Twenty-two of 27 sites returned the questionnaire (response rate 82%). The questionnaire was completed by the clinical director in 15 sites (68%), by researchers in five sites (23%) and by clinic managers in two sites (9%). Nine respondents were female (41%) and thirteen were male (59%).
The characteristics of sites are summarised in . Eight sites (36%) were located in South Africa, two in Brazil, two in Zambia and one each in Argentina, India, Thailand, Botswana, Ivory Coast, Malawi, Morocco, Uganda and Zimbabwe. The occupational programme of a brewery company included five countries (Nigeria, Republic of Congo, Democratic Republic of Congo, Rwanda, Burundi). This programme was standardised across sites and was therefore treated as a single site. All 22 sites were located in urban areas, 19 were specialised ART clinics and three sites (two occupational clinics and a private clinic) also functioned as general practices. Sixteen programmes (73%) were public and government-funded and six were run by non-governmental organisations. Sixteen sites (73%) provided ART free of charge (). The five sites that did not participate included one smaller research cohort in Senegal and four scale-up cohorts in Botswana, Kenya, South Africa and Zambia.
Characteristics of the 22 antiretroviral therapy (ART) programmes included in the survey.
Health education, condoms and other interventions
Health education was provided by 21 of 22 sites (96%). details the topics covered: most programmes addressed the routes of transmission, prevention of sexual transmission by male condoms and prevention of mother to child transmission (PMTCT). Other topics, for example female condoms, were covered by fewer programmes. Health education was delivered through talks in the waiting area (17 sites, 81%), posters (15 sites, 71%) and flyers (13 sites, 62%). Twenty-one sites (96%) provided male condoms and seven (32%) female condoms. Practical instructions on the correct use of male condoms were provided by 12 sites (57%), and on the use of female condoms by 7 sites (33%). Condoms were generally available free of charge. Twelve sites (55%) provided injectable or oral contraceptives. All sites provided post exposure prophylaxis (PEP) for staff, for example after needle stick injuries. No site provided clean needles or syringes for intravenous drug users. Twenty-one sites (96%) tested for STI but only 12 of these (57%) screened asymptomatic patients at the first visit and seven (33%) screened at regular intervals. Twenty sites (91%) screened routinely for syphilis in pregnant women. Point of care testing for syphilis was available in 15 sites (68%) and same day treatment in nine of these 15 sites (60%).
Topics covered in health education activities provided at 21 antiretroviral therapy (ART) programmes.
Ten sites (46%) were involved in activities to reduce poverty in HIV-infected patients, including, for example, projects to generate income or support to access social security grants. One programme was involved in activities to reduce stigma associated with HIV in the community, through marches, radio talks, theatre or the distribution of T-shirts printed with the words ‘HIV-positive’.
Disclosure, counselling and testing, and partner notification
All sites encouraged patients to disclose their HIV test result to partners and spouses. Twenty-one sites (96%) provided psychosocial support. This included counselling (21 sites, 100%), referral to self-help groups (17 sites, 81%) and drop-in centres (4 sites, 19%). Issues addressed included financial problems, stress management, coping strategies and the strengthening of self-confidence. Eleven sites (52%) addressed gender-based violence. Counselling and testing was available on site in 18 (82%) programmes. This included voluntary counselling and testing (VCT) at 16 of 18 sites (89%), couple counselling and testing in 15 sites (83%) and routine, opt-out, testing in pregnant women at 11 sites (61%). Eleven sites (50%) had a protocol for managing partner notification of HIV-infected people; most of them used the patient referral method, where patients themselves inform sexual partners and ask them to attend a clinic for counselling and testing. One site indicated that they used provider referral where the health professional contacts the partner on behalf of the patient, and two sites reported that they would inform partners if the patient had not done so after a certain period of time.
PMTCT and other interventions targeted at specific groups
Twenty sites (91%) provided ART to prevent mother-to-child transmission (). Regimens for the mother varied widely. Nine sites (41%) provided triple combination ART based on NVP or efavirenz. Other regimens included zidovudine (AZT) from 28 weeks and single dose nevirapine (NVP), dual therapy with AZT and lamivudine (3TC) and single dose NVP in all women or in women with CD4 cell counts above 200 cells/μL, Similarly, in newborns, regimens included single dose NVP, single dose NVP and AZT for one week or one month. A minority of sites (8, 36%) recommended elective Caesarean section.
Interventions offered or promoted by 22 antiretroviral therapy (ART) programmes to prevent mother to child transmission (MTCT) during pregnancy and birth, and after birth.
Most programmes (19, 86%) recommended exclusive replacement feeding to prevent MTCT but over half of them (11 of 19, 58%) also recommended exclusive breast feeding either followed by rapid weaning or complementary (mixed) feeding (). Eleven of the 19 programmes (58%) provided formula milk free of charge. With the exception of three sites in South Africa and Botswana, 12 of the 15 programmes in sub-Saharan Africa (80%) recommended six months of exclusive breastfeeding followed by complementary feeding (5 sites) or rapid weaning (7 sites). shows the number of sites involved in preventive services targeted at different groups. In addition to PMTCT, 12 sites (55%) were involved in activities aimed at women or adolescents, and 10 sites (46%) worked with serodiscordant couples. Few sites provided preventive services to other groups.
Number of sites involved in preventive services aimed at specific target groups.
Determinants of provision of preventive services
There were no statistically significant associations with programme characteristics. There was some evidence that partner notification protocols were less likely to be in place in programmes not funded through government (OR 0.39, 95% CI 0.06–2.8), in programmes that charged patients for ART (0.12, 95% CI 0.01–1.29) and in scale-up programmes (0.66, 95% CI 0.11–4.0). Regular screening for STI tended to be less likely in scale-up cohorts compared to other programmes (OR 0.30, 95% CI 0.03–3.3).
In an open-ended question respondents were asked to describe the main problems in implementing preventive services in their programme. The “background of stigma, discrimination, blame” (female respondent from Thailand) was considered a major problem in implementing prevention services and similar comments were made by six other respondents from Argentina, India, South Africa, and Zambia. Another recurring theme was the very high patient load “so there is often inadequate time for counselling” (female respondent from Zimbabwe) and financial constraints, “which prevent programmes from hiring additional staff” (male respondent from Côte d’Ivoire).