Laetitia C. Rispel

HIV prevalence and risk practices among men who have sex with men in two South African cities.

Background:In South Africa, information on HIV among men who have sex with men (MSM) is limited, and HIV prevention programs for men MSM are not widely available, despite global evidence that MSM are at substantial risk for HIV infection. The Johannesburg/eThekwini Mens Study was conducted during 2008 to provide information on HIV among MSM in Johannesburg and Durban. Methods:MSM aged 18 years or older were recruited using respondent-driven sampling. Participants completed a questionnaire and provided finger-prick blood specimens for anonymous HIV testing in a laboratory. Results:From July to December 2008, 285 MSM were recruited in Johannesburg (n = 204) and Durban (n = 81). Participants had a median age of 22 years and were predominantly black Africans (88.3%). The HIV prevalence was 49.5% [95% confidence interval (CI): 42.5% to 56.5%] in Johannesburg and 27.5% [95% CI: 17.0% to 38.1%] in Durban. HIV infection was associated with gay identification [adjusted odds ratio (aOR): 8.4; 95% CI: 3.7 to 19]. Factors in the previous year that were associated with HIV infection included receptive unprotected anal intercourse [aOR 4.3; 95% CI: 2.4 to 7.6]; sex with a person known to be HIV positive [aOR: 2.3; 95% CI: 1.1 to 4.9]; and a sexually transmitted infection diagnosis [aOR 2.4; 95% CI: 1.1 to 5.2]. Conclusions:HIV prevalence among MSM in Johannesburg and Durban is considerably higher compared with men in the general population. There is an urgent need to establish national HIV surveillance among MSM and to expand the availability of HIV prevention programs for MSM.

You become afraid to tell them that you are gay: health service utilization by men who have sex with men in South African cities.

We describe the utilization of health services by men who have sex with men (MSM) in South African cities, their perceptions of available health services, and their service preferences. We triangulated data from 32 key informant interviews (KIIs), 18 focus group discussions (FGDs) with MSM in four cities, and a survey of 285 MSM in two cities, recruited through respondent-driven sampling in 2008. FGDs and KIIs revealed that targeted public health sector programs for MSM were limited, and that MSM experienced stigma, discrimination, and negative health worker attitudes. Fifty-seven per cent of the survey participants had used public health services in the previous 12 months, and 69 per cent had no private health insurance, with no difference by HIV status. Despite these findings, South Africa is well placed to take the lead in sub-Saharan Africa in providing responsive and appropriate HIV services for MSM.

Public perceptions on national health insurance: Moving towards universal health coverage in South Africa

BACKGROUND Since 1994, considerable progress has been made in transforming the South African health care system, implementing programmes that improve the health of the population, and improving access to health care services. However, amid escalating health care costs disparities continue to exist between the public and private health sectors. The implementation of a national or social health insurance remains elusive despite three government-appointed committees on the matter. METHOD AND OBJECTIVE This paper reports on the findings of a national probability household sample of the South African population, drawn as part of the 2005 HIV/AIDS national survey, to gauge public opinion on universal health care coverage. The perceptions of South Africans were assessed on selected health care affordability and financing issues. RESULTS The majority support efforts to contain medicine costs and one-third are of the opinion that the country can provide everyone with all the needed health care and medical services. A large percentage of participants thought it more important to provide improved health care coverage even if it meant raising taxes, while a small percentage said it is better to hold down taxes despite lack of access to health care for some South Africans. Almost a quarter of participants were unable to comment on questions posed to them, indicating the need for improved public education and communication. CONCLUSION The study provides important insights into public opinion on key policy issues. However, greater public awareness is needed to ensure an informed debate, while the design of a universal national health insurance scheme must take into account both the current context and public opinion.

Professionalization of South African Nursing: Who Benefits?:

In this article the authors present a critical and alternative view of the reasons for and nature of professionalism in nursing, with particular reference to the South African situation. They show that professionalizing strategies have not necessarily been in the interests of the majority of nurses or of health care. First, some background information is given on the process of professionalization: its emergence worldwide and in South Africa, partly as a response of a predominantly female group to the power, prestige, and privilege held in the health sector by a predominantly male medical profession. The process in South African nursing is outlined, with particular emphasis on how this has paralleled political developments in South Africa. The proletarianization of a large body of nurses is examined as a contradictory trend to professionalization. The second part of the article is an analysis of the consequences of the professionalization process, which has had deleterious effects on the provision of health care as well as on relationships amongst nurses, their colleagues, and their communities.

Assessing missed opportunities for the prevention of mother-to-child HIV transmission in an Eastern Cape local service area

BACKGROUND Prevention of new HIV infections is a critical imperative for South Africa; the prevention of mother-to-child transmission (PMTCT) is one of the most efficacious HIV prevention interventions. OBJECTIVE Assessment of a PMTCT programme to determine missed opportunities. SETTING The Kouga local service area (LSA), bordering Nelson Mandela Bay Municipality (Port Elizabeth) in the Eastern Cape. METHODS An assessment was conducted in 2007 before implementing technical support for strengthening the PMTCT programme, including: interviews with 20 PMTCT managers, 4 maternity staff and 27 other health workers on service provision, management, infrastructure, human resources and the health information system; 296 antenatal clinic users on their service perceptions; 70 HIV-positive women on HIV knowledge, infant feeding, coping, support and service perceptions; 8 representatives from community organisations and 101 traditional health practitioners (THPs). Observations were conducted during site visits to health facilities, and the District Health Information System (DHIS) data were reviewed. RESULTS Staff had high levels of awareness of HIV policies and most had received some relevant training. Nevirapine uptake varied by clinic, with an average of 56%. There were many missed opportunities for PMTCT, with 67% of pregnant women tested for HIV and only 43% of antenatal care attendees tested during a previous pregnancy. Only 6% of HIV-positive women reported support group participation. CONCLUSIONS Reducing missed opportunities for PMTCT requires strengthening of the formal health sector, intersectoral liaison, and greater community support. Priority areas that require strengthening in the formal health sector include HIV counselling and testing; family planning and nutrition counselling; infant follow-up; human resources; and monitoring and evaluation.

Policy implementation and financial incentives for nurses in South Africa: a case study on the occupation- specific dispensation

Background : In 2007, the South African government introduced the occupation-specific dispensation (OSD), a financial incentive strategy, to attract, motivate, and retain health professionals in the public sector. Implementation commenced with the nursing sector, but there have been unintended negative consequences. Objective : First, to examine implementation of the OSD for nurses using Hogwood and Gunns framework that outlines ‘perfect implementation’ pre-conditions. Second, to highlight the conditions for the successful implementation of financial incentives. Methods : A qualitative case study design using a combination of a document review and in-depth interviews with 42 key informants. Results : The study found that there were several implementation weaknesses. Only a few of the pre-conditions were met for OSD policy implementation. The information systems required for successful policy implementation, such as the public sector human resource data base and the South African Nursing Council register of specialised nurses were incomplete and inaccurate, thus undermining the process. Insufficient attention was paid to time and resources, dependency relationships, task specification, and communication and coordination. Conclusion : The implementation of financial incentives requires careful planning and management in order to avoid loss of morale and staff grievances.

‘We keep her status to ourselves’: Experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine

Abstract In HIV-discordant relationships, the HIV-negative partner also carries the burden of a stigmatised disease. For this reason, couples often hide their HIV-discordant status from family, friends and community members. This perpetuates the silence around HIV-discordant relationships and impacts on targeted HIV prevention, treatment and counselling efforts. This article reports on experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine. During 2008, HIV-discordant couples who had been in a relationship for at least one year were recruited purposively through health-care providers and civil society organisations in the three countries. Participants completed a brief self-administered questionnaire, while semi-structured interviews were conducted with each partner separately and with both partners together. Interviews were analysed using thematic content analysis. Fifty-one couples were recruited: 26 from South Africa, 10 from Tanzania, and 15 from Ukraine. Although most participants had disclosed their HIV status to someone other than their partner, few were living openly with HIV discordance. Experiences of stigma were common and included being subjected to gossip, rumours and name-calling, and HIV-negative partners being labelled as HIV-positive. Perpetrators of discrimination included family members and health workers. Stigma and discrimination present unique and complex challenges to couples in HIV sero-discordant relationships in these three diverse countries. Addressing stigmatisation of HIV-discordant couples requires a holistic human rights approach and specific programme efforts to address discrimination in the health system.

Nursing education reform in South Africa – lessons from a policy analysis study

Background Nursing education reform is identified as an important strategy for enhancing health workforce performance, and thereby improving the functioning of health systems. Globally, a predominant trend in such reform is towards greater professionalisation and university-based education. Related nursing education reform in South Africa culminated in a new Framework for Nursing Qualifications in 2013. Objective We undertook a policy analysis study of the development of the new Nursing Qualifications Framework in South Africa. Design We used a policy analysis framework derived from Walt and Gilson that interrogated the context, content, actors, and processes of policy development and implementation. Following informed consent, in-depth interviews were conducted with 28 key informants from national and provincial government; the South African Nursing Council; the national nursing association; nursing academics, managers, and educators; and other nursing organisations. The interviews were complemented with a review of relevant legislation and policy documents. Documents and interview transcripts were coded thematically using Atlas-ti software. Results The revision of nursing qualifications was part of the post-apartheid transformation of nursing, but was also influenced by changes in the education sector. The policy process took more than 10 years to complete and the final Regulations were promulgated in 2013. The two most important changes are the requirement for a baccalaureate degree to qualify as a professional nurse and abolishing the enrolled nurse with 2 years training in favour of a staff nurse with a 3-year college diploma. Respondents criticised slow progress, weak governance by the Nursing Council and the Department of Health, limited planning for implementation, and the inappropriateness of the proposals for South Africa. Conclusions The study found significant weaknesses in the policy capacity of the main institutions responsible for the leadership and governance of nursing in South Africa, which will need to be addressed if important nursing education reforms are to be realised.Background Nursing education reform is identified as an important strategy for enhancing health workforce performance, and thereby improving the functioning of health systems. Globally, a predominant trend in such reform is towards greater professionalisation and university-based education. Related nursing education reform in South Africa culminated in a new Framework for Nursing Qualifications in 2013. Objective We undertook a policy analysis study of the development of the new Nursing Qualifications Framework in South Africa. Design We used a policy analysis framework derived from Walt and Gilson that interrogated the context, content, actors, and processes of policy development and implementation. Following informed consent, in-depth interviews were conducted with 28 key informants from national and provincial government; the South African Nursing Council; the national nursing association; nursing academics, managers, and educators; and other nursing organisations. The interviews were complemented with a review of relevant legislation and policy documents. Documents and interview transcripts were coded thematically using Atlas-ti software. Results The revision of nursing qualifications was part of the post-apartheid transformation of nursing, but was also influenced by changes in the education sector. The policy process took more than 10 years to complete and the final Regulations were promulgated in 2013. The two most important changes are the requirement for a baccalaureate degree to qualify as a professional nurse and abolishing the enrolled nurse with 2 years training in favour of a staff nurse with a 3-year college diploma. Respondents criticised slow progress, weak governance by the Nursing Council and the Department of Health, limited planning for implementation, and the inappropriateness of the proposals for South Africa. Conclusions The study found significant weaknesses in the policy capacity of the main institutions responsible for the leadership and governance of nursing in South Africa, which will need to be addressed if important nursing education reforms are to be realised.

Exploring corruption in the South African health sector

Recent scholarly attention has focused on weak governance and the negative effects of corruption on the provision of health services. Employing agency theory, this article discusses corruption in the South African health sector. We used a combination of research methods and triangulated data from three sources: Auditor-General of South Africa reports for each province covering a 9-year period; 13 semi-structured interviews with health sector key informants and a content analysis of print media reports covering a 3-year period. Findings from the Auditor-General reports showed a worsening trend in audit outcomes with marked variation across the nine provinces. Key-informants indicated that corruption has a negative effect on patient care and the morale of healthcare workers. The majority of the print media reports on corruption concerned the public health sector (63%) and involved provincial health departments (45%). Characteristics and complexity of the public health sector may increase its vulnerability to corruption, but the private-public binary constitutes a false dichotomy as corruption often involves agents from both sectors. Notwithstanding the lack of global validated indicators to measure corruption, our findings suggest that corruption is a problem in the South African healthcare sector. Corruption is influenced by adverse agent selection, lack of mechanisms to detect corruption and a failure to sanction those involved in corrupt activities. We conclude that appropriate legislation is a necessary, but not sufficient intervention to reduce corruption. We propose that mechanisms to reduce corruption must include the political will to run corruption-free health services, effective government to enforce laws, appropriate systems, and citizen involvement and advocacy to hold public officials accountable. Importantly, the institutionalization of a functional bureaucracy and public servants with the right skills, competencies, ethics and value systems and whose interests are aligned with health system goals are critical interventions in the fight against corruption.

Evaluating an HIV and AIDS community training partnership program in five diamond mining communities in South Africa

In 2006, De Beers Consolidated Diamond Mines in South Africa entered into a partnership with the Soul City Institute for Health and Development Communications to implement an HIV and AIDS Community Training Partnership Program (CTPP), initially in five diamond mining areas in three provinces of South Africa. The aim of CTPP was to improve HIV knowledge and to contribute to positive behavior changes in the targeted populations. This paper describes the evaluation of the CTPP, one year after implementation. The evaluation combined qualitative interviews with key informants and trainers and a post-intervention survey of 142 community members. The successes of the CTPP included capacity building of trainers through an innovative training approach and HIV and AIDS knowledge transfer to community trainers and targeted communities in remote mining towns. The Soul City edutainment brand is popular and emerged as a major reason for success. Challenges included insufficient attention paid to contextual factors, resource constraints and the lack of a monitoring and evaluation framework. Independent evaluations are useful to strengthen program implementation. In remote areas and resource constraint settings, partnerships between non-governmental organisations and corporations may be required for successful community HIV and AIDS initiatives.