An Analysis of the Uptake of Public Sector Voluntary Counseling and Testing Services by Socio-Economic Group: A South Af

1. Michael Thiede, Natasha Palmer, Sandi Mbatsha An Analysis of the Uptake of Public Sector Voluntary Counseling and Testing Services by Socio-Economic Group:A South African Case Study Conference on Reaching the Poor February 18, 2004 Washington, D.C.

2. Background • 24 million people living with HIV/AIDS in sub-Saharan Africa (UNAIDS 2000) • HIV prevalence in South Africa 11.4 percent, in urban informal areas 21.3 percent (HSRC 2002) • HIV/AIDS biggest threat to the health system • Socio-economic status is the principal determinant for exposure to HIV/AIDS, with poverty and social inequalities as leading co- factors in HIV transmission (Gilbert & Walker 2002, Farmer 2001) • SA public sector covers 84% of population (53% of total health expenditure) • Do public sector HIV/AIDS prevention services reach the poor/ the target groups? • What are the barriers to access? • What are the valued benefits?

3. VCT for HIV/AIDS in South Africa • Voluntary counseling and testing (VCT) prioritized as HIV prevention strategy by many severely affected countries • VCT increasingly offered as service in public sector clinics throughout SA • Routine element of antenatal care (excluded from study) • Elements: Voluntary testing for HIV, pre-test counseling, post- test counseling (mostly by lay counselors from communities) • Promoted as key motivating force for people to adopt safer sexual behavior and as an entry point to care for HIV-infected (UNAIDS 2002, Magongo et al. 2002)

4. The Sites • Study focus on peri-urban areas/townships: - diversity of socio-economic backgrounds among relatively deprived segments of SA society - particularly adequate to demonstrate differentials in services uptake - influx of migrants from rural areas into peri-urban settlements poses additional risk factor for HIV (Lurie 2000) • 3 different townships, each representative of its category: a) Masiphumelele: small, relatively recent development, approx. 20,000 people, 1 clinic b) Khayelitsha: largest township in Western Cape, approx. 500,000 people, several clinics c) Langa: oldest township in Western cape, 60,000 people, 1 clinic

5. Methodology • Waiting room survey to assess access to VCT services by different socio-economic groups - personal characteristics (age, gender, education, employment status, …) - household characteristics (no. of people, household durables/ assets synchronized with SA-DHS) - questions on sources of information, motivation etc. around VCT, barriers to access - clinic users, VCT patients • In-depth interviews • Focus group discussions • Analysis of SA-DHS township EAs (Gauteng, Western Cape) • Asset indices and wealth quintiles

6. The SA-DHS • Conducted in 1998 as part of National Health Information System of South Africa, only released in 2001 • PSUs correspond to EAs of SA Census 1996 • 10 households per EA: 12,860 households • ‘Assets’: - Main source of drinking water - Electricity - Household items (Radio, TV, telephone, bicycle, car, …) - Floor material - Roof material • Township sample: 507 households

7. The Sample • 540 waiting room interviews (50 Masiphumelele, 270 Khayelitsha, 220 Langa) • Clinic users above 14 • ‘Systematic’ sample selection • Two sections (VCT and non-VCT patients) • n=525 after data cleaning • 208 VCT patients

8. DHS ‘Township’ Population

9. Service Utilization in Western Cape Townships

10. Progressive Pattern

11. … Compared at ‘National Level’

12. Community views: Information Positive people are not welcome in the family.Woman, Langa What makes people not come [to VCT services] is their background. Sometimes you get that their family do not accept a positive person. They see her as if she is someone who was misbehaving outside and then got positive. One is afraid to tell her husband because she is worried that the husband will divorce her. A mother who is not working is afraid of being left with the children to feed. … Some people think when you touch them you going to make them positive.Woman, Langa People have a fear of knowing, they also say “Why must we test if the government does not treat us?” Woman, Langa

13. Community views: Stigma If [the clinic counsellors] would go outside to the community, it would be worse. People do not want that counsellors be seen who come to their door. It is better if the counsellors stay there, so they can counsel those who go to the clinic.Woman, Khayelitsha HIV/AIDS workshop is not very good because that name is scary.Man, Khayelitsha We also don’t want [the counsellors] really to come to our places.Man, Khayelitsha

14. Community views: Confidentiality … if my counsellor is my neighbour, I think that maybe she can tell people about me and my status. Therefore I decide to go and do the test in Salt River and not here in Langa, you understand?Woman, Langa … sometimes people they go to another clinic. We fear each other.Woman, Langa We don’t have any confidentiality here… for confidentiality we go to Wynberg.Woman, Khayelitsha False Bay is not safe anymore because the health workers do go there and come back and tell, so the only place I see is Fishhoek clinic, and Wynberg. People prefer going to places far away from here.Woman, Masiphumelele

15. Limitations • No data available on HIV/AIDS prevalence according to socio-economic status • Refusals • Asset index may not capture full reality of socio-economic differences in SA peri-urban township setting • Resistance to discuss HIV/AIDS-related matters in in-depth interviews • Post-test interviews not possible • Limited scope of study (excludes urban and rural)  Need for this type of research at a broader level

16. Policy Implications • Number of multiple test patients suggests that VCT services may address limited share of population • Relatively better-off groups within township communities underrepresented due to persistent problems around stigma and confidentiality • General barriers to services uptake resulting from permanent lack of information • Foster culture of participatory health communication (‘health enabling community’), make health information available (by making it culturally secure • Improve trust in communities (via community groups) • Explore possibility of contracting out (voucher system for private sector services) • Introduce monitoring gauge (to keep track of patients’ socio- economic backgrounds and evaluate against community data)

17. Thank You mthiede@heu.uct.ac.za natasha.palmer@lshtm.ac.uksmbatsha@heu.uct.ac.za