A study of patient attitudes towards decentralisation of HIV care in an urban clinic in South Africa

Background: In South Africa, limited human resources are a major constraint to achieving universal antiretroviral therapy (ART) coverage. Many of the public-sector HIV clinics operating within tertiary facilities, that were the first to provide ART in the country, have reached maximum patient capacity. Decentralization or "down-referral" (wherein ART patients deemed stable on therapy are referred to their closest Primary Health Clinics (PHCs) for treatment follow-up) is being used as a possible alternative of ART delivery care. This cross-sectional qualitative study investigates attitudes towards down-referral of ART delivery care among patients currently receiving care in a centralized tertiary HIV clinic. Methods: Ten focus group discussions (FGDs) with 76 participants were conducted in early 2008 amongst ART patients initiated and receiving care for more than 3 months in the tertiary HIV clinic study site. Eligible individuals were invited to participate in FGDs involving 6-9 participants, and lasting approximately 1-2 hours. A trained moderator used a discussion topic guide to investigate the main issues of interest including: advantages and disadvantages of down-referral, potential motivating factors and challenges of down-referral, assistance needs from the transferring clinic as well as from PHCs. Results: Advantages include closeness to patients' homes, transport and time savings. However, patients favour a centralized service for the following reasons: less stigma, patients established relationship with the centralized clinic, and availability of ancillary services. Most FGDs felt that for down-referral to occur there needed to be training of nurses in patient-provider communication. Conclusion: Despite acknowledging the down-referral advantages of close proximity and lower transport costs, many participants expressed concerns about lack of trained HIV clinical staff, negative patient interactions with nurses, limited confidentiality and stigma. There was consensus that training of nurses and improved health systems at the local clinics were needed if successful down-referral was to take place.