Sara Belton, RN, PhD (c) London School of Economics & Political Science London, UK

1. Treating the Nation: The positive impact of antiretroviral drugs on the clinical practice, coping strategies, and workplace morale of health care workers in Kabarole District, Uganda Sara Belton, RN, PhD (c) London School of Economics & Political Science London, UK

2. Introduction • Kabarole District: Mountainous rural region, 88% subsistence farming, 70% on/below poverty line¹ • HIV prevalence rate 11.3%² vs national rate 7.3%³ • PhD research based in Rwimi sub-county • Worked with 3 main stakeholder groups to determine the social representations (“pictures in their heads”) held of HIV & health services • Assessment of post-ARV social reality

3. Study Location4 https://www.cia.gov/library/publications/the-world-factbook/geos/ug.html https://www.cia.gov/library/publications/the-world-factbook/maps/refmap_africa.html

4. Methods • Part of a larger qualitative study (N=142, 48% female): interviews, focus groups, participant observation & ethnographic field data • Data collected from May to August 2011 • This data from Health Care Workers, (n=15, 47% female), via interviews (15 hours) & participant observations (40 hours) • Coded using Attride-Stirling’s Thematic Network Analysis5 framework in NVivo 8

5. Results 1: Impact on Clinical Practice • ARVs give HCWs a sense of “mastery” over HIV never experienced before • “[In the past] it was too much. Because during those days, there were no drugs… But nowadays, at least it is okay… During those days people used to get diarrhea and a terrible loss of weight, someone would look exactly like a skeleton-- but these days, no. (HCW #1, Community Health Worker) • "If [the patient] has started taking drugs, he or she can be as usual. Like any other normal person, in the way they live normally… like any other healthy person." (HCW #22, Nurse) • Report improved sense of clinical competence in treating HIV & patients by using ARVs • “Nowadays there is a big difference, because now the ARVs drugs are available to help those people who have [HIV]. We now have testing facilities and when someone goes and tests and finds that he has it, they start the drugs there and then and they get a good life.” (HCW #1, Community Health Worker)

6. Results 2: Impact on Coping Strategies • ARVs give the courage to hope for their clients & themselves • "I picked up interest when I had joined the course… So, I came to like it. I came to like counselling… those who have problems." (HCW #7, Outreach Worker) • "I care for the life of others, I want them to live up to the time when God wants to take them… I have cared for them, even I care for my family because of my nursing, so I like my nursing very much.” (HCW #28, Nurse) • Optimism for the future, but serious concerns for at-risk youth • "[Most children we see are] okay, they're healthy… some are at school [and] they are doing well. [But] yesterday… there came a small girl-- we have made that girl grow, the mother and father died because of HIV, she is 15 years or maybe 14 years. I asked her, 'why are you not at school?" She said to me, "[I] am sick from time to time… so the one who is taking care of me told me to stop schooling..." Now this girl is going to spread [HIV]-- she will get pregnant in a minute, you see… She‘s now at home… with someone taking care [of her]--not a mother or a father--and she‘s currently sick. [Such] children are suffering." (HCW # 28, Nurse)

7. Results 3: Impact on Workplace Morale & Professionalism • Improved staff-staff interactions, despite a resulting increase in overall workload from ARVs • “We sometimes get a challenge with the staffing, as I told you we are few compared to the expected number. So, if you came here on a Wednesday [HIV clinic day], you will find like 100 people here waiting for two health workers. Because I work here with another nurse. And sometimes we have two expert clients who come and help us… It is like a clinic on its own, [but] then we have to do other activities in other departments.” (HCW #8, Clinical Officer) • Improved staff-patient clinical interactions, despite challenging counseling & clinical situations • "When children get older, we advise the mothers to bring the children with them so we [can] counsel them... Now [that] the child [has] become infected… there’s a way we counsel them smoothly, so they accept and they know that, ‘every day [I] am supposed to take drugs.’" (HCW #26, Nurse)

8. Conclusion: ARVs help HCWs too! • ARVs help HCWs both in their actual day-to-day professional work and in coping with their work • “I feel am motivating myself-- because even if I stay here for the whole day [without breaks] I don’t mind, so long as my client… is doing well." (HCW #35, Nurse) • “[Patients] taking the ARVs… They‘re all doing well, those ones who are on care. They‘re doing well because we monitor them-- because almost every month they‘re supposed to come and we solve their problems early.” (HCW #27, Clinical Officer) • HCWs report improved sense of professionalism from using ARVs in clinical practice, through: • internalized sense of competence & mastery • external validation from peers & patients

9. Conclusion: Opportunity knocks… • Real opportunity for HCWs to also use ARVs as “social change agent”, to challenge continuing stigma in the community • "[The public] talk about [HIV positive children], but they say… that the problem is about the what? The parents. Because the kid, [doesn't] have anything to tell, [there's no] talk about him or her, because he's still young. The blame is all about what? The parents' [actions]." (HCW #34, Nurse) • HCWs representations of HIV changing from a death sentence to a manageable, chronic illness via the use of ARVs is a promising finding • "I think now these days, it's no longer like those days when [the public] used to fear [HIV]. These days it seems like malaria… So, drugs– it's really made a difference in how they react. Yeah. It has made a difference." (HCW #7, Outreach Worker). • Huge potential but needs commitment & funding

10. Thank You for Listening! • Uganda team: Tom, Regina, Lilian, Rose, Julius • Study participants in Kabarole District • Colleagues at LSE’s Institute of Social Psychology, especially Prof. Cathy Campbell • Canadian Institutes of Health Research (ZNF98622) & LSE Postgraduate Travel Fund • AIDS 2012 Conference Organizers & Participants • I declare there are no commercial/financial conflicts of interest in this work

11. References • African Agency for Integrated Development. (2010). Implementation project for improving water, sanitation and hygiene education in Hakebale subcounty in Kabarole district western Uganda. Retrieved 08 July, 2012, from: http://www.globalgiving.org/pfil/6177/projdoc.pdf. • Muhereza, I. (2011). Maternal mortality increased in Kabarole district. Key correspondents. Retrieved 08 July, 2012, from: http://www.keycorrespondents.org/2011/12/19/maternal-mortality-increased-in-kabarole-district/. • Uganda AIDS Commission. (2012). Our HIV/AIDS epidemic: What each one of us must do? Retrieved 08 July, 2012, from: http://www.aidsuganda.org/documents/Our%20HIV%20Epidemic.pdf • CIA World Factbook. Uganda Maps. Retrieved 08 July, 2012, from: https://www.cia.gov/library/publications/the-world-factbook/geos/ug.html and https://www.cia.gov/library/publications/the-world-factbook/maps/refmap_africa.html. • Attride-Stirling, J. (2001). Thematic networks: An analytic tool for qualitative research. Qualitative Research, 1 (3), 385-405. Retrieved 08 July, 2012, from: http://qrj.sagepub.com/content/1/3/385.refs.html.