18 16 12 11 2.6 

9.6 11 22 7.7 

0 

India 

China 

Indonesia 

South Africa 

Nigeria 

Bangladesh 

Ethiopia 

Pakistan 

Philippines 

DR Congo 

Russian 

Viet Nam 

Kenya 

UR Tanzania 

Uganda 

Brazil 

Mozambique 

Thailand 

Myanmar 

Zimbabwe 

Cambodia 

Afghanistan 

HBCs 

Africa 

Global 

Source: WHO (2008). 

% HIV prevalence in incident TB cases 

Figure B4 indicates that in 2007 the HIV/AIDS epidemic 

varied considerably between South Africa’s nine provinces, 

with prevalence among pregnant women ranging from 

12.6% in the Western Cape to 37.4% in KwaZulu-Natal 

(NDoH 2008: 4). At 33.5%, the Free State recorded the 

third highest HIV prevalence among the provinces. The 

Free State was also the only province that recorded an 

increase from 30.3% in 2005 to 33.5% in 2007. 

Figure B4. HIV prevalence estimates – provinces (2005-2007) 

45 

40 

35 

30 

25 

20 

15 

10 

5 

0 

KZN Mpum FS Gauteng NW EC Limpopo NC WC SA 

2005 39.1 34.8 30.3 32.4 31.8 29.5 21.5 18.5 15.7 30.2 

2006 39.1 32.1 31.1 30.8 29 28.6 20.6 15.6 15.1 29.1 

2007 37.4 32 33.5 30.3 29 26 18.5 16.1 12.6 28 

Source: NDoH (2007a). 

The proportion of antenatal care clients who underwent 

HIV testing in 2006/7 was substantially lower in 

Lejweleputswa (53.5%) than in Thabo Mofutsanyana 

(62.0%). In both study districts the antenatal testing rates 

were lower than the provincial and national average rates 

(Figure B5). 

168 99 

234 

311 378 225 287 392 181 107 173 384 312 355 

443 

557 500 

50 142 171 

161 177 363 139 

India 

China 

Indonesia 

South Africa 

Nigeria 

Bangladesh 

Ethiopia 

Pakistan 

Philippines 

DR Congo 

Russian 

Viet Nam 

Kenya 

UR Tanzania 


Brazil 

Mozambique 


Myanmar 

Zimbabwe 

Cambodia 

Afghanistan 

HBCs 

Africa 

Global 


Incidence per 100 000 population 

SECTION B • TB-HIV/AIDS co-epidemic 5

Figure B5. 

53.5 

HIV testing of antenatal clients – districts, Free State, 

South Africa (2006/7) 

62 

66.9 

67.9 



% antenatal clients tested for HIV 

Of further concern is that the proportion of antenatal 

clients who tested HIV-positive in 2006/7 was considerably 

higher in Lejweleputswa District (30.4%) than in the 

province (25.4%) and the country (23.7%). However, the 

proportions of antenatal clients testing HIV-positive in 

Thabo Mofutsanyana (25.2%) and in the Free State were 

also slightly higher than the national HIV prevalence rate 

among antenatal clients (Figure B6). 

Figure B6. 

30.4 

HIV prevalence: antenatal clients – districts, Free State, 

South Africa (2006/7) 

25.2 

25.4 

23.7 

B4. Discussion and conclusion 

Especially in sub-Saharan Africa and in South Africa, HIV/ 

AIDS seems to be fuelling an unprecedented outbreak of 

TB. In 2007, sub-Saharan Africa was home to about seven 

in every ten PLWHA in the world and also accounted for 

more than 70% of global AIDS deaths. HIV prevalence and 

TB incidence in South Africa is of the highest in the world. 

After Kenya, South Africa also recorded the highest HIV 

prevalence in incident TB cases among the 22 TB HBCs. 

The Free State is the only province in South Africa that 

recorded an increase in HIV prevalence among pregnant 

women from 30.3% in 2005 to 33.5% in 2007. Therefore, 

it is of great concern that only 53.5% of antenatal clients 

were HIV tested in Lejweleputswa in 2006/7, compared 

with almost 68% in South Africa. 

Although in 2007 TB treatment outcomes in the Free 

State, and especially in Thabo Mofutsanyana District, were 

somewhat better than the corresponding outcomes for 

the country as a whole, the WHO target of a 75% cure 

rate remains elusive. The reported statistics emphasise the 

compelling need for integrated TB-HIV/AIDS management 

so as to mitigate the effects of the co-epidemic. 


% antenatal clients testing HIV+ 


Among South Africa’s provinces, the Free State is often 

credited with better than average TB control outcomes 

(smear conversion rate and TB cure rate). Figures B7 and 

B8 show that in 2005/6, among the Free State’s five health 

districts, Thabo Mofutsanyana performed best, followed by 

Xhariep and then by Lejweleputswa. 

Section C 

Policy review 

“Like family members associated by nature rather than by 

choice, the [TB] and AIDS communities have long and far to 

travel together” (De Cock 2007: 1268). 

Figure B7. 

69.3 71.5 

Smear conversion rate – districts, Free State, South 

Africa (2006) 

54.3 

67.7 

73.1 

Lejweleputswa Thabo Fezile Dabi Motheo Xhariep 

Mofutsanyana 

% antenatal clients tested HIV+ 


67.2 

55.8 

Free State South Africa 

Figure B8. TB cure rate – districts, Free State, South Africa (2005) 

69 70.1 

61.5 66.7 70 67.5 

57.6 

C1. Introduction 

A number of international and national policies call for 

(i) integration of TB and HIV services and (ii) increased 


The call for increased HCT among TB patients is nestled 

within broader calls for TB and HIV/AIDS programme 

collaboration and integration: “The outcome of integrated 

services is improved health, less waste, less inefficiency and a 

less frustrating experience for patients” (WHO 2002: 5). 

C2. International policies 

Lejweleputswa Thabo Fezile Dabi Motheo Xhariep Free State South Africa 

Mofutsanyana 

% ss+PTB patients completed treatment and proved to be cured 


C2.1 WHO interim policy on collaborative TB/HIV 

activities 

WHO (2004) recommends that TB and HIV disease 

control programmes should incorporate testing, diagnosis, 

treatment and care for both diseases. 


Table C1. 

WHO-recommended collaborative TB/HIV activities 

Establish the mechanisms for collaboration 

1. Set up a co-ordinating body for TB/HIV activities effective at all 

levels 

2. Conduct surveillance of HIV prevalence among TB patients 

3. Carry out joint TB/HIV planning 

4. Conduct monitoring and evaluation 

Decrease the burden of TB in PLWHA 

1. Establish intensified TB case-finding 

2. Introduce IPT 

3. Ensure TB infection control in health care and congregate settings 

Decrease the burden of HIV in TB patients 

1. Provide HIV testing and counselling 

2. Introduce HIV prevention methods 

3. Introduce CPT 

4. Ensure HIV/AIDS care and support 

5. Introduce ART 

Source: WHO (2004: 2 – emphasis added). 

It is thus WHO policy that TB patients should be 

offered HCT and, if tested and found to be HIV-positive, 

offered cotrimoxazole preventive therapy (CPT). People 

diagnosed with HIV should in turn be offered TB testing 

and provided with isoniazid preventive treatment (IPT) 

if found not to have active TB. WHO recommends that 

HIV testing should be offered to all patients when the 

prevalence rate of HIV among TB patients is more than 

5% (Wang et al 2007: 183-184). 

C2.2 WHO/UNAIDS guidance on provider-initiated 

HIV testing and counselling (PITC) 

The WHO/UNAIDS (2007) Guidance on PITC recommends 

an “opt-out” approach to PITC in health facilities, including 

“simplified pre-test information” and recommending of an 

HIV test to (i) all patients whose clinical presentation 

might result from underlying HIV infection, (ii) as a 

standardised part of medical care for all patients attending 

health facilities in generalised HIV epidemics, and (iii) more 

selectively in concentrated and low-level epidemics. 

Although concerns about human rights have also been 

raised, the general reaction of international organisations 

and many national health authorities to the call for PITC 

has been favourable. It is argued, for instance, that greater 

access to HIV testing and counselling (HTC) is not only a 

public health imperative, but also critical to protect and 

promote the right to the highest attainable standard of 

health. Evidence from both industrialised and resourceconstrained 

settings suggests that many opportunities to 

diagnose and counsel individuals at health facilities are 

missed when systems rely solely on clients to initiate HIV 

testing. Some of the cited benefits of PITC include (Open 

Society Institute 2008): 

• Identification of people at earlier stages of HIV 

disease. 

• Increased uptake of ART and other life-saving 

treatments. 

• Improved prevention of mother-to-child-transmission 

of HIV (PMTCT). 

• Possible reduction in HIV transmission risk behaviour. 

• Possible reduction in AIDS-related stigma. 

However, the call for PITC has also evoked critical reactions. 

For example, in the sub-Saharan African context, Asante 

(2007) argues that routine or mandatory HIV testing is 

not feasible in the short or medium term. This author 

identifies four barriers to HIV testing that have to be 

removed before routine (provider-initiated) HIV testing 

would be possible: 

• Lack of access to ART. 

• Inadequate health workforce. 

• Culture of poor use of health services. 

• Widespread stigma and discrimination associated with 

HIV/AIDS. 

C3. National policies 

Comprehensive, integrated PHC has featured prominently 

in the overarching health policy statements of the South 

African post-apartheid government. In 1995, the NDoH 

issued the Policy for the Development of the District Health 

System (NDoH 1995), intended as the main vehicle for 

realising the goal of an integrated PHC system. In 1997, 

the White Paper for the Transformation of the Health System 

in South Africa called for an integrated package of essential 

PHC services available to all South Africans at the first point 

of contact (NDoH 1997). In 2003, the NDoH proclaimed 

that integration of HIV and AIDS-related services into 

existing systems at the primary care level would reinforce 

the national strategy for PHC (NDoH 2003: 60). 

C3.1 Operational Plan for CCMT 

In August 2003, the South African government announced 

its intention to provide ART to all who need it. The 

Comprehensive Care, Management and Treatment (CCMT) 

Plan, set explicit targets for scale-up towards universal 

access to treatment. It also called for a process of health 

systems strengthening, in which integration is one of the 

core principles. Integration means that HIV care should 

not be a vertical programme separate from the PHC 

system. ART should be delivered as part of an integrated 

continuum of HIV/AIDS care and support: “Comprehensive 

care and treatment for HIV and AIDS need to be delivered in an 

integrated fashion within a coherent overarching public health 

policy framework for the provision of basic social services as 

part of the continuum of care” (NDoH 2003: 19). The CCMT 

Plan emphasises the need to improve the integration of 

services at the facility level, especially between HIV/AIDS, 

PMTCT, TB and sexually transmitted infection services 

(NDoH 2003: 49, 54). These services also represent key 

prevention interventions (NDoH 2003: 56). 

SECTION C • Policy review 7

C3.2 National Tuberculosis Control Programme 

Practical Guidelines 

It is an overall objective of the South African National 

TB Control Programme (NTCP) to establish optimal 

coordination with the HIV/AIDS and STI programmes 

(Bamford et al 2004: 215). The NTCP Guidelines state that 

a policy of compulsory HIV testing of TB patients would 

be counterproductive and would result in patients being 

discouraged from seeking care, decreased case-finding 

among at-risk groups, and reduced credibility of health 

services. The NTCP Guidelines also stress that counselling 

with assurance of confidentiality is essential before and 

after HIV antibody testing: “The patient gives explicit informed 

consent to have the test, i.e. the patient understands what 

the test involves and the implications of testing. Counselling 

is a dialogue between the patient and the counsellor, who 

provides information and support” (NDoH 2004: 64). 

for [TB] patients with symptoms and/or signs of HIV-related 

conditions and in [TB] patients having a history suggestive of 

high risk of HIV exposure.” 

C4. Discussion and conclusion 

As shown, a range of international and national policies call 

for (i) integration of TB and HIV services and (ii) increased 


WHO (2004) recommends that TB and HIV disease 

control programmes should incorporate testing, diagnosis, 

treatment and care for both diseases. The South African 

NSP, 2007-2011 and the TB Strategic Plan, 2007-2011, 

both echo these recommendations. Although the policy 

shift from VCT to PITC has also evoked critical reactions, it 

is widely advocated – especially in the case of TB patients. 

The policies are clear. The challenge now is to put PITC for 

TB patients properly into effect. 

C3.3 National HIV and AIDS and STI Strategic Plan 

for South Africa (NSP), 2007-2011 

In 2007, the South African Cabinet and South African 

National AIDS Council (SANAC) approved the NDoH’s 

National HIV and AIDS and STI Strategic Plan for South Africa, 

2007-2011. The NSP’s two main goals are to (NDoH 

2007b: 2): 

• Cut the number of new HIV infections by half. 

• Ensure that at least 80% of people requiring ART and 

nutrition get such care and support by 2011. 

The NSP acknowledges that the epidemics of HIV and TB 

are interlinked and therefore underlines the importance 

of effective management of TB-HIV co-infection (NDoH 

2007b: 8; 12). Key priority area 2, “treatment, care and 

support”, sets the objective to promote regular HIV 

testing by “increasing access to VCT services that recognise 

diversity of needs” and “increasing uptake of VCT” (NDoH 

2007b: 12). 

C3.4 Tuberculosis Strategic Plan for South Africa, 

2007-2011 

The policy directives of the TB Strategic Plan are unequivocal 

(NDoH 2007c: 24): 

• “ Ensure early diagnosis of HIV in TB patients through 

provision of [PITC].” 

• “ Health facilities in South Africa are to provide PITC.” 

The directives of the TB Strategic Plan are also in line with 

international standards of care for TB patients (NDoH 

2007c: 45-46): “Standard 12. In areas with a high prevalence 

of HIV infection in the general population and where [TB] 

and HIV infection are likely to co-exist, [HCT] is indicated 

for all [TB] patients as part of their routine management. In 

areas with lower prevalence rates of HIV, [HCT] is indicated 

Section D 

HIV counselling and testing 

(HCT) of TB patients 

“The definitive diagnosis of HIV infection rests on a positive 

HIV test. Therefore all TB patients should receive HIV 

information and education and offered counselling and HIV 

testing” (NDoH 2004: 55). 

D1. Introduction 

This section presents international and national HCT rates 

among TB patients as reported in the WHO (2008) Global 

tuberculosis control: surveillance, planning, financing report, as 

well as routine HCT data for the Free State and its five 

health districts. 1 

D2. HCT among TB patients – Global 

Universally, since 2003, there has been a threefold increase 

in both HIV testing of TB patients and detection of TB-HIV 

co-infection (WHO 2007a: 37). However, total coverage of 

HIV testing and counselling is still very low. As TB patients 

are already in the health care system, this represents a 

major missed opportunity for HIV prevention, treatment 

and care. 

In 2006, only 12% of the estimated global total number of 

HIV-positive TB cases was identified through HIV testing 

(Figure D1). The corresponding uptake figure for Africa 

1 The FSDoH avails these statistics on its website, http://www. 

fshealth.gov.za. 


was 22%. While this was higher than the global HCT rate 

among TB patients, it was still substantially lower than the 

rates recorded for the Americas and Europe. 

Figure D1. TB patients tested for HIV – WHO region (2006) 

46 

Figure D3. 

25000 

20000 

15000 

10000 

5000 

TB patients undergoing HCT and testing HIV-positive/ 

negative – districts, Free State (2007) 

22 

32 

1.4 

Africa Americas Eastern 

Mediterranian 


Europe South East Asia Western 

Pacific 

% notified TB patients HIV tested 

4.1 2.7 

12 

Global 

No of patients: 

Total no patients 

HIV counselled 

HIV tested 

HIV+ 

HIV- 

*Thabo Mofutsanyana 

Source: FSDoH (2008). 

0 

Lejweleputswa TM* Fezile Dabi Motheo Xhariep Free State 

8273 5359 3850 6343 1353 25187 

4234 3415 2030 5980 976 16635 

2677 2032 1323 3964 864 10860 

1698 1296 910 2196 449 6549 

979 736 413 1768 415 4317 

D3. HCT among TB patients – South 

Africa 

As shown in Figure D2, the 2005 rate of HCT among TB 

patients in South Africa at 22% was higher than that in 

Kenya (14%), Nigeria (10%) and Uganda (7.9%), but much 

lower than the corresponding figure of 43% recorded in 

Brazil (Figure D1). 

Figure D2. 

43 

14 

TB patients tested for HIV and testing HIV+ – 8 HBCs 

(2005) 

2.9 8 2.6 

41 

2.3 

22 

Brazil Cambodia Ethiopia India Kenya Nigeria SA Uganda 

Source: WHO (2007a: 73-157). 

% notified TB cases HIV tested % testing HIV+ 

14 

57 

10 18 22 

D4. HCT among TB patients – Free State 

HIV counselling 

In 2007, the proportion of the total number of registered 

TB patients undergoing counselling (during their current 

episode of TB) was 51.2% in Lejweleputswa District and 

63.7% in Thabo Mofutsanyana District. The corresponding 

figure for Xhariep District, was 94.3% and for the Free 

State as a whole, 66.0% (Figures D3 and D4). 

HIV testing 

In 2007, the proportion of the total number of registered 

TB patients undergoing HIV testing was 32.4% in 

Lejweleputswa District and 37.9% in Thabo Mofutsanyana 

District. In this respect the two study areas were in par with 

the 34.4% of Fezile Dabi. Motheo (62.5%) and Xhariep 

Districts (63.9%) performed much better in this regard. 

The proportion of registered TB patients being tested in 

Lejweleputswa, Thabo Mofutsanyana and Fezile Dabi was 

substantially lower than the mean for the province (43.1%) 

(Figures D3 and D4). 

52 

7.9 

51 

Figure D4. 

51.2 

32.4 

Lejweleputswa 

TB patients HIV counselled and tested – districts, Free 

State (2007) 

63.7 

37.9 

Thabo 

Mofutsanyana 

Fezile Dabi 


Xhariep 

% registered TB patients HIV counselled % registered TB patients HIV tested 


Seropositivity 

52.7 

34.4 

94.3 

62.5 

72.1 63.9 66 

43.1 


Figure D5 shows that the three districts where the 

lowest percentage of TB patients undergo HIV testing, i.e. 

Lejweleputswa, Thabo Mofutsanyana and Fezile Dabi, also 

represent the highest proportions of TB patients testing 

HIV-positive, at respectively, 63.4%, 63.8% and 68.8%. The 

corresponding figure for the province was 60.3%. 

Figure D5. 

63.4 

36.6 

Lejweleputswa 

TB patients testing HIV-positive/negative – districts, 

Free State (2007) 

63.8 

36.2 

Thabo 

Mofutsanyana 


68.8 

31.2 

Fezile Dabi 


% HIV+ % HIV- 

55.4 

44.6 

52 48 

60.3 

Xhariep 

D5. Factors associated with TB 

patients’ uptake/non-uptake of 

HCT 

39.7 


An examination of exiting research on HCT among TB 

patients reveals both differences and similarities in the 

factors promoting or deterring the uptake of HCT by TB 

patients across geographical locations (Table C2). From the 

literature it seems that HCT uptake among TB patients is 

influenced by (i) patient/individual-related and (ii) health 

provider/system-related factors. 

SECTION D • HIV counselling and testing (HCT) of TB patients 9

Table D1. 

Author 

(Year) 

Harries 

et al 

(1995) 

Geduld 

et al 

(1999) 

Stout et al 

(2002) 

Zacharia 

et al 

(2003) 

Gebrekristos 

et al (2005) 

Dare 

(2006) 

Harris et al 

(2006) 

Jham et al 

(2006) 

Kawuma 

et al 

(2006) 

Factors associated with uptake/non-uptake of HIV 

testing – global (1995-2008) 

Country 

Malawi 

USA 

USA 

Malawi 

South 

Africa 

Ethiopia 

Canada 

Zambia 


Method 

Review of TB 

case files 

Review of 

hospital and 

clinic chart 

information 

Surveillance 

of TB case 

reports 

Interviews 

with TB 

patients 

Interviews 



Interviews 



TB case 

cohort study 

TB case 

cohort study 

Analysis of 

counselling 

records 

Factors associated with 

HCT uptake/non-uptake 

Health system-related 

factors – non-uptake: 

Lengthy HCT process of 

about 2-3 weeks. 

Patient/individual factors 

– uptake: 

Male sex, age 30-39 years, 

ss+ TB diagnosis, having two 

or more HIV risk factors. 


– uptake: 

Male sex, black race, foreign 

heritage. 

Health provider/system 

factors – uptake: 

Integration of VCT into 

the TB circuit allowing for 

systematic offer of VCT to 

all TB patients, well-staffed 

(with trained counsellors) 

VCT unit, adequately 

spaced VCT unit, ensuring 

privacy, rapid HIV testing, 

access to cotrimoxazole 

and community care and 

support. 


– uptake: 

Having lost someone to 

AIDS. 

Patient/individual factors – 

non-uptake: 

Fear of death (as a result of 

ignorance about ART) 

Health provider/system – 

uptake: 

Doctor recommendation 

to test, access to HIV 

treatment. 


– uptake: 

Unemployment. 


– uptake: 


diagnosed with both 

pulmonary and extrapulmonary 

TB, diagnosed 

with ss+ TB, having at least 

one risk factor for HIV. 


non-uptake: 

Need to first consult 

spouse, prior knowledge 

of HIV status, patients “not 

ready”. 


non-uptake: 

Belief that “all” TB patients 

are HIV co-infected, belief 

that TB in PLWHA is 

incurable. 

Author 

(Year) 

Leusaree 

et al 

(2006) 

Nnoaham 

et al 

(2006) 

Ronald 

et al 

(2006) 

Van Rie 

et al 

(2006) 

Daftary 

et al 

(2007) 

Dembele 

et al 

(2007) 

Mwangelwa 

et al (2007) 

Thomas 

et al 

(2007) 

Chakaya 

et al 

(2008) 

Country 


United 

Kingdom 

Kenya 

DRC 

South 

Africa 

Burkina- 

Faso 

Zambia 

India 

Kenya 

Method 

Evaluation of 

scale-up of 

HIV and TB 

collaborative 

activities 

Interviews 



Interviews 



Evaluation of 

PITC models 

Interviews 



Evaluation of 

implementing 

HCT policy 

Comparison 

of uptake 

of HCT by 

TB patients 

in two 

communities 

Assessment 

of feasibility 

of screening 

all TB patients 

for HIV 

Descriptive 

study 




non-uptake: 

Non-risk behaviour, 

perceived lack of benefits 

after HIV testing. 


non-uptake: 

Fear of stigmatisation 


non-uptake: 

Sputum-smear negative 

TB diagnosis, female sex, 

knowledge that ARVs do 

not cure AIDS, fear of 

death. 



PITC by TB nurse, offer of 

HCT at beginning of TB 

treatment, assurance of 

confidentiality. 


non-uptake: 

Having had a negative 

experience (e.g. poor 

counselling, feeling 

pressurised to test) during 

previous HCT, male partner 

disapproval of HIV testing, 

“bad timing” of HCT, selfperceived 

good health, felt 

stigma and discrimination, 

uncertainty about eligibility 

for ART. 



Access to ART. 


non-uptake: 

Fear of stigmatisation. 



Stock-out of HIV test kits, 

lack of human resources. 

Health system/provider 


Inadequate counselling 

space, lack counsellors. 


– uptake: 


rural residence, higher 

education, employed, 

married. 


non-uptake: 

Non-risk behaviour, old age, 

perception that testing was 

unnecessary, prior testing. 



Lack of privacy, unavailability 

of a testing technician. 



Improved recording and 

reporting system. 


Author 

(Year) 

Corneli 

et al 

(2008) 

Gasana 

et al 

(2008) 

Kanara 

et al 

(2008) 

Odhiambo 

et al 

(2008) 

Pope 

et al (2006; 

2008) 

Van Rie 

et al 

(2008) 

Country 

DRC 

Rwanda 

Cambodia 

Kenya 

South 

Africa 

DRC 

Method 

Evaluation of 

HCT models 

Evaluation of 

PITC models 

Evaluation 

of TB-HIV 

activities 

Evaluation of 

PITC models 

Evaluation of 

PITC models 

Evaluation of 

PITC models 





Offer of HCT by TB nurse. 



PITC. 


non-uptake: 

Age

E2. Aim and objectives 

The aim of the cross-sectional patient survey was, firstly, 

to identify the motivating and deterring factors impacting 

on TB patients’ uptake of HCT in Lejweleputswa and 

Thabo Mofutsanyana Districts. 2 Secondly, the research also 

aimed to establish baseline (pre-intervention) data to 

enable observation of the “patient effect” of the planned 

intervention (Part II of the overall project). Specifically, the 

objectives were to investigate: 

• possible association between socio-demographic 

variables and self-reported HIV testing; 

• patients’ knowledge about asymptomatic HIV; 

• possible association between patients’ knowledge 

about the relationship between TB and HIV and selfreported 

HIV testing; 

• possible association between patients’ perceived risk to 

HIV, their awareness about HIV/AIDS, their sexual and 

risk-reduction practices and uptake of HIV testing; 

• patients’ experience of the HCT process and different 

types of counsellors; 

• patients’ explanations for non-uptake of HCT; and 

• possible predictors of uptake/non-uptake of HIV 

testing. 

E3. Methods and sampling 

E3.1 Population 

As explained in par. A3, the patient survey was limited 

to specific subdistricts in Lejweleputswa and Thabo 

Mofutsanyana Districts. Two subdistricts in each of the 

study areas were purposefully matched in terms of their 

largely urban vs. largely rural characteristics, i.e. Nketoana 

Subdistrict (rural) and Maluti-a-Phofung Subdistrict (urban) 

in Thabo Mofutsanyana, and Masilonyana Subdistrict (rural) 

and Matjhabeng Subdistrict (urban) in Lejweleputswa. 

The study population was defined as all TB patients 

reporting at facilities that delivered services to at least 

ten TB patients during 2007 and that simultaneously 

provided HCT services. A total of 61 fixed clinics met 

this requirement and were all included in the study. The 

requirement was not met by any mobile clinic. Given that 

TB patients are mostly referred to clinics once they are 

stabilised at district/regional hospitals, hospitals were also 

excluded. It is also not the norm for hospitals to provide 

HCT services to outpatient TB patients. The number of 

patients recruited at each of the clinics was based on the 

2 Note: For convenience sake throughout this section the 

patient sample is referred to as the Lejweleputswa and the 

Thabo Mofutsanyana samples. As explained in par. E31, the 

patient survey was actually conducted only in two subdistricts 

in each of the two districts. 

proportional distribution of TB patients registered per 

clinic during 2007. The sample was representative of TB 

patients aged 18 years or older in the four subdistricts. 

E3.2 Fieldwork 

Fieldwork took place during February and March 2008 

in Thabo Mofutsanyana and Lejweleputswa. Pre-survey 

exploration at clinics in both districts revealed that TB 

patients received priority treatment in the early morning. 

Therefore, the fieldworkers visited clinics mostly between 

07h30 and 10h00. The fieldworkers were located 

outside the TB consultation room and recruited patients 

after leaving the room. Voluntary informed consent to 

participate in the study was obtained by both the attending 

nurse and the fieldworker. The process continued until the 

total number of patients required from each clinic was 

attained. Trained fieldworkers conducted the interviews 

of approximately 30 minutes at the selected clinics. The 

patients were interviewed in private and each received a 

food gift to thank them for their time and contribution. 

E3.3 Instrument and data collection 

A structured interview schedule was developed. Questions 

were formulated from the existing literature on TB, HIV 

and HCT (e.g. Bond et al 2005, Gebrekristos et al 2005 

etc). Formulation of the questions was done in consultation 

with domain experts. The schedule included both closeand 

open-ended questions collecting information on 

patients’: 

• socio-demographic characteristics; 

• clinical details; 

• knowledge of TB and HIV; 

• self-perceived risk to HIV; 

• awareness about HIV/AIDS; 

• sexual and risk reduction practices; 

• experience of HCT; 

• views of factors motivating uptake of HCT; and 

• explanations for non-uptake of HCT. 

The questionnaire was translated into Sesotho, pilottested 

for practicality, and adapted to ensure that patients 

understood all the questions. 

E3.4 Data analysis 

Uni-, bi- and multivariate analysis was conducted using 

STATA and SPSS. The analysis involved calculation of 

frequencies, chi-square tests of association, t-tests for 

continuous variables and logistic regression tests. A set of 

simple logistic regression models was initially developed to 

test the association of each of the following independent 

variables with self-reported HIV testing: 


• sex; 

• age; 

• marital status; 

• education level; 

• employment status; 

• patient category; 

• type of TB; 

• whether patients knew about the relationship between 

TB and HIV; 

• whether patients had received information on the link 

between TB and HIV; 

• whether patients perceived AIDS as a problem in their 

community; and 

• whether patients knew someone with HIV/AIDS. 

This was followed by developing an adjusted logistic 

regression model comprising all the above-mentioned 

variables’ association with self-reported HIV testing. 

In developing this model, the interaction between 

independent variables was examined. Significant interaction 

was found between marital status and the variable 

“received TB-HIV information”. Results take cognisance of 

this interaction. 

Simple content analysis (Varkevisser et al 2003) was used in 

the analysis of open-ended questions. Each of four coders 

independently compiled responses from a sample of 25 

patients. After examination of these responses, the coders 

used key words to group similar responses. The emergent 

categories were further scrutinised before compiling a 

short list of mutually-exclusive categories. One coder went 

through all the questionnaires to calculate the frequency 

of each category. Categories with very low frequencies 

were combined to form the category “other”. 

E4. Findings 

E4.1 Sample description 

The total sample for both districts comprised predominantly 

black (99.2%, n=595) TB patients aged between 18 

and 73 (mean=38.4) years. Slightly more than half of 

the patients were female (51.7%, n=310); almost three 

quarters were unmarried (73.3%, n=439); and just over 

six in every ten patients (60.0%, n=366) had secondary 

school education. The large majority (85.5%, n=513) of 

the patients were unemployed. There was significantly 

(p 71 24.0 83 28.0 154 26 

Total 296 100.0 296 100.0. 592** 100.0 

Marital status 

Married 76 25.2 84 28.2 160 26.7 

Unmarried 225 74.8 214 71.8 439 73.3 

Total 301 100.0 298 100.0 599** 100.0 

Education 

No formal 

education 

21 7.0 23 7.7 44 7.3 

Primary 90 29.8 87 29.2 177 29.5 

Secondary 184 60.9 182 61.1 366 61 

Tertiary 7 2.3 6 2.0 13 2.2 

Total 302 100.0 302 100.0 600 100.0 

Employment*** 

Unemployed 249 82.5 264 88.6 513 85.5 

Employed 53 17.5 34 11.4 87 14.5 

Total 302 100.0 298 100.0 600 100.0 

*Mean age Lejweleputswa = 37.1 years; Thabo Mofutsanyana = 39.1 years. 

**n

Further to the TB patient survey, significantly (p

The importance of educating TB patients about the 

relationship between TB and HIV is confirmed by the 

finding that knowledge about this relationship was 

significantly (p

E4.6 Patients’ self-perceived risk for HIV 

Figure E5 indicates patients’ self-perceived risk to contract 

HIV across the two districts. A significantly (p

E4.8 Patients’ experience of HCT and counsellors 

of different types 

Figure E8 indicates the provider types the patients 

reported to have conducted their pre-test counselling 

in each district. Although pre-counselling in both districts 

was mostly undertaken by lay counsellors, there was 

more utilisation of nurses, doctors and social workers 

(i.e. professional staff) for pre-test counselling in Thabo 

Mofutsanyana than in Lejweleputswa. 

Figure E11. 

49.0 

43.7 

Patients’ indication of location of post-test counselling 

– districts 

26.6 

31.1 

% Lejweleputswa (n=159) % Thabo Mofutsanyana (n=196) 

24.5 25.2 

Counselling room Consultation room Other 

Figure E8. 

66.7 

58.2 

Patients’ indication of provider type: pre-test 

counselling – districts 

Figure E12 describes patients’ responses to whether and 

in what way they had consented to HIV testing. Very small 

proportions of patients stated that they had not provided 

consent or that they could not recall if they did. 

31.4 

34.7 

1.9 

6.1 

0.0 1.0 

Lay counsellor Nurse Doctor Social worker 


Figure E9 also shows that lay counsellors were also the 

major providers of post-test counselling in both districts. 

Again, more PHWs (especially nurses) were utilised in 

Thabo Mofutsanyana than in Lejweleputswa. 

Figure E9. 

68.5 

54.1 

Patients’ indication of provider type: post-test 

counselling – districts 

28.7 

40.7 

2.8 4.4 

0.0 0.7 

Lay counsellor Nurse Doctor Social worker 


Figure E10 shows patients’ indication of the location of 

their pre-test counselling. In both districts, counselling was 

most often conducted in designated counselling rooms. 

Figure E10. Patients indication of location of pre-test counselling – 

districts 

49.1 48.5 

27.0 

31.6 

23.9 

Counselling room Consultation room Other 


Figure F7 indicates that, as with pre-test counselling, posttest 

counselling was reportedly mostly conducted in 

special counselling rooms. 

19.9 

Figure E12. Patients’ indication of consent to HIV testing – 

districts 

65.8 

57.9 

31.0 

38.5 

1.3 1 1.9 2.6 

Yes, written consent Yes, verbal consent No Cannot remember 


Figure E13 shows that most of the tested patients in 

Lejweleputswa and Thabo Mofutsanyana reported 

that they had received both pre- and post-test HIV 

counselling. Significantly (p

As shown in Figure E14, a large percentage (68.3%, n=114) 

of patients in Lejweleputswa and a small majority (52.3%, 

n=104) of patients in Thabo Mofutsanyana indicated that 

their counsellors were older than they. This difference was 

statistically significant (p

• lack of privacy (Lejweleputswa, n=2; Thabo 

Mofutsanyana, n=1); 

• unacceptable staff conduct (Lejweleputswa, n=1; 

Thabo Mofutsanyana, n=3); and 

• “ no”/”too little” information received (Thabo 

Mofutsanyana, n=2). 

Patients’ estimations of the time spent on various activities 

before, during, and after HIV testing are shown in Table E9. 

On average, patients reportedly spent about forty minutes 

travelling to testing facilities Patients in Lejweleputswa 

spent significantly (p

• Motivate and emotionally support patients: e.g. 

“provide psychological support”, “support groups” 

(Lejweleputswa – 35.2%, n=119; Thabo Mofutsanyana 

– 31.4%, n=103). 

• Other: e.g. “test all patients”, “involve police”, “no 

treatment without HIV test result”, “mobile testing”, “involve 

tested patients”, “group and couple counselling”, “give 

proper counselling”, “provide incentives” (Lejweleputswa 

– 10.7%, n=36; Thabo Mofutsanyana – 7.0%, n=23). 

Figure E19. 

Patients’ ideas how health workers can encourage 

uptake of HCT – districts 

Figure E20. 

56.0 57.2 

Motivate/support 

emotionally 

Patients’ ideas how others can encourage uptake of 

HCT – districts 

17.9 

10.7 

Get involved 

in TB-HIV 

6.8 

10.4 

Do not stigmatise 

15.6 

12.1 

Do not know 

% Lejweleputswa (n=338 citations) % Thabo Mofutsanyana (n=328 citations) 

3.7 

Other 

9.5 

38.5 

54.0 

35.2 

31.4 

15.7 

7.6 

10.7 

7.0 

E4.12 Patients’ suggestions of factors that discourage 

uptake of HCT 

Figure E21 presents patients’ reasons for non-uptake of 

HCT. In both districts the largest group of reasons for nonuptake 

of HCT was categorised as “indecisiveness”. 

TB-HIV IEC 

Motivation and 

support 

Do not know/ 

no suggestion 


Figure E21. 

Patients’ reasons for non-uptake of HCT – districts 

37.5 36.4 

18.0 20.5 10.2 


E4.11 Patients’ suggestions of how others can 

encourage uptake of HCT 

Concerning what other people (e.g. family, friends, and 

community members) could do to encourage more TB 

patients to test for HIV (Figure E20), just over half of all 

suggestions in both districts (Lejweleputswa: 56.0%, n=197; 

Thabo Mofutsanyana: 57.2%, n=198) indicated that other 

people should motivate and provide emotional support 

to TB patients. Examples of responses in each category are 

mentioned below: 

• Motivate and provide emotional support to patients: 

e.g. “stress the importance of HIV testing”, “encourage 

very ill patients to go the clinic”, “create support groups”, 

“care for patients” (Lejweleputswa – 56.0%, n=197; 

Thabo Mofutsanyana – 57.2%, n=198). 

• Get involved in TB-HIV awareness campaigns: e.g. 

“read pamphlets to patients”, “involve influential people 

in TB-HIV education”, “workshops”, “TB-HIV campaigns” 


– 10.7%, n=37). 

• Stop stigmatising/discriminating against patients: e.g. 

“do not judge patients”, “do not gossip about patients” 

(Lejweleputswa – 6.8%, n=24; Thabo Mofutsanyana – 

10.4%, n=36). 

• Other: e.g. “prayer”,“community should build a special TB 

hospital”, “take very ill patients to clinic”, “help patients 

without transport to clinics” (Lejweleputswa – 3.7%, 

n=13; Thabo Mofutsanyana – 9.5%, n=33). 

18.2 

Indecisiveness Fear No/low risk 

perception 

11.7 13.6 8.6 9.1 

Still dealing 


Not yet 

advised 

14.1 



The different response categories in Figure E22 may be 

explained as follows: 

• Indecisiveness: Most of the patients were undecided 

about HIV testing, e.g. “do not feel like testing”, “not 

ready for HIV test”, “need more time”, “still planning to go” 


36.4%, n=32). 

• Fear: Patients said they were afraid of the HIV test 

itself (blood taking), stigma attached to HIV, and 

consequences of testing HIV-positive, e.g. “afraid of 

people gossiping”, “fear of [side effects] of HIV treatment” 


20.5%, n=18). 

• No/low risk perception: Some patients did not 

perceive themselves at risk for HIV infection, e.g. 

“I know I am negative”, “My girlfriend tested and was 

negative”, “I have not been involved in sexual relationships 

in a long time”, “I am always careful”, “I am still fine”, “I 

trust my partner”, “I am old” (Lejweleputswa – 10.2%, 

n=13; Thabo Mofutsanyana – 18.2%, n=16). 

• Still dealing with TB: A few patients were grappling 

with TB and did not wish to subject themselves to the 

additional burden of HIV, e.g. “I’m still on TB treatment”, 

2.3 


“I’m still very sick” (Lejweleputswa – 11.7%, n=15; 


• Not yet advised: These patients stated that they had 

not been advised to test, e.g. “nurse has not yet told 

me”, “Nobody invited me” (Lejweleputswa – 8.6%, n=11; 


• Other: e.g. “I don’t know about HIV”, “I don’t know where 

to go”, “I will lose money if I am absent from work”, “The 

clinic is always full” and “the [lay counsellor] arrives late” 


– 2.3%, n=2). 

E4.13 Predictors of HIV testing 

Table E11 presents the findings of simple and adjusted 

logistic regression analyses on the variables found to be 

significantly associated with self-reported HIV testing 

among the sampled TB patients. The table shows that in 

the simple logistic regression model (i) sex, (ii) marital 

status, (iii) employment status, (iv) patient category, (v) 

knowledge of whether there is a relationship between 

TB and HIV, (vi) whether the patient received TB-HIV 

information from the TB clinic, and (vii) knowing someone 

with HIV, were all statistically significantly associated with 

self-reported HIV testing. In the final model (adjusted 

for all independent variables) knowing whether there 

is a relationship between TB and HIV was no longer 

significantly associated. 

However, due to an interaction effect between the 

variables of marital status and receiving TB-HIV information 

from clinics, unmarried patients who had received TB-HIV 

information from TB clinics were 5.4 times more likely to 

have tested for HIV compared with unmarried patients 

who had not received such information. Although not 

significant, married patients who had received TB-HIV 

information were almost twice (OR 1.9, 95% CI 0.8-4.4) as 

likely to have tested for HIV compared with those who 

were married but did not receive information on the link 


Table E11. 

Variable**** 

Sex? 

Female 

(ref: male) 

Marital status? 

Not married 

(ref: married) 

Employment? 

Unemployed 

(ref: 

employed) 

Patient category? 

Logistic regression models of variables associated with 

HIV testing – total 

Ever tested for HIV? 

Yes No 

% % 

(95% CI) (95% CI) 

56.8 

(52.3-61.2) 

75.8 

(70.5-80.4) 

89.6 

(85.4-93.0) 

41.0 

(33.2-49.3) 

68.0 

(60.8-74.5) 

76.9 

(69.0-83.3) 

Simple 

models 

Odds Ratio 

(95% CI) 

1.9 

(1.3-2.7)**** 

1.5 

(1.0-2.2)** 

2.6 

(1.6-4.1)**** 

Adjusted 

Model 

Odds Ratio 

(95% CI) 

2.3 

(1.4-3.7)**** 

0.5 

(0.2-1.1) 

2.2 

(1.2-4.1)** 

Variable**** 

Re-treatment 

(ref: new 

patient) 

Ever tested for HIV? 

Yes No 

% % 

(95% CI) (95% CI) 

43.5 

(38.2-49.0) 

29.7 

(23.6-36.6) 

Simple 

models 

Odds Ratio 

(95% CI) 

1.8 

(1.3-2.6)** 

Know about TB-HIV link? 

77.3 59.3 2.3 

Yes (ref: no) 

(71.8-82.0) (51.9-66.4) (1.6-3.4)**** 

Clinic informed about TB-HIV link? 

74.6 43.1 3.9 

Yes (ref: no) 

(69.3-79.2) (33.7-53.0) (2.7-5.6)**** 

Whether patient knows someone with HIV/AIDS? 

Yes (ref: no) 

51.1 

(46.2-56.0) 

26.2 

(20.6-32.5) 

*Only significant associations presented. 

**Significant at 5% level. 

*** Significant at 1% level. 

****Significant at 0.1% level. 

3.0 

(2.0-4.3)**** 

E5. Discussion and conclusion 

Adjusted 

Model 

Odds Ratio 

(95% CI) 

2.0 

(1.2-3.2)*** 

1.0 

(0.6-1.6) 

Unmarried 5.4 

(3.1-9.5)*** 

3.6 

(2.2-5.8)**** 

Results show that HIV testing across the two districts was 

significantly associated with the sex of patients. Female TB 

patients showed higher uptake of HIV testing than their 

male counterparts. 

Logistic regression analysis revealed that, compared with 

males, female TB patients in the current study were more 

than twice as likely to have tested for HIV. This observation 

aligns with the findings of a Ugandan study by Kizito et 

al (2008) among pregnant women and their sexual 

partners. Higher uptake of HIV testing among females in 

the present study was probably in part attributable to the 

fact that significantly (p

in Durban, found that lack of knowledge of asymptomatic 

HIV was a barrier to uptake of HIV testing. 

The logistic regression analysis furthermore showed 

that having received information about the link between 

TB and HIV was the most important predictor of selfreported 

HIV testing among TB patients. However, there 

was interaction between this variable and marital status in 

the adjusted model. On the one hand, unmarried patients 

who had received information about the relationship 

between TB and HIV were more than five times as likely 

to have undergone HIV testing compared with those who 

had not received such information. On the other hand, 

compared with those who were not informed, married 

patients who were informed about the TB-HIV link were 

twice as likely to have tested for HIV. 

These findings highlight the importance of adequately 

informing TB patients about HIV-related issues. Our 

research also reaffirms the results of a study by Mitra 

et al (2006) in Canada that, due to lack of knowledge, 

patients were initially unable to state their preferences for 

HIV testing and could only do so after the interviewers 

had explained the various testing options. Therefore, it 

should not be surprising that the leading self-reported 

reason for non-uptake of HCT in the current study was 

“indecisiveness”. Our TB patient respondents thought that 

they were not adequately informed about TB-HIV and 

were therefore not confident to take up HCT. 

Of the risk awareness variables measured, “knowing 

someone with HIV/AIDS” was significantly related to uptake 

of HIV testing among TB patients in both the districts. 

The logistic regression analysis showed that patients who 

reported knowing somebody with HIV/AIDS were over 

three-and-a-half times more likely to have undergone 

HIV testing compared with those who did not. These 

findings support research by Gebrekristos et al (2005) 

in Durban, Hutchinson & Mahlalela (2006) in the Eastern 

Cape, and Bond et al (2005) in the USA. Gebrekristos 

et al explained that witnessing HIV/AIDS in other people 

probably caused patients to reflect on the issue of HIV/ 

AIDS, which subsequently resulted in their uptake of the 

HIV test. This was especially the case when access to ART 

was available. 

In line with Jerene et al (2007) in Ethiopia, we found 

that, compared with employed patients, unemployed 

TB patients were twice as likely to have tested for HIV. 

From research among pregnant women in Côte d’Ivoire 

and Burkina-Faso, Cartoux et al (1998) established that 

employed women had a negative attitude towards HCT 

and were likely to refuse HIV testing. The researchers 

explained that employed people probably refuse HIV 

testing due to extant discrimination against HIV-positive 

people in the workplace. Another possible explanation 

is that unemployed patients spend more time at public 

health care facilities than their employed counterparts. 

Contrary to some other studies (e.g. Thomas et al 2007; 

Kanara et al 2008), current findings indicate that education 

level and age were not associated with uptake of HIV 

testing by TB patients. However, this observation probably 

needs further investigation. 

Other studies have also identified fear of stigma/HIV 

positivity as a major barrier to uptake of HIV testing (e.g. 

Iliyasu et al, 2006 in Nigeria, Nnoaham et al 2006 in the 

UK, and Daftary et al 2007 in Durban). For TB patients, 

concerns about “dual stigma” exacerbate their fear of 

testing positive for HIV. HIV counselling of TB patients 

needs to take cognisance of their feelings and beliefs about 

felt stigma (Nnoaham et al 2006). 

In conclusion, the TB patient survey found: 

• In both districts, HIV testing among TB patients was 

stronger associated with female sex. 

• The association between uptake of HIV testing and 

patient category (more re-treatment than new TB 

patients HIV-tested) was significant in Lejweleputswa. 

• In both districts, the majority of patients were not 

informed that HIV-infection may be asymptomatic. 

• In both districts, knowledge about the relationship 

between TB and HIV was associated with uptake of 

HIV testing. 

• In both districts, having received information about the 

relationship between TB and HIV was associated with 

uptake of HIV testing. 

• In both districts, knowing someone ill with HIV/AIDS 

was significantly related to uptake of HIV testing. 

• In both districts, the main barriers to uptake of HIV 

testing included patients’ indecisiveness about HCT, 

fear of stigma and HIV positivity, lack of/low HIV risk 

perception, wanting to first deal with the burden of TB, 

and HCT not yet having been offered/recommended. 

• In both districts, provision of information about TB 

and HIV was identified as the most important health 

service-related facilitating factor. 

• Patients in both districts also thought that communities 

could best facilitate uptake of HCT by providing 

emotional and motivational support to patients. 

• In both districts, predictors of HIV testing included 

having been informed about the link between TB and 

HIV, knowing someone with HIV, being female, being 

unemployed and being a re-treatment patient. 

This study identified self-reported indecisiveness about 

undertaking HCT as an important deterring factor to 

uptake of HIV testing by TB patients. Fear of stigmatisation 

and HIV positivity was also observed to de-motivate 

HCT uptake. The major health systems-related factor 

dissuading patients from accessing HCT was that patients 

reportedly had not (yet) been advised to do so at the 


TB treatment facility. Overall, uptake of HCT among TB 

patients was seemingly encouraged by the communication 

of information on the link between TB and HIV. The 

TB patient respondents also indicated a need for both 

facility-based and community-based support systems to 

aid their HCT decision-making process. 

Figure F1. Availability of CHWs – five African countries (2003/4). 

3.34 

1.41 

0.91 

0.2 0.26 

South Africa Ethiopia Nigeria Rwanda Swaziland 

Density per 1000 population 

Source: WHO (2006a: 192-197) 

Section F 

Fact finding: community health 

workers (CHWs) 

“[S]everal generations of AIDS interventions would not have 

been possible without their presence. CHWs are generally 

seen to be adding value and meeting new needs, rather 

than simply substituting for professionals” (Schneider et al 

2008: 185). 

F1. Introduction 

Community health workers 

CHWs have become an invaluable asset in diffusing 

HIV/AIDS/TB/STI prevention messages, linking facilities 

to communities, and integrating HIV-related services. 

Particularly in low-income countries, the use of CHWs has 

been identified as a core strategy to address the growing 

shortage of professional health workers (Lehmann & 

Sanders 2007: v-vi). These authors reviewed the literature 

on the feasibility and effectiveness of CHW programmes 

and report that there is much consensus on the following, 

amongst others: 

• CHWs can contribute to community development 

and improve access to and coverage of communities 

with basic health services. 

• To enable CHWs to make an effective contribution 

they must be carefully selected, appropriately trained, 

and adequately and continuously supported. 

• Numerous CHW programmes have failed because 

of unrealistic expectations, poor planning, and an 

underestimation of the efforts and inputs required to 

make them work. 

CHWs have also been identified as a cornerstone for 

integrating HIV/AIDS and PHC services (Mukerjee & 

Eustache 2007). Yet, until recently, South Africa made 

comparatively sparse use of these non-professional health 

workers (Figure F1). 

Loveday et al (2007) reported that South African CHWs 

“spoke with frustration and bitterness about the selection and 

remuneration process”, claimed that their training “had no 

system” and complained that there was “no coordination, 

support or monitoring of their work”. However, positive 

experiences with the use of CHWs, adherence counsellors 

and lay counsellors have also been documented in the 

South African context. For example, in Lusikisiki District 

in the Eastern Cape Province, Médicins Sans Frontières & 

Eastern Cape Department of Health (2006: 19) reported 

that task shifting has proven its effectiveness: “Two critical 

elements that permitted a dramatic enrolment were reliance 

on lay counsellors to do VCT and nurses to initiate HIV 

treatment.” 

The National Human Resources for Health Planning 

Framework, 2006, envisages revitalisation of the CHW 

programme. More utilisation of CHWs is necessitated by 

the dramatic increase in the need for chronic and palliative 

care (NDoH 2006: 30). Recent years have witnessed 

rapid growth across a range of CHW types, including lay 

counsellors and DOT supporters in South Africa. This 

growth has principally been in response to an expansion 

in budgets and programmes for HIV, notably the ART 

programme (Schneider et al 2008). The inclusion of PITC 

in the Tuberculosis Strategic Plan for South Africa, 2007-2011 

probably implies that further growth in the numbers and 

utilisation of CHWs will be required if more patients are 

to be referred for HCT. The resources needed to recruit, 

train, remunerate and supervise them will be substantial. 

Lay counsellors 

It has been established that lay counsellors’ presence in the 

clinic is welcomed by professional health workers (Evans 

et al 2008). The use of people with no medical experience 

in VCT has been found to be feasible in several countries, 

including South Africa (Makhetha et al 2002), Botswana 

(Kazadi et al 2008a; 2008b), Malawi (Kamanga & Gumbo 

2006), Zambia (Munansangu et al 2006), Zimbabwe 

(Ncube et al 2006), Thailand (Muang et al 2006) and India 

(Ramachandran et al 2006). However, the often-cited 

provisos for this are that CHWs should be (i) well-trained, 

(ii) well-supervised and (iii) well-supported 

A number of researchers have also raised doubts about 

the quality of services provided by lay counsellors. 

Ndabishimye’s (2004) evaluation of HIV counselling 

services in the Lejweleputswa District is a case in point: 

SECTION F • Fact finding: community health workers (CHWs) 23

• “ A general lack of adequate counselling skills by the 

counsellors was observed.” 

• “ The content of counselling did not cover all the necessary 

grounds and important issues adequately.” 

• “ The duration of counselling was short and communication 

with the clients tended to be one-way.” 

• “ Stigma, discrimination and lack of adequate awareness, 

short opening hours in some clinics, and the lack of privacy 

and confidentiality negatively affected utilisation of VCT 

services among others.” 

Chopra et al’s (2005) research is another case in point. 

These authors assessed the quality of counselling provided 

to women through the mother-to-child transmission 

(PMTCT) programme in South Africa. They found that, 

although the general quality of communication skills 

was good, the quality of the counselling in respect of 

communication of several crucial informational aspects 

was so poor that it reduced the effectiveness of the 

programme (Chopra et al 2005: 357). 

Research in Kenya on the quality and quantity of antenatal 

HIV counselling in a PMTCT programme returned equally 

negative results (Delva et al 2006): 

• The frequency and duration of counselling was low. 

• Crucial topics (e.g. the window period) were covered 

haphazardly. 

• Information was rarely repeated or summarised. 

Further concerns were raised by studies in Lesotho and 

Zimbabwe. Research on lay counsellors serving Lesotho’s 

“Know Your Status” campaign revealed that the supervision 

of lay counsellors was poor and that the quality control 

mechanisms were almost completely absent (Lohman et al 

2008). A study on counsellor experiences and perceptions 

in Zimbabwe concluded that “some clients received not only 

inappropriate services, but in some cases services that were 

psychologically harmful” (Richards et al 2006). 

There is much literature on the difficulties of and how 

to improve HIV counselling. For example, in South 

Africa, Rohleder & Swartz (2005) found that counsellors’ 

workplace issues should be taken into account when 

planning HCT services. In Uganda, Kanobe (2006) writes 

that standardisation is the key to improve the quality of 

service provision. Curriculum development should be 

continuous to keep pace with emerging issues in HCT. 

Also, regular follow-up and support supervision is necessary 

after training. In the Russian Federation, it was established 

that, despite effective training, counsellors still felt the need 

for post-training support (Demchenko 2006). 

DOT supporters 

In 2003, the South African Minister of Health set the goal 

to ensure that no more than 5% of TB patients fail to 

complete their treatment. To that end, she emphasised 

the importance of directly observed treatment (DOT) 

supporters (Tshabalala-Msimang 2003). Again in the case 

of DOT supporters the policy directives of the TB Strategic 

Plan, 2007-11, aspire to meet international standards of 

care for TB patients (NDoH 2007b: 45): “[M]easures [to 

promote adherence to treatment] should be tailored to the 

individual patient’s circumstances and be mutually acceptable 

to the patient and the provider. Such measures may include 

direct observation of medication ingestion ... by a treatment 

supporter who is acceptable and accountable to the patient 

and to the health system.” 

Directly Observed Treatment, Short course (DOTS) for 

TB is one of the most common services provided in 

the public health service in South Africa (Naidoo et al 

2008). Because DOT supporters are (i) best placed to 

build amiable relationships with patients, (ii) aware of TB 

patients’ re-treatment status, and (iii) often the first to 

spot symptoms of other HIV opportunistic infections in 

TB patients, it was imperative for them to be included as a 

surveyed interest group in the current study. 

F2. Methods and sample 

As with the other interviewed interest groups, the 

objective was to identify and illuminate barriers to as well 

as facilitators of uptake of HCT among TB patients, this 

time from the perspective of lay counsellors and DOT 

supporters (n=97). 3 

Group interviews were used. The general advantages of 

group interviews are well known. Among others, they 

provide quick and inexpensive sources of information, 

allow for collection of more detailed data, and offer 

opportunities to probe and clarify further to the initial 

response. Also, informants have the opportunity to develop 

their reactions to, and build upon, the responses of other 

participants in the group (Baker 1994: 188; Kitzinger 1995: 

311; Lindlof 1995: 174-5; Varkevisser et al 2003: 184-5). 

During September-October 2007, altogether 30 group 

interviews with lay counsellors (n=40) and DOT supporters 

(n=57) were conducted in each of the subdistricts in 

both Thabo Mofutsanyana and Lejweleputswa Districts. 

Nineteen health care facilities were included in the survey. 

Lejweleputswa: 

• Fixed PHC clinics (n=6). 

• District hospitals (n=2). 

• Regional hospitals (n=1). 

3 Nurses’ views on patient satisfaction with lay counsellor 

services are reported in par G3.5. PHWs’ views on problems 

with lay counselling are reported in par G3.6. Patients’ 

experiences of HCT and lay counselling are reported in 

par E4.8. 


Thabo Mofutsanyana: 

• Fixed PHC clinics (n=7) 

• District hospitals (n=3). 

As indicted in Figure F2, the majority (82.7%) of the 

interviewees were women. The number of participants 

per group interview ranged between two and three 

lay counsellors and between five and twelve DOT 

supporters at a time. At each facility all lay counsellors and 

DOT supporters were invited to participate. They were 

assured that their participation was voluntary and that the 

information they provide would be treated anonymously. 

Depending on the number of participants and the group 

dynamics, the discussions lasted between 30 and 50 

minutes. 

Figure F2. 

3 

8 

Male lay 

counsellor 

CHW sample – districts 

16 

13 

Female lay 

counsellor 

2 

4 

Male DOT 

supporter 


25 26 

Female DOT 

supporter 

The semi-structured interview schedules for both the lay 

counsellors and the DOT supporters included questions 

about perceived barriers to and facilitators of uptake of 

HCT by TB patients. The instruments were translated 

into Sesotho and IsiXhosa and pre-tested to ensure 

comprehensibility and practicality. The facilitators of the 

group discussions were fluent in the local languages spoken, 

i.e. Sesotho and IsiXhosa. Respondents were asked for 

their permission to use an audio recorder. The discussions 

were then facilitated by one person, while another took 

notes to supplement the information on the audio tapes. 

Qualitative data analysis examines patterns of similarities and 

differences, and involves organising data into categories on 

the basis of themes (Neuman 2000: 418). The information 

gathered in the group discussions with lay counsellors 

and DOT supporters was transcribed verbatim from the 

audiotapes. The data were then thematically transcribed 

and analysed by two persons. 

F3. Findings 

It was established that, across the two districts, lay 

counsellors on average had undergone ten days of training, 

while the DOT supporters typically underwent the more 

comprehensive 59-day home-based care training course. 

In both districts, the lay counsellors were trained by the 

Departments of Health and Social Welfare, while DOT 

supporters were trained by the South African National 

Tuberculosis Association (SANTA) and the Department 

of Health. The work days and work hours of both the lay 

counsellors and the DOT supporters was also the same, 

i.e. five days a week and four hours per day. However, 

a large difference in the number of clients seen per lay 

counsellor per day was observed (i.e. five patients per day 

in Lejweleputswa compared with 15 patients per day in 

Thabo Mofutsanyana). 

Table F1 indicates responsibilities other than counselling 

and treatment support undertaken by lay counsellors 

and DOT supporters in PHC clinics and hospitals. These 

data corroborate a recently observed trend towards 

a more multifaceted CHW role in ART facilities in the 

Free State (Schneider et al 2008). The authors note that 

one of the key elements of the South African National 

CHW Policy, 2004 is that it allows for both generalist and 

single-purpose CHWs, thus “proposing better coordination 

of [CHWS] at community level”. One of their subjects 

remarked: “The thing is we now have patients on ARVs, so 

we do follow-ups for those who miss return dates. We also do 

counselling, home-based care and drug readiness [training]. 

We rotate, for example, if I do home-based care today, I do 

counselling tomorrow” (Schneider et al 2008: 183). 

Table F1. 

Mean number 

of days trained 

Training by 

Mean work 

days/week 

Mean work 

hours/day 

Mean clients 

per day/in 

care 


responsibilities 

F3.1. 

CHW sample: training, other responsibilities, work 

hours, number of patients – districts 


Lejweleputswa 

Thabo 

Mofutsanyana 


Lejweleputswa 

Thabo 

Mofutsanyana 

10 10 59 59 

• Dept of 

Health 

• Dept of 

Social 

Welfare 

• Dept of 

Health 

• Dept of 

Social 

Welfare 

• SANTA 

• Dept of 

Health 

• SANTA 

• Dept of 

Health 

5 5 5 5 

4 4 4 4 

5 15 6 5 

• Health 

talks 

• PMTCT 

• Drug 

readiness 

training 

• ARV 

treatment 

support 

• Assist clerk 

• Awareness 

campaigns 

• Counselling 

• Homebased 

care 

• Drug 

readiness 

training 

• Home-based 

care 

• Door-todoor 

health 

education 

• ARV 

treatment 

support 

CHWs’ views on barriers to HCT uptake by 


As indicated in Table F2, patients’ fear or denial of the 

possibility that they may be HIV-positive, as well as their 

fear of TB-HIV co-infection and/or fear of death, was the 

most common reason CHWs advanced for non-uptake 

of HCT by TB patients. This fear, they argued, was linked to 

patients’ anxiety about being stigmatised or discriminated 

against, should they test HIV-positive. According to many 

SECTION F • Fact finding: community health workers (CHWs) 25

of the CHWs interviewed, patients also sometimes did 

not trust the confidentiality of their HIV test results to 

be assured – neither in the clinic/hospital (nurses and lay 

counsellors), nor in the community. 

Table F2. 

CHWs’ suggestions of main barriers to uptake of HCT 

by TB patients – total 

Fear/denial of HIV-positivity/TB-HIV co-infection/death 

“HIV is a feared disease.” 

“Clients who are ill with TB don’t want to test, because they fear having 

both TB and HIV.” 

“They are avoiding testing, because they think that if one has TB, they 

already have HIV.” 

“Patients are afraid to know that they have TB and HIV.” 

“One finds patients who just do not want to test, because they are afraid 

of the truth.” 

“Death is feared by many people in the community.” 

“People say when you test for HIV and find out that you are positive, you 

die faster.” 

“Some are very ill with TB and are now afraid to test for HIV, because 

they will die.” 

Stigmatisation/discrimination 

“Since not all of the community understand HIV and TB, some still do not 

want to accept ill people carrying any of the diseases.” 

“Patients are still been discriminated against out there.” 

“Patients say people with TB and HIV are not treated the same by other 

people.” 

“Patients feel discriminated when there is a separate place for testing at 

clinics.” 

“Others fear they will be treated differently in their homes and in their 

community, if they test and find out that they are HIV-positive.” 

“The community have already labelled TB patients as being HIV-positive.” 

“HIV carries a stigma to its name, so people are afraid to test as they do 

not want to have the stigma.” 

Confidentiality 

“Patients still do not trust that their results are strictly confidential.” 

“They also say that there is no confidentiality when it comes to HIV.” 

“People say that the nurses and the lay counsellors gossip a lot.” 

“The community talks too much.” 

“People from the community do not trust us as lay counsellors.” 

Lack of support 

“Family and friends still fail to give their support to those that are ill.” 

“Some families chase people with AIDS out of their homes telling them 

that they do not belong there.” 

“When people are HIV [positive] they are rejected by the families and 

community.” 

Posters in English 

“Posters that are in English are not easy to understand as it is not a 

mother tongue to all.” 

ARV waiting period 

“Some patients say, if they test and find out that they are HIV-positive, 

they will have to be put on the long waiting list, and they will die before 

they even get help.” 

felt that nurses could be more effective in referring and 

encouraging TB patients to “VCT rooms”. The same applied 

to doctors, although the shortage of doctors was less often 

remarked on. In respect of what they themselves could 

do to encourage HCT uptake by TB patients, the CHWs 

mostly agreed on two notions: (i) they should (continue 

to) encourage patients, and (ii) there should be more lay 

counsellor outreach in the community. 4 The suggestion 

that HCT should be offered door-to-door HCT was often 

voiced. 

Table F3. 

CHWs’ suggestions of main facilitators of uptake of 

HCT by TB patients – total 

Nurses 

“There is a great shortage of nurses, so if they could be increased they 

would be able to help all patients and not have to send some home.” 

“More patients co-operate with the nurses, so if they could get more 

nurses then a lot would change.” 

“They should encourage everyone who coughs to come to the VCT room.” 

“Nurses at casualty should also encourage patients to test. All nurses 

should refer all patients to the VCT room.” 

Doctors 

“Patients are afraid of doctors, so they listen to whatever the doctor tells 

them to do. Like testing for HIV.” 

“When patients have been seen by the doctor, they go more willingly to 

the clinic to test.” 

“Doctors don’t come to the clinic every day; so firstly, there should be a 

permanent doctor at every facility, because patients listen when a doctor 

tells them to test.” 

“Doctors should not tell patients that they are HIV-positive without 

counselling them first.” 

“Even the private doctors must encourage patients to test.” 


“We should carry on encouraging patients.” 

“They should help us do door-to-door and test patients outside of the 

clinic.” 

“We must still keep encouraging patients – not just those that come to 

us, but all patients coming to the clinic.” 

“They should give counselling outside of the clinic.” 


“They should have more door-to-door.” 

“We should be involved in community activities and go talk at churches.” 

“They must be able to handle more patients and keep encouraging them 

to come and test.” 

“We should also work at hospitals and be able to encourage the TB 

patients to test.” 

Community 

“The community should attend [TB-HIV/AIDS IEC] activities.” 

“They should advise each other to live healthier lives.” 

“The community must learn to support the ill.” 

“People must be able to take care of each other as a community.” 

F3.2. 

CHWs’ views on facilitators of HCT uptake by 


To facilitate the group discussion about facilitators of HCT 

uptake by TB patients, CHWs were asked what could 

be done respectively by nurses, doctors, lay counsellors, 

DOT supporters and the community. Table F3 lists the 

most common responses. In respect of nurses, the lay 

counsellors, firstly, complained of severe effects of nurse 

shortages in the facilities where they work. Secondly, they 

4 Cf par. J4.2 for the district research feedback workshop 

attendees’ suggestions of how CHWs could improve HCT 

uptake by TB patients. 


F4. Discussion and conclusion 

Given the dire shortage of qualified health professionals 

in South Africa, public health services are very reliant on 

CHWs in their response to the TB and HIV/AIDS epidemics. 

Especially since the commencement of public-sector ART 

rollout in 2004, this reliance has increased. Not only are 

there more CHWs; they are also becoming more multiskilled. 

The traditional boundaries of DOTS for TB patients 

and ART support for PLWHAs are becoming blurred. 

CHWs, such as lay counsellors and DOT supporters, are 

increasingly becoming involved in both TB and HIV/AIDS 

prevention, diagnosis, treatment and care. 

The interviewed CHWs perceived TB patients’ fear of HIV 

and/or TB-HIV, as well as their fear of stigmatisation should 

they test HIV-positive, to be the most important barriers 

to HCT uptake. Hence, the most often voiced suggestion 

to facilitate HCT among TB patients was that the patients 

should be continuously encouraged and motivated. 

Essentially this means that health workers should engage 

with patients about their fear of HIV-positivity, TB-HIV coinfection 

and death. TB patients should thus be informed 

(especially by doctors and nurses) of the preventive and 

prognostic advantages of early HIV/AIDS diagnosis. 

Section G 

Fact finding: professional 

health workers (PHWs) 

“Sub-Saharan Africa faces the greatest challenges. While it 

has 11 percent of the world’s population and 24% of the 

global burden of disease, it has only 3 percent of the world’s 

health workers” (WHO 2006b). 

G1. Introduction 

In anticipation of the introduction of TB-HIV collaborative 

services, research was recently conducted in western 

Kenya to identify barriers to providing quality diagnostic 

HIV testing and counselling (DTC) and HIV treatment for 

TB patients. This study – utilising interviews with health 

workers responsible for TB care, inspection of facilities, 

collection of service delivery data, and self-administered 

questionnaires on training attended – revealed the 

following barriers to HIV testing among TB patients (Van’t 

Hoog et al 2008: S32): 

• Most facilities (72%) advise HIV testing only if HIV is 

suspected in TB patients. 

• Unaccommodating TB clinic schedules. 

• Lack of space compromising confidential discussion. 

• Need to refer for HIV testing and/or HIV care. 

In the past few years, there has been a great increase in 

the capacity for HCT in sub-Saharan Africa, mostly through 

expansion of services offering rapid testing by nurses or 

primary care counsellors (Matambo et al 2006: 569). 

Gaining understanding of the realities faced by professional 

health workers (PHWs) in implementing policies in underresourced 

settings is important, because research has 

revealed that processes of policy development have often 

neglected input from these frontline health care providers 

(e.g. Phaladze 2003; Edwards & Roelofs 2007). Walker & 

Gilson (2004: 1256) found that nurses in South Africa 

resented the lack of consultation about new policies. These 

authors report that 38% of nurses claimed that they first 

heard about new policies through the media: “Nurses also 

felt far removed from health authorities. They pointed to a 

large gulf between policy makers and front-line providers. This 

led to a sense of disregard for health policy in general and a 

narrow focus on their own particular clinic and patients.” 

In PITC, the onus is on PHWs to offer HCT to all TB 

patients. If the patient refuses HCT, the PHW has numerous 

opportunities during the course of TB treatment to (i) 

determine why the patient refused HCT; (ii) re-emphasise 

the importance of and re-offer counselling and testing; 

(iii) inform patients of the availability of ART; and (iv) 

encourage patients who are HIV-negative to remain 

uninfected (Fujiwara et al 2005:954). 

Hence, the importance of the PHW’s role in ensuring TB 

patients’ uptake of HCT. However, a literature search on 

PHWs’ ( particularly nurses’) experiences of and attitudes 

towards providing HCT, revealed a relative absence of such 

research and information. One study of nurses’ experiences 

of providing VCT in Limpopo Province reported a lack 

of counselling rooms, educational materials, rapid HIV 

testing kits, consent forms, human resources and time for 

counselling (Mavhandu-Mudzusi et al 2007:256-257, 260). 

Further to this research, the nurses expressed concerns 

about patients being stigmatised, and indicated doing all 

in their power to prevent this from happening, e.g. HIV 

counselling rooms were not labelled as such. In another 

study among nurse counsellors providing PHC for mine 

employees in the Free State, nurses identified patients’ 

fear of a positive HIV test result and that they would be 

stigmatised and lose their jobs as a result, as a main barrier 

to uptake of HIV testing (Ginwalla et al 2002). 

The current exploratory and descriptive study set out 

to investigate frontline PHWs’ perceptions of the factors 

facilitating or discouraging TB patients from undergoing 

HCT in two districts of the Free State Province. So doing, 

the research contributes to understanding of PHWs’ 

perceptions of the feasibility of the provider-initiated or 

routine HIV counselling and testing policy. 

SECTION G • Fact finding: professional health workers (PHWs) 27

G2. Methods and sample 

G2.1 Sampling of facilities and respondents 

Facilities and respondents were selected through a 

process of multistage cluster sampling, stratifying for district, 

subdistrict and facility type. All TB reporting units in each 

of the five subdistricts in Lejweleputswa (Matjhabeng, 

Masilonyana, Thokologo, Tswelopele and Nala) and Thabo 

Mofutsanyana (Maluti-a-Phofung, Nketoana, Setsoto, 

Dihlabeng and Phumelela) were listed alphabetically and 

categorised according to type (mobile clinic, fixed clinic, 

district hospital and regional hospital). In each subdistrict 

area where all four types of facilities occurred, four fixed 

clinics, one mobile clinic, one district hospital and one 

regional hospital were randomly selected using a table 

of random numbers. In local service areas without all 

categories of facilities, it was necessary to adjust the number 

of each type of facility selected. In total, 26 fixed clinics, ten 

mobile clinics and eight hospitals located across 26 towns 

in ten subdistricts were sampled (Table G1). All facilities, 

except for two mobile clinics (one each in Lejweleputswa 

and Thabo Mofutsanyana), provided HCT services. 

Table G1. 

Facilities sampled for PHW survey – district, total 

Facility type Lejweleputswa Thabo Mofutsanyana Total 

Fixed clinic 13 13 26 

Mobile clinic 5 5 10 

Regional hospital 1 1 2 

District hospital 3 3 6 

Total 22 22 44 

A total of 81 respondents (41 in Lejweleputswa and 40 in 

Thabo Mofutsanyana) – including clinic managers, hospital 

nursing services managers, doctors, nurses responsible 

for the TB and HIV/VCT programmes – and mobile clinic 

nurses participated in the research. 

Table G2. 

PHW sample per district and facility type – district, 

total 

Lejweleputswa 

Thabo 

Mofutsanyana 

Total 

Fixed clinic 

Manager 4 1 5 

Manager/TB/HIV nurse 6 5 11 

Manager/TB nurse 2 4 6 

Manager/HIV nurse 1 3 4 

TB/HIV nurse 2 1 3 

TB nurse 3 3 6 

HIV nurse 4 4 8 

Mobile clinic 

Nurse 5 5 10 

Hospital 

Nursing services 

manager 

4 4 8 

Doctor 4 4 8 

TB nurse 3 2 5 

HIV nurse 2 2 4 

TB/HIV nurse 1 2 3 

Total 41 40 81 

G2.2 Instrument 

A structured interview schedule, comprising both openand 

closed-ended questions, was developed, subjected 

to expert commentary, and pilot-tested for clarity and 

usability. The instrument elicited professional health 

workers’ views on the following issues related to HCT 

among TB patients: 

• human resource availability; 

• operating hours; 

• space and location; 

• referral procedures; 

• waiting times; 

• patients’ satisfaction with lay counsellors; 

• problems with HCT procedures; and 

• factors perceived to encourage/discourage uptake of 

HCT among TB patients. 

G2.3 Data gathering and analysis 

The data gathering took place in September 2007. 

Appointments for individual interviews were made at 

each facility with the managers, concerned nurses and, 

where applicable, doctors. Informed consent was obtained 

prior to conducting an interview. All data were coded 

and captured in SPSS. Frequencies and percentages were 

calculated and presented in distribution tables. 

G3. Findings 

G3.1. 

PHWs’ views on human resources for HCT 

The advancement of comprehensive PHC is hampered 

by shortages of nurses in the public health sector. In 2007, 

the Health Systems Trust noted that 35.7% of public 

sector nursing posts were vacant in the Free State, while 

36.3% were vacant in the country as a whole (Day & 

Gray 2007: 310). More recently, Daviaud & Chopra (2008) 

reported as follows on a study estimating human resources 

requirements for PHC in South Africa by using the WHO 

Workload Indicators of Staff Need (WISN) tool 5 : 

• “ There is 94% of the required number of professional 

nurses but with wide variations between districts, with a 

few districts having excesses while most have shortages.” 

• “ The number of enrolled nurses is 60% of what it should 

be.” 

• “ There are 17% too few enrolled nurse assistants. 

5 This WISN tool entails setting activity standards and standard 

workloads and applying annual work rates to annual statistics 

to show how many staff in each category are required to 

accomplish a workload to acceptable professional standards 

(Peter J. Shipp Initiatives Inc 1998). 


While two-thirds of the clinic managers (69.2%, n=18) 

in the current study reported having insufficient nurses 

to provide HCT for TB patients (Lejweleputswa, n=10; 

Thabo Mofutsanyana, n=8), almost three-quarters (73.1%, 

n=19) indicated that there were enough lay counsellors 

(Lejweleputswa, n=8; Thabo Mofutsanyana n=11) to 

provide this service. The situation was less favourable 

at hospitals, with only one nursing services manager (in 

Lejweleputswa) of the opinion that there were sufficient 

numbers of nurses to provide HCT for TB patients. With 

regard to the availability of lay counsellors, four of the 

eight HIV hospital nursing services managers indicated 

that there were sufficient lay counsellors to attend to 

patients coming for HCT. 

The majority of nurses responsible for the TB and/or HIV 

programmes were reportedly trained in both TB (86.7%, 

n=52) and HIV (78.3%, n=47). The Practical Approach 

to Lung Health and HIV/AIDS in South Africa (PALSA 

Plus) (46.7%, n=28) and HIV&AIDS/STI/TB (HAST) 

(41.7%, n=25) training was attended by less than half 

of the respondents (Table G3). PALSA Plus training was 

particularly lacking in Thabo Mofutsanyana (35.5%, n=11) 

compared with Lejweleputswa (58.6%, n=17). Slightly 

more than half of the nurses (56.7%, n=34) were trained 

to provide HIV counselling, with Lejweleputswa (41.4%) 

being worse off in this regard. 

Table G3. 

Nurses’ TB and HIV-related training – district, total 

Lejweleputswa 

(n=29) 

Thabo 

Mofutsanyana 

(n=31) 

Total 

(n=60) 

n % n % n % 

TB 26 90.0 26 83.9 52 86.7 

HIV 21 72.4 26 83.9 47 78.3 

HIV counselling 12 41.4 22 71.0 34 56.7 

PALSA Plus 17 58.6 11 35.5 28 46.7 

HAST 8 27.6 17 54.8 25 41.7 

G3.2 PHWs’ views on operating hours 

HCT was available at all fixed clinics from Monday to Friday 

(Table G4). At most clinics (73.1%, n=19), this service was 

available eight hours per day. 

Table G4. 

Times HCT is offered at fixed clinics – district, total 

Lejweleputswa 

(n=13) 

Thabo 

Mofutsanyana 

(n=13) 

Total 

(n=26) 

n % n % N % 

Mon-Thur 

4 hours/day 

3 23.1 1 7.7 4 15.4 

Mon-Thur 

7 hours/day 

1 7.7 1 7.7 2 7.8 

Mon-Thur 

8 hours/day 

9 69.2 11 84.6 20 76.9 

Fri 4 hours/day 4 30.8 1 7.7 5 19.2 

Fri 7 hours/day 1 7.7 1 7.7 2 7.7 

Fri 8 hours/day 8 61.5 11 84.6 19 73.1 

Similarly, all hospitals offered HCT at least five days 

a week from Monday to Friday, with two hospitals in 

Lejweleputswa also offering this service on weekends 

(24 hours). While HCT was generally available all day at 

hospitals in Lejweleputswa, this service was only available 

half days in Thabo Mofutsanyana hospitals. Mobile clinics 

offered HCT at every visit, however, visits to a particular 

service point tended to be at least a month apart. Most 

mobile clinics in Thabo Mofutsanyana visited a particular 

point every four weeks, with one mobile visiting a point 

every two weeks. This varied in Lejweleputswa, where 

three mobiles visited a point every six weeks and two 

visited every four weeks. 

G3.3 PHWs’ views on space and location 

Slightly less than half of the clinic managers (Lejweleputswa, 

n=7; Thabo Mofutsanyana, n=5) and HIV nurses 

(Lejweleputswa, n=6; Thabo Mofutsanyana, n=5) reported 

that there was insufficient space to provide private HCT 

for TB patients. The HIV nurses pointed out that: 

• The rooms were too small (Lejweleputswa, n=1). 

• There was no specific room(s) for counselling 

(Lejweleputswa, n=3; Thabo Mofutsanyana, n=4). 

• There was only one room for counselling 

(Lejweleputswa, n=2). 

The availability of space at hospitals for HCT was 

somewhat problematic, with three of the eight nursing 

services managers reporting inadequate space. Two 

hospitals in Lejweleputswa did not have a dedicated room 

for HIV counselling and considered the space available as 

being inadequate. One hospital in Thabo Mofutsanyana 

reported that the counselling rooms had thin walls and 

this compromised the privacy of counselling sessions. 

G3.4 PHWs’ views on waiting times 6 

Overall, the PHWs reported that patients did not spend 

much time waiting for HCT (Table G5). Reportedly, far 

more patients in Thabo Mofutsanyana (76.9%, n=10 

facilities) spent no time waiting for HIV pre-test counselling 

compared with patients in Lejweleputswa (46.2%, n=6 

facilities). In contrast, more patients in Lejweleputswa 

(76.9%, n=10 facilities) did not wait to be tested for HIV 

compared with patients in Thabo Mofutsanyana (46.2%, 

n=6 facilities). Across the two districts, most patients 

(88.5%, n=23 facilities) reportedly received post-test 

counselling as soon as the test results were available. 

6 Cf par. E4.8 for patients’ reports of waiting times. 


Table G5. Time patients spend waiting for HCT at clinics – 

district, total 

Lejweleputswa 

(n=13) 

Thabo 

Mofutsanyana 

(n=13) 

Total 

(n=26) 

Pre-test counselling 

No waiting 6 46.2 10 76.9 16 61.5 

30 min or less 5 38.5 3 23.1 5 19.2 

An hour 1 7.7 0 0 1 3.8 

Till afternoon 1 7.7 0 0 1 3.8 

Testing 

No waiting 10 76.9 6 46.2 16 61.5 


Post-test counselling 

As soon as 

results are 12 92.3 11 84.6 23 88.5 

available 


Similarly, HIV nurses at hospitals reported that patients 

generally did not spend much time waiting to receive 

HCT. At two hospitals in Lejweleputswa, patients spent 

less than 15 minutes waiting for pre-test HIV counselling, 

while the three hospitals in Thabo Mofutsanyana ensured 

that patients spent no time waiting for pre-test counselling. 

Overall, patients spent no time waiting to have the HIV 

test. At one hospital in Lejweleputswa patients waited 

less than 15 minutes for post-test counselling. 

G3.5 Nurses’ views on patients’ satisfaction with lay 

counsellors 

More than half of the nurses at the fixed clinics and hospitals 

(57.6%, n=19) were of the opinion that patients were 

generally satisfied and comfortable with being counselled 

by lay counsellors. 7 Schneider et al’s (2008) report on a 

study entailing interviews with nurses at 16 ART facilities 

also showed that the majority of professional nurses were 

positive about the contribution made by CHWs in their 

clinics, “referring not only to their counselling and educational 

functions but also to their roles as mediators between the facility 

and the community”. It is noteworthy that approximately 

four in ten patients in the patient survey total sample who 

were counselled by a nurse actually would have preferred 

a lay counsellor (cf Section F). A possible explanation for 

this is that patients might feel less social distance between 

themselves and lay counsellors than between themselves 

and more highly educated PHWs. The highest level of 

formal education for more than 60.0% of the patient 

respondents was secondary school. 8 

Reasons provided by the nine clinic nurses as to why (some) 

patients were not comfortable receiving counselling from 

lay counsellors included: 

7 Cf par. E4.8 for a discussion of patients’ preferences for 

professional vs. lay counsellors. 

8 Cf Table E1. 

• Patients prefer counselling by nurses (Lejweleputswa, 

n=2; Thabo Mofutsanyana, n=4). 

• Patients do not trust lay counsellors (Lejweleputswa, 


• Patients do not want to be counselled by young/ 

inexperienced lay counsellors (Thabo Mofutsanyana, 

n=1). 

It was the opinion of 78.8% (n=26) of the respondents 

at fixed clinics and hospitals that lay counsellors were 

capable of providing HIV counselling (Table G6). More 

nurses in Lejweleputswa (88.2%, n=15) than in Thabo 

Mofutsanyana (68.8%, n=11) shared this opinion. 

Table G6. 

Nurses’ views whether lay counsellors are capable of 

counselling – district, total 

Lejweleputswa 

Thabo 

Mofutsanyana 

Total 

Yes 15 88.2 11 68.8 26 78.8 

No 2 11.8 4 25.0 6 18.2 

Some are 

and some 0 0 1 6.2 1 3.0 

are not 

Total 17 100.0 16 100.0 33 100.0 

G3.6 PHWs’ views on problems experienced with 

the process of HIV counselling 

The problems the PHWs suggested in respect of HCT 

services for TB patients related to the following: lay 

counsellors, nurses, patients and the health system. 


• Lay counsellors provide patients with too little 

information (Lejweleputswa, n=1; Thabo Mofutsanyana, 

n=1). 

• Some patients prefer to see a nurse and not a lay 

counsellor (Lejweleputswa, n=1). 

• Patients do not trust lay counsellors (Lejweleputswa, 

n=2). 

Nurses 

• Some patients are uncomfortable with young nurses 

doing counselling (Thabo Mofutsanyana, n=1). 

• Nurses have not been trained to do counselling 

(Lejweleputswa, n=3). 

• Language barriers (Lejweleputswa, n=5). 

Patients 

• Patients are not emotionally ready for HCT 


• Patients do not listen during counselling (Thabo 



• Patients lack knowledge about HIV (Lejweleputswa, 


• Cultural beliefs of patients interfere with advice and 

treatment (Lejweleputswa, n=2). 

• Stigmatisation surrounding HIV (Thabo Mofutsanyana, 

n=3). 

• Patients do not understand what they are told during 

counselling (Lejweleputswa, n=2; Thabo Mofutsanyana, 

n=3). 

Health system 

• Long waiting times for HCT (Lejweleputswa, n=1). 

• Lack of private space for counselling (Lejweleputswa, 

n=1). 

• Staff shortages means that nurses spend too little 

time with patients (Lejweleputswa, n=2; Thabo 


G3.7 PHWs’ views on factors discouraging and 

encouraging uptake of HCT 

PHW respondents were asked to indicate possible factors 

preventing/discouraging patients from going for HCT 

(Table G7). Slightly less than two-thirds of the respondents 

(60.0%, n=38) – although more so in Thabo Mofutsanyana 

(n=22, 73.3%) than in Lejweleputswa (53.3%, n=16) – 

reported that there were factors discouraging patients 

from accessing HCT services. 

Table G7. 

PHWs’ ideas re. factors discouraging uptake of HCT by 

TB patients – district, total 

Lejweleputswa 

Thabo 

Mofutsanyana 

n % n % n % 

Patient-related 

Stigma surrounding HIV 8 19.5 7 14.6 15 16.8 

Patients deny that they may 

have HIV/ fear that they may 8 19.5 2 4.2 10 11.2 

have HIV 

Patients do not want to be 

counselled by lay counsellors 

(they know them, loss of 

5 12.2 4 8.3 9 10.1 

confidentiality) 

Patients prefer to cope with 

one disease at a time (first TB 1 2.4 6 12.5 7 7.9 

and then HIV) 

Patients lack information about 

HIV 

2 4.9 2 4.2 4 4.5 

Farm patients are not able to 

leave the fields and visit the 1 2.4 2 4.2 3 3.4 

mobile 

Very sick patients do not go for 


2 4.9 0 0 2 2.2 

Traditional beliefs of patients 2 4.9 0 0 2 2.2 

Total 

Lejweleputswa 

Thabo 

Mofutsanyana 

n % n % n % 

Facility-related 

Lack of space/counselling rooms 

and subsequent lack of privacy 

4 9.8 9 18.8 13 14.6 

Specific waiting areas and 

rooms for counselling (lack of 3 7.3 7 14.6 10 11.2 

confidentiality) 

Long waiting times (often due 

to insufficient counselling rooms 3 7.3 3 6.3 6 6.7 

and too few lay counsellors) 

Lay counsellors are too busy/ 

unavailable and patients are 1 2.4 1 2.1 2 2.2 

asked to return the next day 

Lack of after-hour lay counsellor 

services 

0 0 2 4.2 2 2.2 

Staff-related 

Lay counsellors and DOT 

supporters not confident to 

do counselling/lack training and 

0 0 2 4.2 2 2.2 

supervision 

Negative attitudes of nurses 

towards patients 

0 0 1 2.1 1 1.1 


Poor weather 1 2.4 0 0 1 1.1 

Total 41 100.0 48 100.0 89 100.0 

While a third of the responses were categorised as 

“facility-related” factors that deter uptake of HCT by TB 

patients, slightly more than half of the responses illustrated 

that “patient-related” factors discouraged TB patients from 

taking up HCT. 

Patient-related factors 

• Stigma surrounding HIV (16.8%, n=15). 

• Patients deny that they may have HIV/ fear that they 

may have HIV (11.2%, n=10). 

• Patients do not want to be counselled by lay counsellors 

(they know them, loss of confidentiality) (10.1%, n=9). 

• Patients prefer to cope with TB and then HIV (7.9%, 

n=7). 

Facility-related factors 

• Lack of space/counselling rooms and subsequent lack 

of privacy (14.6%, n=13). 

• Specific waiting areas and rooms for counselling (lack 

of confidentiality) (11.2%, n=10). 

• Long waiting times (often due to insufficient counselling 

rooms and too few lay counsellors) (6.7%, n=6). 

Most respondents (with the exclusion of one in 

Lejweleputswa and two in Thabo Mofutsanyana) reported 

that, despite all the negative factors that discouraged 

patients from going for HCT, there were also numerous 

positive factors that enabled patients to opt for this service 

(Table G8). 

Total 


Table G8. 

PHWs’ ideas re. factors encouraging uptake of HCT by 

TB patients – district, total 

Lejweleputswa 

Thabo 

Mofutsanyana 

n % n % n % 

Facility-related 

Health education and counselling 21 30.9 20 26.7 41 28.7 

Sufficient privacy at the facilities 2 2.9 8 10.7 10 6.7 

Advertise VCT (e.g. posters) 2 2.9 4 5.3 6 4.2 

Easy access 2 2.9 1 1.3 3 2.1 

A translator is used during 


1 1.5 0 0 1 0.7 

Staff-related 

Staff encourage patients to go 4 5.9 9 12.0 13 9.1 

Positive attitude of nurses and lay 

counsellors 

3 4.4 7 9.3 10 6.7 

Staff re-offer HCT 1 1.5 4 5.3 5 3.5 

Trustworthy lay counsellors 1 1.5 3 4.0 4 2.8 

Strict nurses tell patients that they 

cannot refuse to be tested 

2 2.9 1 1.3 3 2.1 

Staff have a good relationship with 


2 2.9 0 0 2 1.4 

Same sex lay counsellors and 


0 0 1 1.3 1 0.7 

Treatment and support-related 

Availability of ART 14 20.6 8 10.7 22 15.4 

Availability of disability grants for 

patients with a low CD4 count 

3 4.4 1 1.3 4 2.8 

Use of ART patients to 

demonstrate how well ARVs work 

3 4.4 0 0 3 2.1 

Support groups for HIV-positive 


1 1.5 1 1.3 2 1.4 

Outreach 

Community activities (e.g. doorto-door 

visits and education 2 2.9 4 5.3 6 4.2 

campaigns) 

Very ill patients and patients who 

refuse testing are visited at home 

1 1.5 0 0 1 0.7 

Personal reasons 

Patients can choose if nurses or 

lay counsellors should do HIV 1 1.5 2 2.7 3 2.1 


Patients see other patients going 

for counselling and are encouraged 1 1.5 1 1.3 2 1.4 

to do the same 

Nurses provide counselling for 

patients who prefer not to see the 1 1.5 0 0 1 0.7 

lay counsellor 

Total 68 100 75 100 143 100 

The main factors encouraging TB patients to go for HCT 

related to the facility, staff, and availability of treatment 

and support. Facility-related issues mainly focused on the 

provision of health education and counselling for patients 

(28.7%, n=41), while staff issues highlighted the role that 

staff played in encouraging patients to go for HCT (9.1%, 

n=13), as well as the positive attitude of staff (6.7%, 

n=10). The availability of ART (15.4%, n=22) was the 

most frequently occurring treatment and support option. 

However, the scale-up of ART services in South Africa is 

subject to substantial rationing: “Consequences of rationing 

manifest in the high number of patients lost to the system 

and the difficulties faced by the most impoverished clients in 

Total 

gaining access to ART services on an ongoing basis” (Jacobs 

et al 2008: 19). 

The overwhelming majority of TB nurses, including all 

the mobile clinic nurses, (95.4%, n=42) indicated that 

TB patients were always given information about HIV 

and AIDS and advised to go for HCT. Almost all nurses 

(86.4%, n=42) who advised TB patients to go for HCT, did 

so immediately once the patient was diagnosed with TB. 

Similarly six of the eight doctors also referred patients for 

HCT immediately after a TB diagnosis. 

Re-offering HCT at every contact with the TB patient 

(60.9%, n=14) was the most frequently mentioned strategy 

for dealing with patients who refused the TB nurses’ initial 

offer of counselling and testing (Table G9). 9 

Table G9. 

PHWs’ suggested strategies to encourage HCT uptake 

at clinics – district, total 

Lejweleputswa 

Thabo 

Mofutsanyana 

n % n % n % 

Re-offer at every visit/opportunity 8 57.1 6 66.7 14 60.9 

Continued health education 2 14.3 2 22.2 4 17.4 

Refer to DOT supporters for 

further health information and 1 7.1 0 0 1 4.3 

encouragement 

Tell patients that counselling in not 

voluntary, it is compulsory 

1 7.1 0 0 1 4.3 

Do not start TB treatment until 

patient goes for counselling 

1 7.1 0 0 1 4.3 

Refer the patient to sister in charge 0 0 1 11.1 1 4.3 

Again refer patient for HCT at end 

of TB treatment 

1 7.1 0 0 1 4.3 

Total 14 100 9 100 23 100 

All clinic TB nurses reported that there were procedures 

in place to inform them whether a patient had gone for 

HIV counselling. Procedures to follow up patients who did 

not take-up HCT were in place at 23 fixed clinics (88.5%) 

(Lejweleputswa, n=11; in Thabo Mofutsanyana, n=12). 

Patients who did not go for HCT were followed up by: 

• TB nurses checking the patient files and necessary 

registers (Lejweleputswa, n=5; Thabo Mofutsanyana, 

n=4). 

• Discussions with patients about HIV counselling 


• DOT supporters and lay counsellors talking with 

patients and following up whether they went for 

counselling and testing (Lejweleputswa, n=2; Thabo 


Only one hospital in Thabo Mofutsanyana did not have a 

procedure in place for informing nurses whether patients 

9 Cf par. J4.1 for the district research feedback workshop 

attendees’ suggestions of how nurses could improve HCT 

uptake by TB patients. 

Total 


eferred for HCT actually utilised this service. Half of the 

hospitals, the majority in Lejweleputswa (three out of 

four), had a procedure in place for following up patients 

who did not go for HCT. 

G4. Discussion and conclusion 

Summarily, the main barriers that PHC nurses believe could 

discourage TB patients from accepting and undergoing 

HCT include: 

• Stigma surrounding HIV/AIDS. 

• Patients’ denial/fear that they may be HIV-positive. 

• Shortages of both nurses and lay counsellors to 

provide HIV counselling for TB patients. 

• Lack of training emphasising the integration of the TB 

and HIV&AIDS programmes. 

• Lack of adequate space for HIV counselling. 

• Lack of patient trust in the lay counsellors. 

• Lack of confidentiality due to allocated counselling 

rooms. 

On the positive side, by far most responses suggested 

that PHC facilities and nurses played an important role in 

encouraging TB patients to access HCT: 

• HCT was available weekdays at all fixed clinics and 

hospitals. 

• Reportedly, the vast majority of TB patients were 

referred for HCT, generally at diagnosis of TB. 

• A key strategy to motivate all TB patients to go for 

HCT was to re-offer this service at each visit. 

• Procedures were in place to follow up TB patients 

who did not go for HIV counselling. 

• Health education and counselling. 

• Positive attitudes of nurses and lay counsellors. 

• Availability of ART for HIV-positive patients. 

The finding that the vast majority of TB patients are 

reportedly referred for HCT is in line with international 

recommendations for PITC of TB patients, using an “optout” 

approach. Similarly, continuing to re-offer HCT to TB 

patients who refuse the offer, corresponds with Fujiwara 

et al’s (2005) suggestion that health workers should utilise 

frequent contacts with TB patients to emphasise the 

importance of and re-offer HCT. Therefore, at least from 

the nurses’ perspective, attempts are made to ensure that 

all TB patients access HCT services. 

However, as reported in other studies (cf Ginwalla et 

al 2002; Mavhandu-Mudzusi et al 2007), this study also 

highlights numerous factors that hinder patients from 

going for HCT. More particularly, the current study found 

that human resource shortages, lack of relevant training, 

inadequate space, and extended waiting times, are especially 

problematic. Also, patients’ fear of the stigmatisation that 

is perceived to accompany an HIV-positive diagnosis 

was emphasised by nurses as a barrier to uptake of HIV 

testing. Of particular concern is some nurses’ view that 

patients often do not trust lay counsellors and prefer to 

be counselled by a nurse. 

Section H 

Fact finding: programme line 

managers 

“Where policies are introduced, and bring with them extra 

resources (from internal or external sources), bureaucrats may 

be very supportive because of the increase in managerial 

resources gained by the new policy, but they may also jealously 

guard such resources ... Management and administrative 

skills are also an important resource, and where these are 

lacking, implementation may be slow or distorted” (Walt 

2000: 176). 

H1. Introduction 

Given their control of managerial resources such as 

budgets, personnel and support services, public health 

managers exert substantial bureaucratic power in the 

introduction of new policies. However, the available 

literature on line managers’ views on new health policies 

generally, and on policies pertaining to TB and HIV/AIDS 

programmes specifically, is limited. Given the importance 

of line managers’ roles in policy development and 

implementation, and in ensuring effective service delivery, 

this gap in the literature needs to be addressed. Therefore, 

this study set out to investigate line managers’ views on 

possible barriers/challenges and solutions to increase 

uptake of HCT among TB patients. Better understanding 

of such factors may facilitate the implementation of the farreaching 

and resource-intensive new PITC policy. While, 

as will be shown, there are major barriers perceived by 

line managers to deter uptake of HCT by TB patients, 

there are also significant opportunities perceived by these 

managers to have potential to rectify TB patients’ nonuptake 

of HCT. 

H2. Methods and sample 

Thirteen TB and HIV&AIDS programme managers at 

different levels were purposively selected as strategic 

informants: 

• Subdistrict level (n=3). 

• District level (n=2). 

• Provincial level (n=4). 

• National level (n=4). 

SECTION H • Fact finding: programme line managers 33

All the provincial-level managers were based in the Free 

State, and all the district and subdistrict managers in the 

study areas, Lejweleputswa and Thabo Mofutsanyana. In 

addition to authorisation obtained from the Department 

of Health for the fact-finding research as a whole, informed 

consent was obtained from each manager to conduct 

the interview, and to tape record her/his answers. The 

qualitative data were collected through semi-structured, 

individual interviews. 

Two open-ended questions were posed to each manager: 

• What barriers discourage uptake of HCT among TB 

patients? 

• What facilitators encourage uptake of HCT among TB 

patients? 

These questions were followed by ample probing to clarify 

responses. Audiotapes were typed verbatim and simple 

content analysis (Varkevisser et al 2003) of responses 

performed. Common ideas were categorised into key 

themes grounded in the managers’ accounts. 

H3. Findings 

The following sections present the findings on the 

managers’ views of barriers to and facilitators of uptake of 

HCT by TB patients. 

H3.1 Line managers’ views on the barriers to uptake 

of HCT by TB patients 

The findings regarding barriers to uptake of HCT by TB 

patients relate to two major identified themes, i.e. (i) 

patient-related and (ii) health service-related factors. 

Patient-related barriers 

Table H1 lists the identified themes and examples of the 

managers’ responses categorised as “patient-related” barriers. 

Table H1. 

Identified 

themes 

Fear of stigma 

Perceived 

lack of lack 

confidentiality 

Fear of 

(additional) 

burden of HIV 

Lack of 

knowledge 

Line managers’ ideas re. patient-related barriers to 

HCT uptake – total 

Examples 

“They fear stigma in the community.” 

“They fear stigmatisation by other patients.” 

“They fear TB-related stigma.” 

“They worry about dual stigmatisation of TB and HIV.” 

“There are stigmatising messages on posters in the 

clinics” 

“There are serious issues of trust and confidentiality.” 

“They don’t want to be sent to someone else.” 

“Patients’ have resistance to dealing with dual infection.” 

“TB is already a severe disease to deal with.” 

“Community members are mostly very uneducated 

about TB/HIV.” 

“People lack knowledge on the benefits of [HCT] for 

TB patients.” 

Among the patient-related barriers pointed out by all the 

managers, fear of stigmatisation and lack of confidentiality 

featured most prominently: 

• “ If somebody has been diagnosed with TB and might have 

HIV, we (including health care workers) do not talk about 

it as we do about any other disease. We are suppose to 

be at the level where we can talk about HIV without any 

stigma attached to it.” 

• “ Already the patient is stigmatised, because in our 

community there are those people that do not accept TB. 

So patients are already reluctant to have another stigma 

of HIV and they just don’t go for testing.” 

• “ All the other patients know that you are going to be 

tested. Even though it is not a fact that you are positive, 

others think that you are.” 

• “ In some clinics you find that patients come from the 

community around the clinic, and the people who 

are doing the counselling are lay counsellors; they are 

community people, the patients know them, and they live 

with them. The patients will not come to that particular 

facility, or they will not agree to test, but would rather go 

somewhere else to test. So there are issues of trust and 

confidentiality.” 

• “ Confidentiality plays a big role. Clinics are not really TB 

and HIV friendly. One person handles a patient and a 

rapport develops. Then the patient is sent to someone 

else for counselling and testing. They don’t feel comfortable 

with that. They don’t want to be sent to someone else.” 

One manager reflected as follows on perceived 

stigmatisation in a poster message: “Some messages can 

be deemed ... uhm, you know, misleading. Somebody brought 

me a poster saying ‘the dangerous link’, in black. A black line 

and written in white, with columns for TB, HIV and STI. I mean, 

how that could be perceived by the community, I don’t know. 

I go into the clinic and I see ‘the dangerous link’, ‘TB-HIV-STI’s’, 

I will hide my cough if I cough, or I would refuse to have an 

HIV test.” 

Health service-related barriers 

Table H2 indicates the identified themes and examples 

of the managers’ responses categorised as “health servicerelated” 

barriers. 

Table H2. 

Identified 


Staff shortage 

Line managers’ ideas re. health service-related barriers 

to HCT uptake – total 

Examples 

“There is a high number of programmes in relation to the 

number of nurses.” 

“There is a shortage of staff to manage VCT.” 

“We have a big shortage of trained lay counsellors.” 

“The clinics in general are inundated with clients with 

consequent queuing.” 


Identified 


Lack of 

integration of 

services 

Recording 

systems 

Lack of 

infrastructure 

Examples 

“There is no working conjunction between nurses and 

volunteers.” 

“The person suggesting counselling and testing does not 

actually provide these services.” 

“There is no comprehensive TB and HIV service.” 

“The link between TB and HIV is missed in the treatment 

process due to compartmentalisation of services.” 

“Statistics are unavailable or nonexistent.” 

“Patients tested are not recorded.” 

“Information on the percentage of HIV-positive patients 

screened for TB is not available.” 

“Data on HIV-positive patients on TB treatment is not 

there.” 

“TB patients’ HIV test results are not available.” 

“The available space in the facilities is not conducive to 

private counselling.” 

The line manager respondents particularly had concerns 

about the shortage of staff for PITC in facilities: 

• “ They are suffering in the clinics. There are only a few 

professional nurses that have to do all the programmes. 

[This is] a big, big, big concern.” 

• “ We don’t have enough lay counsellors trained to offer 

PITC.” 

In respect of a lack of integration of services, some 

managers argued: 

• “ For me, the very person who suggested I go for TB and 

HIV testing should do the counselling and the testing, 

because I’ve already established a relationship with that 

person. Now people are told to test by the nurse, then the 

patient must move to another room for VCCT and, instead 

of the patient going to the other room, he/she just walks 

out of the clinic. So there is no correct channelling of the 

patients.” 

• “ The main reason they [TB patients] become lost, is 

because we do not have a comprehensive TB and HIV 

service that is available from one service-provider.” 

• “ The patient has got TB, but it is not known that that 

patient has TB. The patient goes to the clinic for whatever 

reason and is tested for HIV, but this is not linked to TB. 

This patient does not come up as a patient who has 

been tested for TB and is also HIV-positive. The issue of 

integration is lost in the process.” 

The TB-HIV recording system in clinics was also described 

as problematic 10 : “The recording is a problem, I remember at 

some stage I had a problem where I wanted to look at their 

statistics and all that, and I started to talk to them and ask 

them ‘where are your figures?’ But ... patients are tested, but 

it is not recorded. There’s no system in between patients who 

have been seen in the TB room that have been transferred 

to the VCCT room. The counsellors are not recording the 

information.” 

H3.2 Line managers’ views on the facilitators of 

uptake of HCT by TB patients 

The line managers’ views regarding factors that facilitate 

uptake of HCT by TB patients related to two major and 

closely related themes, i.e. (i) health service-related-related, 

and (ii) health worker-related factors. 

Health service-related facilitating factors 

Table H3 presents examples of health service-related 

facilitating factors identified from the managers’ 

responses. 

Table H3. 

Identified 


Address staff 

shortage 

Integration of 

services 

Improve 

infrastructure 

Line managers’ ideas re. health service-related 

facilitating factors – total 

Examples 

“All facilities need doctors to do VCCT.” 

“Increase the number of [PNs] at facilities.” 

“Strengthen the health system so that patients are 

treated holistically, rather than by specialised (for 

example ART) personnel in specific programmes.” 

“Integrated service provision facilitates uptake of HCT.” 

“Extend clinics to accommodate VCT and more patients, 

and improve the appearance of clinics.” 

“Create a special area for HIV patients to increase their 

confidence to test.” 

Among the health service-related facilitating factors, 

solutions to address staff shortages at facilities featured 

most prominently. Due to staff shortages, health care 

providers reportedly experience high workloads and time 

constraints, which also means that nurses are unable to 

manage VCT and patients subsequently often face long 

queues: 

• “ All facilities need to get doctors who must get involved 

in VCCT.” 

• “ If there are enough staff – professional nurse to deal 

with antenatals, babies, and you have someone to deal 

with the TB patients – it would be possible.” 

Concerning the actual physical facilities, poor infrastructure 

and lack of space for counselling reportedly also 

compromise patients’ right to confidentiality and privacy. 

The interviewed line managers made recommendations 

such as: 

• “ There should be a special area where co-infected 

patients are handled.” 

• “ Let’s extend the clinics for counselling purposes and to 

accommodate more patients.” 

Health worker-related facilitators 

Table H4 presents the health worker-related facilitating 

factors identified from the managers’ responses. 

10 Cf Section I for a rapid assessment of the TB-HIV information 

system in the Free State. 

SECTION H • Fact finding: programme line managers 35

Table H4. 

Identified 


Revise 

the roles 

of types 

of health 

workers in 

the HCT 

process 

Improve TB- 

HIV training 

of health 

workers 

Improve TB- 

HIV health 

education 

to patients 

Improve 

relationships 

and support 

among 

health care 

workers 

Improve 

support of 


Improve 

community 

awareness 

of TB-HIV 

Line managers’ ideas re. health care worker-related 

facilitators – total 

Examples 

“Doctors should get much more involved in VCCT.” 

“Only counsellors should counsel patients; all other services 

are then provided by nurses.” 

“Only nurses should counsel TB patients.” 

“Counselling should include referral of patients to [PHWs] 

for further counselling about related diseases.” 

“A patient should be counselled and tested by the same 

person.” 

“Nurses should provide information to the patient before 

pre-counselling by lay counsellors.” 

“In bigger settings, such as district hospitals, senior 

counsellors who have gone for refresher courses can 

mentor new counsellors.” 

“There should be a programme for lay counsellors to be 

trained to do pricking.” 

“DOT supporters and home-based carers should be 

trained to do counselling.” 

“Improve the quality of training on TB and HIV that 

professional nurses receive.” 

“There should be ongoing training of lay counsellors and 

DOT supporters on TB and HIV.” 

“Lay counsellors should receive comprehensive training.” 

“We’ve got to improve the skills of lay counsellors.” 

“People should receive more information about HIV-related 

diseases, such as TB.” 

“The quality of information imparted by lay counsellors 

should really be improved.” 

“Patients need convincing, detailed and understandable 

information that highlights the benefits of [HCT].” 

“Patients need to hear that they are taking a step in the 

right direction by testing for HIV – that this will not worsen, 

but improve their situation.” 

“We should always explain to patients that TB is the most 

common opportunistic infection.” 

“Provide local in-house mentor support for lay counsellors 

by nurses.” 

“Volunteers should be given uniforms and made part of 

professional health care workers.” 

“There should be a working relationship between lay 

counsellors, nurses and doctors, and regular meeting 

should be held.” 

“... establish and encourage support groups for patients.” 

“Patients who did not test the first time they were offered 

HCT should be continuously advised to do so.” 

“There should be more awareness campaigns in the 

community.” 

“We need more door-to-door campaigns.” 

The line managers suggested specific and sometimes 

opposing strategies related to their suggestions for 

changed roles for the types of health workers involved in 

HCT for TB patients: 

• “ The responsibility of imparting convincing and good 

quality information to patients should be given to nurses, 

because they are in the forefront. They are the people 

who can even apply the relationship of TB and HIV better 

that any counsellor, better than somebody that did not do 

physiology.” 

• “ We need enough lay counsellors in all services and the 

professional nurses will do the other jobs [i.e. nursing].” 

• “ It is for them [nurses] to evaluate the readiness of the 

patient to be tested. It is for them to evaluate the quality 

of information that has been given to this person who is 

taking the opportunity of knowing their status.” 

• “ We are thinking that if patients can be counselled or 

even tested by one person, you know, one nurse who does 

everything rather than having to move from the TB room 

where you are just coming to take your treatment and 

results, and then you must go and wait in another queue 

for counselling, and come back again and wait for the 

test.” 

• “ What we need to emphasise to the lay counsellors is 

the referral. They must be able to identify issues and refer 

to nurses.” 

• “ If we could have, test a model where the very same 

service provider counsels the patient and does the HIV 

test, you know, at the same time. Perhaps that could 

work.” 

• “ The TB programme should have somebody who is in 

charge of TB only, because this programme is big and time 

consuming, and should be excluded from the supermarket 

approach.” 

One manager argued that HIV-positive patients on 

treatment should be involved in counselling, “because 

somebody who has followed that route can actually explain 

it better.” Another respondent cautioned that the person 

to whom tasks are shifted, should have the necessary 

background to take on the new tasks. Preparations should 

also be made so that task shifting is done in such a manner 

that it does not become detrimental to the HCT process, 

and the person to whom the tasks are shifted. 

According to district and provincial managers, insufficient 

training, inadequate counselling, lack of counselling 

skills, and difficulties experienced in addressing patients 

about HCT, all call for improved training of health care 

workers. The respondents recommended that all health 

care professionals and non-professionals, including lay 

counsellors, should receive ongoing training and should 

be trained specifically on the importance of HCT for TB 

patients, co-infection and counselling. 

The line manager respondents believed that health care 

workers “were the people who must take the lead” in terms 

of bringing about improved uptake of HCT by TB patients. 

In this respect, the managers stated that it was necessary 

to improve the working relationships among different 

cadres of health care workers, as well as between health 

care workers and their clients: 

• “ Lay counsellors, nurses and doctors must work together 

... they must have meetings to discuss patients and 

problems arising at the clinic.” 

• “ Communication between patients and health care 

workers should be strengthened.” 


In addition to the key health care worker-related themes 

mentioned previously, the managers particularly stressed 

the importance of patient education and the quality of 

information given to patients during consultations and 

counselling sessions: 

• “ People must have more information about HIV/AIDS and 

TB, and about the relation between the two.” 

• “ The patient needs detailed information, something that 

will make them to understand, that will convince them; 

something that will actually show them that there are 

benefits in doing this.” 

• “ It [i.e. deciding to take an HIV test] is not a step that will 

worsen the situation; I think, that is the kind of message 

that people need to hear.” 

Further recommendations regarding counselling practices 

were that counsellors should adhere to a set time of 30- 

45 minutes per session, and should use counselling tools 

to improve the quality of their work. Criteria were also 

stipulated to consider when recruiting lay counsellors: “I 

think we don’t have a choice in using lay counsellors. The only 

thing we have to do, is for us to be able to identify the right 

people to do the lay counselling. So, I think we need to look 

at those things, you know, when we recruit volunteers; look at 

the age, gender of counsellors, and the community traditions 

amongst the people, you know.” 

H4. Discussion and conclusion 

The managers’ interviewed were inclined to identify 

barriers to HCT on the sides of both the TB patient and 

the health system/facility. 

Summarily, and in order of importance, the main factors 

thought to hinder TB patients from going for HCT were (i) 

fear of stigmatisation, (ii) lack of infrastructure, and (iii) the 

unavailability and high workload of health care workers. 

The three most important factors thought to facilitate 

uptake of HCT were (i) clarification and assignment of 

specific roles and/or task shifting, (ii) improved training, 

and (iii) improved counselling. 

Most of the patient-related factors that the line managers 

perceived to contribute to low uptake of HCT among 

TB patients – fear, denial, lack of trust and confidentiality, 

inadequate knowledge, lack of awareness, misperceptions 

and misbeliefs – seem closely connected with fear of 

stigmatisation. The managers’ responses that link with these 

factors made it clear that stigmatisation is felt at a number 

of levels: individual, family, community, programmatic and 

societal. The managers suggested, amongst others, that 

health care workers should follow a patient-centred 

approach; that counselling and health education should be 

improved; that support groups for TB/HIV patients should 

be established and encouraged; and that communication 

between patients and health care workers should be 

improved. 

The perceived health system/facility-related barriers 

mentioned by the line managers mainly concern issues 

of weakened service delivery as a consequence of 

human resource, infrastructural and educational resource 

constraints. To address these problems, the respondents 

argued, would involve finding the right “skill-mixes”, including 

finding the right balance and distribution between lay 

health care workers and professional staff, and seeing to it 

that health care workers are adequately trained on issues 

such as health promotion and TB-HIV/AIDS co-infection. 

Section I 

Fact finding: TB-HIV/AIDS 

information system 

I1. Introduction 

The benefits of information technology (IT) for medical 

and health information systems are widely proclaimed. 

These include that data recorded in computer memories 

can be readily retrieved and re-used for a variety of 

purposes. Also, once data are available in computer 

memories, it can be easily transported. However, it is 

equally important for decision makers and users that IT 

and health information systems and their use are rigorously 

evaluated (Ammenwerth et al 2003: 125). 

A study in Limpopo (previously Northern Province) 

to evaluate computerised health information systems 

warned that concentrating on hardware and software 

to the detriment of “human ware” was a risky strategy 

(Herbst et al 1999: 308). Littlejohns et al (2003) evaluated 

the implementation of a computerised health information 

system in 42 hospitals in Limpopo Province. These authors 

described the attempt as a failure, and ascribed this to 

not ensuring that users understood the reasons for 

implementation from the outset, and to underestimating 

the complexity of their health care tasks. 

Recent years have seen the FSDoH and the HIV&AIDS/ 

STI/CDC and TB programmes invest heavily in IT for routine 

data recording and monitoring systems. Investments have 

included procurement and implementation of major IT 

systems, including the appointment and training of staff 

to enable and expedite the flow of routine information 

from the patient and health worker to data capturers, 

information officers and programme managers, and at the 

facility, subdistrict, district, provincial and national levels. 

SECTION I • Fact finding: TB-HIV/AIDS information system 37

However, frustrations about the IT system and the 

demands of recording, storing, aggregating and submitting 

information are often voiced. Our interviews with 

provincial-level managers revealed challenges such as: 

• “ The roll-out of Meditech system is slow.” 

• “ The data capturers have a poor work ethic.” 

• “ Pre- and post-test numbers do not tally.” 

Particularly in the TB and HIV&AIDS/STI/CDC 

programmes where high patient volumes often inundate 

health care providers, they might perceive the recording 

and processing of routine information as a lesser priority, 

one that is second to patients’ care needs and demands. 

We set out to establish how different types of users and 

managers at different levels perceive the functionality of 

the information system in respect of TB-HIV integration. 

Questions were also posed as to the “user-friendliness” of 

the information system, and to what extent it contributes 

to the everyday management of the TB and HIV/AIDS 

programmes. 

Note: The study did not evaluate the information 

technology (IT) component as such, but rather assessed 

the health information system as experienced by its users 

at the facility level. The main aim of the research was to 

evaluate the TB-HIV/AIDS information system. More 

specifically, the objectives were to: 

• Compare information in the files of TB patients with 

information captured on the electronic registers and 

submitted to the province. 

• Gauge users’ views and experiences of the strengths 

and weaknesses of the information system, and to 

record their suggestions for improving the current 

system to render it more user-friendly and of greater 

value to patients, health workers and managers. 

I2. Methods and sample 

Fieldwork was conducted in all five districts of the Free 

State during November-December, 2007. In each district, 

one mobile and one fixed clinic, one community health 

centre (CHC) (or large clinic if there was no CHC), and 

one district hospital were purposively selected. After 

authorisation was obtained from district and facility 

managers, each facility was visited on an appointment 

basis. Firstly, data were recorded on a random sample of 

TB and TB/HIV patients (20 per facility) selected directly 

from facility-based recording mechanisms – including 

patient files and electronic registers – by means of a table 

of random numbers. This data were compared with the 

data for particular patients retrieved from the provinciallevel 

data. 

Secondly, semi-structured interviews were conducted 

with the TB programme coordinating nurse at each 

facility. These interviews were conducted on an informed, 

voluntary basis, and were arranged so as to least intrude 

on nurses’ clinical duties and activities. TB patient data 

from the facility and province were captured in Excel and 

checked for inconsistencies. Responses to the open-ended 

questions were coded and captured in SPSS. Frequencies 

were calculated for these responses. 

I3. Findings 

I3.1 Inconsistencies between facility-based and 

provincial-level data 

In terms of the comparison between facility and provincial 

level data, seven indicators were selected: 

• patient surname and name; 

• TB file number; 

• treatment status; 

• date treatment started 

• date treatment ended; and 

• patient transfer. 

Overall, out of a total of 2800 data entries, 21% 

inconsistency between data in patient files/clinic registers 

and provincial-level data was measured (Figure I1). 

Among the selected indicators, the most inconsistencies 

were observed in respect of the treatment start (44%) 

and treatment end (41%) dates. The least number of 

inconsistencies occurred with the TB file number (4%). 

Figure I1. 

Total 

Patient transferred 

Date treatment ended 

Date treatment started 

Treatment status 

TB file number 

Patient’s name 

Patient’s surname 

Inconsistency between facility and provincial 

information (%) (n=2 800 entries) – total 

4 

8 

9 

12 

21.0 

30 

41 

44 

When compared to the provincial-level data, one-third 

of the files showed no inconsistencies. Four in every ten 

files (41%) had one to two errors, and just more than a 

quarter of the files (27%) had three to six errors. 

Figure I2. 

5 

4 

3 

2 

1 

0 

1 

Number of inconsistencies per file (%) (n=2 800 data 

entries) – total 

6 

20 

21 

20 

33 


I3.2 TB coordinating nurses’ views on problems 

with TB-HIV/AIDS information system 

Half of the respondents (n=10) noted that there were 

no problem areas in the TB-HIV/AIDS information system. 

The problems most frequently raised by the remaining ten 

TB coordinating nurses related to staffing and capacity/ 

training of staff. Another problem was to keep track of 

patients of whom many provided incorrect contact 

information. 

Figure I3. 

TB coordinating nurses’ problems with information 

system (n=20) – total 


Difficulty keeping track of patients 

Staff shortages, lack of training, too many forms 

None 

I3.3 TB coordinating nurses’ suggestions on how to 

improve TB-HIV/AIDS information system in 

respect of management of TB patients 

Respondents were asked to provide suggestions as to how 

the TB-HIV/AIDS information system could be improved 

for the management of TB patients and patients coinfected 

with TB-HIV/AIDS (Table I1). Most suggestions 

for the improvement of the information system for the 

management of TB patients focused on the need for 

more staff to treat TB patients and training for staff (n=6); 

providing IEC for patients and the community (n=3); and 

ensuring that all clinics had computers so that data could 

be captured on site. 

Table I1. 

TB coordinating nurses’ ideas to improve information 

system to manage TB patients (n=17) – total 

Increase TB staff and provide more training 6 

Provide improved/more IEC both for patients and the community 4 

Supply computers/electronic registers so that data can be 

captured on site 

3 

Introduce formal system for sending referral letters between 

health facilities 

1 

Better integration of the TB and HIV&AIDS programmes 1 

One TB card and one TB register to capture all TB-HIV/AIDS 

information 

1 

PALSA Plus guidelines in all consultation rooms 1 

I3.4 TB coordinating nurses’ suggestions on how to 

improve TB-HIV/AIDS information system in 

respect of management of TB/HIV patients 

Suggestions for the improvement of the TB-HIV/ 

AIDS information system for the management of coinfected 

patients, included: better integration of the two 

programmes, including a single information system (n=6); 

improved information, education and counselling for 

patients and the community (n=3); and feedback on data 

and patients (n=3) (Table I2). 

3 

3 

4 

10 

Table I2. 

TB coordinating nurses’ ideas to improve information 

system to manage TB/HIV patients (n=19) – total 

Integration/single information system for TB-HIV&AIDS 

programmes 

6 

Provide improved/more IEC both for patients and the 

community 

3 

Feedback on data and patients 3 

Reduce need for secrecy about HIV/ AIDS (i.e. address stigma) 2 

Training for all staff on TB-HIV/AIDS 2 

Supply all facilities with computers/electronic registers 2 

PALSA Plus guidelines should be in place in all consultation 

rooms. 

1 

Table I3. 

TB nurses’ ideas to improve user-friendliness of the 

information system for nurses (n=20) – total 

Improve feedback and communication systems regarding data 5 

Decrease paperwork 4 

Integration of TB-HIV&AIDS programmes (including capturing all 

information on one form) 

4 

Supply all facilities with computers/electronic registers 3 

Increase staff and provide more training for them 3 

Improved information, education and counselling for patients and 

the community 

1 

I3.5 TB coordinating nurses’ indication of the 

usefulness of TB-HIV/AIDS information system 

All respondents reported using the TB-HIV/AIDS data for 

planning purposes, while the majority of these respondents 

(19 of 20) found the TB-HIV/ AIDS data useful. 

Table I4. 

TB nurses’ indication of ways in which TB-HIV/AIDS 

data is used for planning (n=28) – total 

Monitoring performance and outcomes of TB programme 9 

Providing feedback to managers, staff and community 6 

Resource planning and management 5 

Tracing TB patients lost to follow-up 3 

Co-diagnosis and management of TB/HIV patients 3 

Planning farm visits 2 

TB-HIV/AIDS data was reportedly used to: 

• monitor performance and outcomes of the TB 

programme (n=9); 

• provide feedback to managers, staff and the community 

(n=6); and 

• calculate what resources were required, for example 

how much medication or stationery to order (n=5). 

I4. Discussion and conclusion 

Despite investments and efforts to improve the IT used to 

gather TB and HIV&AIDS programme data, the fact-finding 

research found 21% inconsistency between facility- and 

province-based data in respect of seven indicators/data 

items. Nevertheless, half of the TB coordinating nurses 

interviewed did not perceive the TB-HIV information 

system to be problematic. The remaining half pointed 

especially to problems related to (i) staff shortages, (ii) lack 

of training, (iii) “too many forms”, and (iv) the difficulty to 

keep track of patients. The main suggested improvements 

SECTION I • Fact finding: TB-HIV/AIDS information system 39

to the TB-HIV information system was to (i) “increase TB 

staff”, (ii) provide improved/more TB-HIV-related IEC to 

patients and communities, and (iii) have a single/integrated 

information system for both the TB and the HIV&AIDS 

programmes. 11 The TB coordinating nurses also thought 

that feedback and communication about the data they 

submit, could be improved. Nevertheless, they stated that 

they found the data useful for planning and performance 

monitoring purposes. 

• What can be done by provincial, district, subdistrict and 

facility managers to increase TB patients’ HCT uptake? 

• What can be done by nurses/CHWs to increase TB 

patients’ HCT uptake? 

• What can be done by community organisations/ 

communities to increase TB patients’ HCT uptake? 

• What can be done health information-wise to increase 

TB patients’ HCT uptake? 

The following is the amalgamated recommendations 

emanating from the five workshops. 

Section J 

Fact finding: district feedback 

workshops 

J1. Introduction 

Following the fact-finding research, feedback workshops 

were held from early September until mid October 2008 in 

each of the Free State’s five districts (Thabo Mofutsanyana 

– Phuthaditjhaba, 5 September; Xhariep – Bloemfontein, 

18 September; Fezile Dabi – Kroonstad, 22 September; 

Motheo – Bloemfontein, 23 September; Lejweleputswa – 

Welkom, 15 October). 

Collaborating with the CHSR&D in organising these 

workshops, representatives from each district’s health 

management (i.e. PHC managers and TB and HIV 

coordinators) assisted in making the necessary logistical 

arrangements. The workshops were aimed at district 

health managers, TB and HIV coordinators and nurses, 

as well as all other relevant stakeholders in the TB 

programme, including medical officers, facility managers, 

CHWs, monitoring and evaluation (M&E) officers, health 

information officers, community development officers, 

non-governmental organisation (NGO) representatives 

and traditional healers. 

The purpose of the workshops was to provide feedback 

on the fact-finding research among health managers, health 

care workers and TB patients. In addition, attendees were 

asked to suggest solutions and make recommendations 

on how to improve TB patients’ uptake of HCT. More 

specifically, the attendees were divided into groups and 

asked to respond to questions relevant to their work 

situation/experience, including: 

• What can be done at mobile and fixed clinics and 

hospitals to increase TB patients’ uptake of HCT? 

11 Cf par. J6 for the district research-feedback workshop 

attendees’ suggestions to improve the TB-HIV/AIDS 

information system. 

J2. How to improve TB patients’ 

uptake of HCT: health care 

facilities 

J2.1 Hospitals 

Workshop attendees indicated a need to revise the 

training curriculum of doctors and nurses to ensure that 

HIV/AIDS and TB are treated more comprehensively. 

Human resource issues also featured prominently and 

suggestions included: 

• appointment of an assistant nurse at each facility to 

provide HIV counselling after hours and on weekends; 

• appointment of a PN to provide combined HIV/AIDS 

and TB services; and 

• ensuring that staff maintain a positive attitude towards 

patients. 

The need for amended protocols at hospitals, which 

allowed nurses to offer PITC, without referral from 

a doctor, was suggested at four workshops, while the 

suggestion to ensure that there was enough space to 

provide private counselling and testing at hospitals, was 

made at all five workshops. 

J2.2 Fixed clinics 

At all five workshops it was suggested that information 

should be given to TB patients on HIV and TB. Information 

could be provided during health talks at the facilities or 

via posters and pamphlets placed in strategic locations 

throughout facilities. The second most frequently 

mentioned strategy was to provide comprehensive HIV/ 

AIDS and TB training for all staff (including nurses and 

CHWs) (n=4 workshops). Suggestions relating to human 

resources also featured at three of the five workshops and 

included the proposed appointment of additional nurses 

in the HIV&AIDS and TB programmes, as well as attempts 

to ensure that nurses have a positive and friendly attitude 

towards patients. Additional recommendations included: 

providing incentives to encourage TB patients to test for 

HIV (e.g. food vouchers) (n=2 workshops); providing 

routine HCT for all TB patients (n=2 workshops); and 


ensuring that there was sufficient space to provide HCT 

(e.g. upgrading existing buildings or using “containers”) 

(n=2 workshops). 

patients’ uptake of HCT by setting targets and including 

these targets in the monitoring and evaluation schedules 


J2.3 Mobile clinics 

At three of the workshops attendees noted that strategies 

should be devised to enable nurses to spend more time 

with TB patients, including increasing the number of 

mobiles so that more frequent visits were possible, and 

allocating a specific day for HCT at particular points. As 

with the hospitals and fixed clinics, it was also indicated 

that nurses should attend integrated HIV/AIDS and TB 

training (n=2 workshops). Additional strategies to be 

employed at mobile clinics to increase HCT uptake were: 

involving the farmers in health campaigns on the farms 

(n=2 workshops); providing comprehensive treatment 

(n=2 workshops); and counsellors to provide health 

information on the link between HIV/AIDS and TB (n=2 

workshops). 


uptake of HCT: managers 

J3.1 Provincial and national managers 

At all workshops it was noted that national and provincial 

mangers should support lower-level managers by, amongst 

others, establishing clear lines of communication between 

all levels of management; providing lower level managers 

with comprehensive training schedules; and recognising 

diligence and hard work. In addition, all necessary budget 

and human resources should be in place to provide the 

service (n=3 workshops); arrangements should be made 

for all programme coordinators to meet annually to plan 

and draft in-service training schedules (n=3 workshops); 

increase the number of training workshops for CHWs 

(n=2); ensure that PITC is offered at all facilities (n=2 

workshops); and make certain that integrated HIV/ 

AIDS and TB services are provided at all facilities (n=2 

workshops). 

J3.2 District and subdistrict managers 

Attendees were of the opinion that district and subdistrict 

managers should promote full integration of HIV/AIDS, 

HCT and TB at all facilities (n=4 workshops). They felt 

that all nurses should be trained on how to integrate the 

programmes, and more specifically all nurses should attend 

HAST and PALSA Plus training. In addition, managers 

should implement new policies in partnership with 

their subordinates, and this could be achieved through 

support visits; guiding and allowing staff to participate in 

decision-making; providing on-the-job training; identifying 

problems; and opening clear lines of communication (n=3 

workshops). Managers could also ensure an increase in TB 

J3.3 Facility managers 

The workshop attendees recommended that facility 

managers should ensure the proper implementation of 

PITC at their facilities, and, more specifically, that protocols 

and guidelines should be available and followed (n=4 

workshops). In addition, it was noted that managers 

should make certain that all staff at their facilities are 

trained in HAST and HCT (n=2 workshops). 


uptake of HCT: health care 

workers 

J4.1 Nurses 

Attendees at three of the workshops suggested that all 

nurses should practice PITC for TB patients, and where 

necessary (e.g. if lay counsellors are absent or too busy) 

the nurses should provide the counselling themselves. 

Furthermore, nurses should receive comprehensive 

training in TB and HIV/AIDS (n=3 workshops) and ensure 

that they provide comprehensive care (n=2 workshops). 

It was also suggested that nurses should repeatedly 

inform patients about the relationship between TB 

and HIV/AIDS (n=2 workshops); ensure that patients 

receive quality counselling (n=2 workshops); support 

daily health education (n=2 workshops); avoid labelling 

and discriminating against patients (n=2 workshops); and 

conduct home visits (n=2 workshops). 

J4.2 Community health workers 

The most frequent suggestion as to how CHWs could 

improve TB patients uptake of HCT was to ensure 

that all CHWs received comprehensive training on the 

relationship between HIV/AIDS and TB (n=4 workshops). 

It was also indicated that nurses should motivate CHWs to 

provide quality care, and one way to achieve this would be 

to increase the stipend CHWs receive (n=3 workshops). 

In addition, nurses should provide proper supervision and 

support to lay counsellors (n=2 workshops). It was also 

recommended that CHWs should actively encourage 

patients to disclose their HIV status to persons they trust 



uptake of HCT: communities 

At four of the workshops it was noted that there should 

be increased collaboration among the facilities and 

their surrounding communities through door-to-door 

SECTION J • Fact finding: district feedback workshops 41

campaigns and health education at schools and taverns. 

Attendees felt that there should be support groups in 

the communities both for patients and for their families 

(n=4 workshops). They recommednded that “proper” 

training should be given to leaders in the community 

(e.g. traditional healers) so that the “correct” information 

is given to patients (n=3 workshops). Finally, it was also 

suggested that communities need to “actively participate” 

in TB and HIV activities organised by health facilities (n=3 

workshops). 

J6. How to improve TB-HIV/AIDS: 

information system 

To improve the health information system and provide for 

the collection of accurate and reliable data, attendees at 

the workshops recommended that an audit be conducted 

of all data records at the facilities to ensure that HCT 

information is recorded on all the necessary forms (n=4 

workshops). It was also indicated that dedicated staff be 

appointed for the capturing of HIV/AIDS and TB data 

(n=3 workshops). The development of one form to 

capture all information on HIV/AIDS and TB would also 

simplify the paperwork process (n=3 workshops). Health 

information officers would be able to function more 

optimally if they had the necessary resources, such as 

computers and transport (n=3 workshops), and training 

(n=3 workshops). In addition, nurses should ensure that 

all information is recorded legibly on the forms to facilitate 

the data capturing process (n=2 workshops). Feedback, 

both positive and negative, should be given to the health 

information officers to improve the quality of data (n=2 

workshops). 

J7. Discussion and conclusion 

Attendees at the research-feedback workshops responded 

favourably to the study and its findings, and all expressed 

an interest in having the intervention implemented in their 

districts. The main suggestions to improve TB patients’ 

uptake of HCT included: 

• appointment of additional staff to provide this service; 

• training of staff on the integrated management of 

patients with TB and HIV/AIDS; 

• ensuring that a comprehensive TB-HIV/AIDS service is 

provided at all facilities; 

• provision of health education focusing on the link 

between TB and HIV/AIDS to all TB patients; 

• implementing and consistently practising PITC for TB 

patients; 

• support from managers for health care workers; and 

• collaboration between facilities and their communities 

on TB-HIV/AIDS-related activities. 

Section K 

Recommendations and 

way forward 

The policy directive of the TB Strategic Plan, 2007-2011 

(NDoH 2007a: 24) is unequivocal: “Ensure early diagnosis 

of HIV in TB patients through provision of PITC.” 

As a baseline to compare the outcomes of the planned 

intervention (Part II of the overall project), the HIV testing 

rates among TB patients was 32.4% in Lejweleputswa 

District and 37.9% in Thabo Mofutsanyana District in 2007. 

The corresponding figure for the Free State Province as a 

whole was 43.1%. Summarily, the Free State has far to go 

to achieve the NSP, 2007-2011 targets of 75% HIV testing 

among TB patients by 2008 and 100% testing by 2011. 

In light of the fact-finding results, the current study 

recommends the following towards scale-up of HCT and 

PITC among TB patients: 

• Intensify dissemination of information on the link 


• Motivate and support patients in the HCT decisionmaking 

process. 

• Especially target males, patients newly diagnosed with 

TB, employed, and married patients. 

• Improve counsellors’ training and skills, and manage, 

support and monitor their work. 

• Encourage disclosure of HIV status by TB-HIV coinfected 

patients, and involve them in motivating other 

TB patients to test for HIV in order to reap the same 

benefits from integrated care, treatment and support. 

Facilitating factors identified in the fact-finding research 

not only offer a possible conceptual framework to inform 

successful implementation of PITC policy, but also to guide 

the development of interventions to increase TB patients’ 

access to care, treatment, prevention and support by way 

of HCT. More in-depth discussion is needed on how to 

realise many of the solutions proposed by the various 

interest groups: TB patients (cf Section E), community 

health workers (cf Section F), professional health 

workers (cf Section G), and programme line managers 

(cf Section H). 

The fact-finding research results have been presented 

to and now become part of the contemplations of a 

steering group to lead the development, implementation 

and testing of the multifaceted intervention (Part II of 

the overall project). This group includes the CHSR&D 

researchers responsible for the fact-finding research, the 

domain experts acknowledged at the outset of this report, 

and the collaborating FSDoH provincial and district-level 

TB and HIV&AIDS programme managers. 


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