Expert Clients Research Articles

"I do all I can but I still fail them": Health system barriers to providing Option B+ to pregnant and lactating women in Malawi.

Malawi’s Option B+ program is based on a ‘test and treat’ strategy that places all HIV-positive pregnant and lactating women on lifelong antiretroviral therapy. The steep increase in patient load placed severe pressure on a health system that has struggled for decades with inadequate supply of health care workers (HCWs) and poor infrastructure. We set out to explore health system barriers to Option B+ by asking HCWs in Malawi about their experiences treating pregnant and lactating women. We observed and conducted semi-structured interviews (SSIs) with 34 HCWs including nine expert clients (ECs) at 14 health facilities across Malawi, then coded and analyzed the data. We found that HCWs implementing Option B+ are so overburdened in Malawi that it reduces their ability to provide quality care to patients, who receive less counseling than they should, wait longer than is reasonable, and have very little privacy. Interventions that increase the number of HCWs and upgrade infrastructure to protect the privacy of HIV-infected pregnant and lactating women and their husbands could increase retention, but facilities will need to be improved to support men who accompany their partners on clinic visits.

Acceptability of HIV testing for men attending televised football venues in Uganda

BackgroundWorldwide, HIV remains a major public health challenge, especially in Sub-Saharan Africa. Literature indicates that men’s involvement in HIV testing, care, and treatment services is lower compared to women, therefore novel approaches are required to engage men in the cascade of HIV care. This study aimed to explore men’s perception on the provision of HIV testing services in venues where English Premier League football games are televised.MethodsAn exploratory qualitative study was conducted between February and May 2018. Six focus group discussions were conducted with 50 conveniently selected men aged 18 years and older using a pre-tested discussion guide. All focus group discussions were audio recorded, transcribed verbatim, and analyzed thematically.ResultsOverall, HIV testing at venues telecasting English Premier League football games was acceptable to men. There was a very strong preference for health workers providing testing and counseling services be external or unknown in the local community. Possible motivators for testing services provided in these settings include subsidizing or eliminating entrance fee to venues telecasting games, integrating testing and counseling with health promotion or screening for other diseases, use of local football games as mobilization tools and use of expert clients as role models.ConclusionsThis study suggests that HIV testing services at venues where EPL football games are televised is generally acceptable to men. In implementing such services, consideration should be given to preferences for external or unknown health workers and the motivating factors contributing to the use of these services. Given that HIV testing is currently not conducted in these settings, further research should be conducted to evaluate the feasibility of this approach as a means of enhancing HIV testing among Ugandan men.

A frame work for mining huge data by non-expert users with the assistance of knowledge base

Data mining is the examination of (regularly huge) observational enlightening files to find unsuspected associations and to plot the data in novel ways that are both legitimate and valuable to the information proprietor. At the end of the day information mining is a procedure of finding beforehand obscure, beneficial and utilizes designs covered up in information, with no earlier theory. Robotized Data Mining and demonstrating programming gives supervisors a device to perform examinations that generally would should be dealt with by an exceptionally prepared specialist. Robotized information mining systems isn’t to give more exact outcomes yet endeavors to enable non expert clients to accomplish sensible outcomes with least exertion. Data mining is a troublesome and arduous action that requires a lot of mastery for acquiring quality outcomes. We require new techniques for wise information investigation to separate important data with less exertion. For that in this paper we propose an edge work with the assistance of learning base. That will be tried on e-realizing which creates better outcomes.

Methods of Valuing Construction Variation in Lump Sum Contract from the Public Client’s Perspective

A valuation of variation orders has become a daily task on large construction contracts. It is a norm where one of the contracting parties disagrees about the valuation of work done. Therefore, the valuation of variation orders has become one of the main causes of conflicts and disputes in construction management. The aims of study to determine the best practicing method in valuing a variation order for lump sum contract and identify the main related causes of variation project. The mixed method (interview and case study) of research was adopted in the collection of necessary data. Interview was conducted from 6 construction expert (clients) were analyzed. 6 case study building projects were selected by targeting sampling technique and used as the source of data for this study. The data were analysed with frequencies, sums and percentages. The study found that the client needs, lack of coordination during design and omission in design are the main causes of variation. An analysis of data indicated that used schedule of rate, fair market rate, daywork rate and negotiation are the four most famous method practicing in valuing a variation order in lump sum contract but its rely on the circumstances and the character of works.

Health Provider Perspectives of Health Facility Preparedness and Organization in Implementation of Option B+ among Pregnant and Lactating Women in Central Uganda: A Qualitative Study.

Introduction:Uganda adopted Option B+ for prevention of mother-to-child transmission (PMTCT) of HIV in 2012. However, there is limited data on preparedness and organization of Option B+ services. These data are critical in informing PMTCT programs and provision of universal antiretroviral therapy (ART) for all populations. This study explored health providers’ experiences of preparedness and organization of Option B+ services in Central Uganda.Methods:Key informant interviews with 54 health providers from 6 health facilities in 3 districts were conducted. Thematic approach was employed to analyze data.Results:Themes identified on preparedness were training of frontline health providers and provision of Option B+ guidelines, supervision and mentorship, and provision of essential medicines and medical health supplies, whereas those concerning organization were HIV counseling and testing, ART initiation, follow-up, and patient support mechanisms. Innovations like use of expert clients, assessing women’s readiness to start Option B+, and retaining women in antenatal care clinic depending on the need are important in provision of Option B+.Conclusion:This study provides insights into preparedness and organization of Option B+ services which are important in provision of Option B+ and universal ART for all populations. Research around models of follow-up is recommended.

A Case of TASO Tororo Surge Strategy: Using Double Layered Screening to Increase the Rate of Identification of New HIV Positive Clients in the Community

Introduction: HIV testing services is the entry point to HIV prevention, care, treatment, and support services. According to Uganda Population HIV impact assessment preliminary report released in 2018, 72.5% of people living with HIV in Uganda knew their status, which is below the UNAIDS target of 90%. We proposed a double layered screening of the population using the Ministry of Health HIV Testing Services (HTS) screening tool to identify more HIV positives and start them on treatment. The objective of this study was to assess the impact of the double layered screening approach on HIV test yield. Methods: A double layered screening approach involved using community and technical teams from TASO Tororo HIV clinic through the surge strategy. The community team (first layer) comprised of expert clients, local council 1, market and church leaders who were trained on how to screen the people in the community using the HTS screening tool. The technical team (second layer) comprised of medical personnel and counselors who subjected all people mobilized and screened by the community team to a second layered screening before offering an HIV test. We compared proportions of HIV test yields before and after the implementation of the double layered HTS strategy using proportions test and we assessed the impact of the double layered screening using a difference in difference (DID) evaluation method. Results; There was a general increase in HIV test yield from 4.75% with single screening (period: January-March 2018) to 12.25% with double screening (period: April – June 2018) (P<0.001). The increase was more in males (from 3.51% to 11.06%) than in females (from 6.36% to 13.31%) and this difference was significant (P=0.035). The increase in HIV test yield did not differ by age (P=0.060), by marital status (P=0.606) or by first time tester (P=0.167), Conclusion: The double layered screening before HIV test could be an effective strategy to maximize HIV test yield in the general population, which if scaled up can save huge resources, time and help focus on actual targets for HIV testing services, leading to early attainment of the UNAIDS 1st target of 90-90-90.

PIN109 - EVALUATION OF KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING HIV/AIDS AMONG PREGNANT WOMEN AND THEIR PARTNERS INVOLVED IN PREVENTION MOTHER-TO-CHILD TRANSMISSION (PMTCT) PROGRAMS IN MALAWI.

Malawi has one of the highest HIV prevalence (10%) in the world despite the impressive progress made in controlling HIV epidemic. Only 66% of all people living with HIV are treated with antiretroviral drugs. World Health Organization estimated that the prevalence of condom use by adults during higher-risk sex is around 43%, but only a low portion of the population (26%) showed a comprehensive correct knowledge of HIV/AIDS in the period 2007-2013. To investigate what Malawian population knows about HIV/AIDS, what believes and how behaves in relation to HIV/AIDS prevention. To assess knowledge, attitude and practice (KAP) among couples enrolled in HIV programs, we designed a survey using a structured and standardized questionnaire. An ad hoc questionnaire has been designed tailoring already used KAP questionnaires to our aim, population and context, as well as devising new questions with the involvement of two expert clients. Following practical KAP guidelines that support us in the design of the survey, we pre-tested the questionnaire and implemented the survey, until now. The questionnaire includes a socio-demographic part and 45 close questions divided into three parts covering the following areas: knowledge, attitude and practice. As a pre-test, on 4th June 2018 the expert clients administered questionnaire to 20 randomly selected pregnant women enrolled in PMTCT service of the DREAM centre (HIV/AIDS center) of Blantyre. The pre-test phase highlighted that four questions were subject to multiple interpretations and two questions seemed redundant. Based on the pre-test results we identified areas needing improvement in questionnaire. This survey will be conducted in more than one healthcare centre in a segment population and it could help healthcare managers and the policymakers to plan HIV/AIDS programs.

Time taken to link newly identified HIV positive clients to care following a home-base index case HIV testing: Experience from two provinces in Zimbabwe.

BackgroundHomebased index case HIV testing (HHTC) has shown higher uptake and good yield than traditional HIV testing methods. World Health Organization has called for increased operational research to evaluate HIV care processes particularly linkage to care. In this paper, we present project results of the time taken to link newly identified PLHIV to care after HHTC in the Manicaland and Midlands provinces of Zimbabwe.MethodsWe retrospectively reviewed community-facility referral data from the Zimbabwe HIV Care and Treatment project for newly diagnosed PLHIV for the period March–September 2016. A referral slip was given to a client after receiving a positive HIV results and was presented and filed upon reaching a health facility. In July 2016, the project started working with trained expert clients to assist with linkage to care. Data was entered in a spreadsheet and then imported for descriptive statistical analysis with EpiInfoTM Version 7.2.0.1. Odd ratios were used to identify factors associated with linkage to care within seven days.ResultsOut of 1004 newly identified PLHIV between March and September 2016, 650 (64.7%) were linked to care. The median time taken to be linked to care was four days (Interquartile range 19 days). Overall, 63.1% (410) of PLHIV were linked to care within seven days of diagnosis and 85% within 30 days. PLHIV were more likely to be linked to care within seven days of diagnosis between July and September 2016 (OR = 4.1; p< 0.001), a period when ZHCT started working with expert clients to support linkage to care.ConclusionHHTC resulted in almost 63% of newly diagnosed PLHIV being linked into care within seven days, and 85% within 30 days. Linkage to care within seven days was significantly associated with the period of engaging expert clients in the project. We recommend community based HIV testing programs to work with expert clients to ensure timely linkages of new PLHIV.

Managing advertising agency client partnerships for value co-creation: Characteristics, categories, and challenges

This article examines the role and characteristics of professional client partners in the value co-creation process. Previous literature has studied the role of clients in the co-creation process; however, the effects of different characteristics of clients on co-creation of value are less clear. This study examines these through a research design comprising depth multiple case studies of client relationships with professional service firms (PSFs). Empirical primary data were collected from in situ in-depth interviews with senior account managers in leading advertising agencies in Spain. Our initial results suggested that the type of clients and their characteristics was important for determining the potential and approach to managing their relationships for positive value creation. Further analysis identified key client characteristics and a classification of four types of clients: low involved novice clients, highly involved novice clients, control-concerned expert clients, and integration-concerned expert clients. We also found that not all client relationships resulted in positive value creation because some eventually produce detrimental or negative value consequence. We conceptualize this as the value depletion circle (VDC) and discuss the practical and theoretical implications of this phenomenon. Finally, alternative service relationships scenarios are described which can help institutions understand success and failure in their value creation relations and practices with clients and partners of different types. The contribution of this article is threefold. First, it analyses theoretically the role of client in the service co-creation process. Second, our multi-case study develops a classification of PSF clients into four categories. Third, we explain how dealing with called complex clients may generate a vicious circle, the VDC, which in the long run can seriously damage the sector image.

The GIPA Concept ‘Lost in Transition’

AbstractFollowing the call by UNAIDS in 2006 to involve people living with HIV (PLHIV) in treatment programmes, expert clients were recruited to provide services within healthcare settings as volunteers alongside paid health workers. Swazi law requires employment contracts for anyone working in a full-time capacity for three months, complicating the status of expert clients. This article traces the genesis of the volunteer framework used to engage PLHIV in the provision of HIV care in Swaziland and describes how the quest for PLHIV to be involved coupled with donors’ promotion of the Greater Involvement of People Living with HIV/AIDS (GIPA) principle have together resulted in PLHIV serving as low-cost workers, disempowering the very people GIPA was meant to empower. I call for review of GIPA-based policies and a paradigm shift regarding a non-medically trained cadre of workers in an era of acute health-worker shortages in resource-limited countries hard hit by HIV.

Improving the performance of community health workers in Swaziland: findings from a qualitative study

BackgroundThe performance of community health workers (CHWs) in Swaziland has not yet been studied despite the existence of a large national CHW program in the country. This qualitative formative research study aimed to inform the design of future interventions intended to increase the performance of CHW programs in Swaziland. Specifically, focusing on four CHW programs, we aimed to determine what potential changes to their program CHWs and CHW program managers perceive as likely leading to improved performance of the CHW cadre.MethodsThe CHW cadres studied were the rural health motivators, mothers-to-mothers (M2M) mentors, HIV expert clients, and a community outreach team for HIV. We conducted semi-structured, face-to-face qualitative interviews with all (15) CHW program managers and a purposive sample of 54 CHWs. Interview transcripts were analyzed using conventional content analysis to identify categories of changes to the program that participants perceived would result in improved CHW performance.ResultsAcross the four cadres, participants perceived the following four changes to likely lead to improved CHW performance: (i) increased monetary compensation of CHWs, (ii) a more reliable supply of equipment and consumables, (iii) additional training, and (iv) an expansion of CHW responsibilities to cover a wider array of the community’s healthcare needs. The supervision of CHWs and opportunities for career progression were rarely viewed as requiring improvement to increase CHW performance.ConclusionsWhile this study is unable to provide evidence on whether the suggested changes would indeed lead to improved CHW performance, these views should nonetheless inform program reforms in Swaziland because CHWs and CHW program managers are familiar with the day-to-day operations of the program and the needs of the target population. In addition, program reforms that agree with their views would likely experience a higher degree of buy-in from these frontline health workers.

Self-management as management of the self: Future directions for healthcare and the promotion of mental health

In lieu of an abstract, here is a brief excerpt of content: In a recent attempt to update 1948 World Health Organization definition of health as a state of complete well-being and absence of disease, it has now been proposed to change its emphasis to ability to adapt and manage in face of social, physical and emotional challenges (Huber et al., 2011). The question how we should conceptualize such self-management, however, is rarely raised and its theoretical foundations remain largely unexplained. Still, to an increasing extent, scholars, health professionals, researchers, caretakers and policy makers emphasize great potential of self-management strategies in somatic as well as mental healthcare. Patients, so argument runs, should not be treated merely as objects of diagnosis and treatment, but as expert clients, actively involved in management of their own care. The advantages of this approach are considered twofold: it holds prospect of more efficient and (cost)effective preventive and care strategies to promote mental health and well-being, and converges with recent research findings which acknowledge that incorporating patients' subjective perspectives is beneficial to treatment progress. At same time, it is clear that self-management in context of mental healthcare poses profoundly challenging problems (Van Geelen, 2013; Van Geelen, 2014), as we need to take into account that it is often the self that is part and parcel of problem in psychiatric and psychosomatic conditions (Kyrios et al., 2015; Santhouse, 2008; Sadler, 2007). In context of mental healthcare, then, self-management confronts us with fundamental questions: what is our understanding of this in psychosomatic and psychiatric settings, and how does that understanding, directly or indirectly, affect diagnoses, treatment plans and nosology in fields of psychopathology and psychosomatic medicine? Answering such questions will also be of vital importance to a theoretically sound and practically relevant, implementable notion of self-management. Given complexity of this subject matter, addressing such [End Page 179] problems requires an interdisciplinary approach, as we have argued in introduction (Van Geelen & Franssen, 2017). A conceptual framework for self-management should integrate insights from a variety of disciplines, as it needs to acknowledge multifaceted character of self-experience – with all its embodied, affective, cognitive, moral and social complexities. It is imperative, in other words, that insights in structure and characteristics of and self-experience as developed in humanities traditions – i.e., phenomenology, philosophy of mind and action, ethics, narrative theory – are brought into a dialogue with results obtained in psychiatric and psychosomatic research and practice.

Long-Term Antiretroviral Treatment Adherence in HIV-Infected Adolescents and Adults in Uganda: A Qualitative Study.

BackgroundLong-term success of HIV antiretroviral therapy requires near-perfect adherence, maintained throughout one’s lifetime. However, perceptions towards ART and patterns of adherence may change during the life course. We assessed challenges to long-term adherence in adolescents and adults in three regional HIV treatment centers in Uganda.MethodsWe conducted 24 in-depth interviews and 2 focus group discussions with a total of 33 health-care providers and expert clients (HIV patients on long-term ART who assist with adherence support of fellow patients). Interview topics included experiences with patients on long-term treatment with either declining adherence or persistent poor adherence. Transcribed texts were coded and analyzed based on the social-ecological framework highlighting differences and commonalities between adolescents and adults.ResultsThe overarching themes in adolescents were unstructured treatment holidays, delays in disclosure of HIV status by caretakers, stigma, which was mainly experienced in boarding schools, and diminishing or lack of clinical support. In particular, there was minimal support for early and gradual disclosure for caretakers to the infected children, diminishing clinical support for young adults during transition to adult-based care and declining peer-to-peer support group activities. The predominating theme in adults was challenges with treatment access among temporary economic migrants. Common themes to adults and adolescents were challenges with disclosure in intimate relationships, treatment related factors including side effects, supply of single tablets in place of fixed-dose combined drugs, supply of drug brands with unfavorable taste and missed opportunities for counseling due to shortage of staff.ConclusionAdherence counseling and support should be adapted differently for adolescents and adults and to the emerging life course challenges in long-term treated patients. Programs should also address constraints experienced by temporary economic migrants to ensure continuity of treatment within the host country.

Pathways and access to mental health care services by persons living with severe mental disorders and epilepsy in Uganda, Liberia and Nepal: a qualitative study.

BackgroundAccess to mental health care services for patients with neuropsychiatric disorders remains low especially in post-conflict, low and middle income countries. Persons with mental health conditions and epilepsy take many different paths when they access formal and informal care for their conditions. This study conducted across three countries sought to provide preliminary data to inform program development on access to care. It thus sought to assess the different pathways persons with severe mental disorders and epilepsy take when accessing care. It also sought to identify the barriers to accessing care that patients face.MethodsSix in depth interviews, 27 focus group discussions and 77 key informants’ interviews were conducted on a purposively selected sample of health care workers, policy makers, service users and care takers in Uganda, Liberia and Nepal. Data collected along predetermined themes was analysed using Atlas ti software in Uganda and QSR Nvivo 10 in Liberia and NepalResultsIndividual’s beliefs guide the paths they take when accessing care. Unlike other studies done in this area, majority of the study participants reported the hospital as their main source of care. Whereas traditional healers lie last in the hierarchy in Liberia and Nepal, they come after the hospital as a care option in Uganda. Systemic barriers such as: lack of psychotropic medicines, inadequate mental health specialists and services and negative attitudes of health care workers, family related and community related barriers were reported.ConclusionAccess to mental health care services by persons living with severe mental disorders and epilepsy remains low in these three post conflict countries. The reasons contributing to it are multi-faceted ranging from systemic, familial, community and individual. It is imperative that policies and programming address: negative attitudes and stigma from health care workers and community, regular provision of medicines and other supplies, enhancement of health care workers skills. Ultimately reducing the accessibility gap will also require use of expert clients and families to strengthen the treatment coalition.

Quality Improvement Interventions for Early HIV Infant Diagnosis in Northeastern Uganda

Introduction. Early infant diagnosis (EID) of human immunodeficiency virus (HIV) ensures prompt treatment and infant survival. In Kaabong Hospital, 20% of HIV exposed infants (HEIs) had access to HIV diagnosis by eight weeks. We aimed to improve EID of HIV by deoxyribonucleic acid-polymerase chain reaction (DNA-PCR) testing by eight weeks from 20 to 100% between June 2014 and November 2015. Method. In this quality improvement (QI) project, EID data was reviewed, gaps prioritized using theme matrix selection, root causes analyzed using fishbone tool, and improvement changes were selected using counter measures matrix but implemented using Plan-Do-Study-Act cycle. Root causes of low first DNA-PCR testing included maternal EID ignorance, absent lost mother-baby pairs (LMBP) tracking system, and no EID performance reviews. Health education, Continuous Medical Education (CMEs), and integration of laboratory and EID services were initial improvement changes used. Results. DNA-PCR testing increased from 20 to 100% between June 2014 and July 2015 and was sustained at 100% until February 2016. Two declines, 67% in September 2014 and 75% in June 2015, due to LMBP were addressed using expert clients and peer mothers, respectively. Conclusion. Formation of WIT, laboratory service integration at MBCP, and task shifting along EID cascade improved EID outcomes at 6 weeks.

Patient and provider perspectives on improving the linkage of HIV-positive pregnant women to long-term HIV care and treatment in eastern Uganda

Despite strong evidence that antiretroviral therapy (ART) reduces the risk of mother-to-child transmission of HIV and improves the health of HIV-positive mothers, many HIV-positive pregnant women do not enrol into long-term HIV care and treatment. This study examined barriers and facilitators to the linkage of HIV-positive pregnant women from antenatal care (ANC) to long-term HIV care from patient and provider perspectives, following the implementation of a collaborative quality improvement project in Eastern Uganda. It also solicited recommendations for improving linkages to HIV care. Structured interviews were conducted with 11 health providers and 48 HIV-positive mothers enrolled in HIV care. Facilitators to linking HIV-positive pregnant women to long-term HIV care identified included support from expert clients, escorted referrals, same-day HIV care registration, and coordination between ANC and HIV services. Barriers reported included shortages in HIV testing kits and fear of social, physical and medical consequences. Participants recommended integration of ANC and HIV services, reduction in waiting times, HIV counselling by expert clients, and community-based approaches for improving linkages to HIV care. Linking HIV-positive pregnant women to HIV care can be improved through deliberate implementation of quality improvement interventions in facilities to address barriers to access and provide stronger support and community mobilisation.

“They are human beings, they are Swazi”: intersecting stigmas and the positive health, dignity and prevention needs of HIV‐positive men who have sex with men in Swaziland

IntroductionDespite the knowledge that men who have sex with men (MSM) are more likely to be infected with HIV across settings, there has been little investigation of the experiences of MSM who are living with HIV in sub-Saharan Africa. Using the framework of positive health, dignity and prevention, we explored the experiences and HIV prevention, care and treatment needs of MSM who are living with HIV in Swaziland.MethodsWe conducted 40 in-depth interviews with 20 HIV-positive MSM, 16 interviews with key informants and three focus groups with MSM community members. Qualitative analysis was iterative and included debriefing sessions with a study staff, a stakeholders’ workshop and coding for key themes using Atlas.ti.ResultsThe predominant theme was the significant and multiple forms of stigma and discrimination faced by MSM living with HIV in this setting due to both their sexual identity and HIV status. Dual stigma led to selective disclosure or lack of disclosure of both identities, and consequently a lack of social support for care-seeking and medication adherence. Perceived and experienced stigma from healthcare settings, particularly around sexual identity, also led to delayed care-seeking, travel to more distant clinics and missed opportunities for appropriate services. Participants described experiences of violence and lack of police protection as well as mental health challenges. Key informants, however, reflected on their duty to provide non-discriminatory services to all Swazis regardless of personal beliefs.ConclusionsIntersectionality provides a framework for understanding the experiences of dual stigma and discrimination faced by MSM living with HIV in Swaziland and highlights how programmes and policies should consider the specific needs of this population when designing HIV prevention, care and treatment services. In Swaziland, the health sector should consider providing specialized training for healthcare providers, distributing condoms and lubricants and engaging MSM as peer outreach workers or expert clients. Interventions to reduce stigma, discrimination and violence against MSM and people living with HIV are also needed for both healthcare workers and the general population. Finally, research on experiences and needs of MSM living with HIV globally can help inform comprehensive HIV services for this population.

“The Adopted Children of ART”: Expert Clients and Role Tensions in ART Provision in Uganda

The implementation of the greater involvement of people living with HIV (GIPA) principle in Ugandan AIDS care is described by focusing on the engagement of expert clients in two rural health centers during a time of antiretroviral therapy (ART) scale-up. We contrast how the expert clients help overburdened nurses to manage the well-attended ART programs in the public and in the nongovernmental organization clinic. They are unpaid, but acquire preferential status in the ART program because of their knowledge of AIDS medicines (and its adverse effects) and because of the compassionate care that they provide. Despite the assistance provided, nurses in the public facility felt threatened in their professional status by these expert clients, who were seen to overstep the boundaries of their role. We pay particular attention to the double burden for HIV-positive nurses, who fear stigma, and (unlike the expert patients) keep their HIV status secret.

Working with expert clients to enhance patients' follow up and retention; home care experience of St Raphael of St Francis Hospital, Nsambya, Kampala

Background: Nsambya Home Care (NHC) is a department of St Raphael of St Francis Hospital, Nsambya that was established in 1987 to primarily decongest the hospital wards of overwhelming number of AIDS patients. The main beneficiaries are the women and children living with HIV, their families and the communities within 21 km radius. The program provides holistic home-based care quality services to HIV/AIDS-infected and affected persons, their families and communities. Through its HIV facility-based and home-based services, and support with various community linkages, over 13,494 patients and their families have been served since inception. It has built a human resource capacity in community involvement and several community linkages that support the patient identification, home-based care and referrals. Method: In 2001 the program realized a service gap between the facility and the community, identified 50 patients from its clientele who were trained in community mobilization skills, home-based care, use of the first-aid package, basic counseling, monitoring and follow up of patients. They were equipped with home-based care kits, gumboots, umbrellas, bicycles to easy transport, and air time to enable them to communicate and link up with the main facility. Consented clients are linked to respective community volunteers for follow up. Monthly meetings are held to share experiences and address challenges. Refresher courses are carried out to update them on the new method. Results: There has been an increase in clients visited, from 200 (2001) to 1240 in the year 2012 per month leading to increased adherence levels to ART and general care. The volunteers have led to the formation of peer support groups at community level, providing emotional support amongst the members. Lost-to-follow-up cases have reduced from 80 clients to 15 clients per month reduction. The patient missed appointments have also reduced. The community served have been sensitized, mobilized and are now actively involved in HIV prevention, care and support services/ activities being implemented by Nsambya Home Care Program. Male community volunteers have helped in changing attitudes of fellow men to support clients in HIV care, treatment and prevention since 12 of 50 volunteers are male. Conclusion: The community volunteers' efforts have contributed to improved quality of life among people living with HIV/AIDS, therefore should be enhanced and acknowledged as important in HIV programming and care.

More Hands in Complex ART Delivery? Experiences from the Expert Clients Initiative in Rural Uganda

This paper aims to analytically describe the experiences and outcomes of involving peopleliving with HIV/AIDS in clinical care of HIV/AIDS within the healthcare clinic in a poorlyresourced setting. With HIV/AIDS treatment finally available in poorly resourced settings,there was huge number of people in need of clinical care. As a result, professional health workersbecame overwhelmed by the demand for treatment and care. Consequently, this called for anew way to handle the rising numbers and needs of clients at the health clinic level so as tominimise the burden of care on the health professionals. An 18 months ethnographic studywas conducted between 2005 to 2007 with professional medical workers (including Doctors,nurses and counsellors, clinicians), ART clients and with family care givers of ART clients, ata Health center IV-HIV clinic in a rural district in Uganda. The result shows that the scalingup of ART and subsequent introduction of Expert Clients as a new care arrangement withinthe health clinic has opened up the clinical space as some pseudo space where at least in principle, the patient has a voice in care with various outcomes.