HIV/AIDS competent households: Interaction between a health-enabling environment and community-based treatment adherence support for people living with HIV/AIDS in South Africa

摘要

In the context of severe human resource shortages in HIV care, task-shifting and especiallycommunity-based support are increasingly being cited as potential means of providingdurable care to chronic HIV patients. Socio-ecological theory clearly stipulates that–in allsocial interventions–the interrelatedness and interdependency between individuals andtheir immediate social contexts should be taken into account. People living with HIV/AIDS(PLWHA) seldom live in isolation, yet community-based interventions for supporting chronicHIV patients have largely ignored the social contexts in which they are implemented.Research is thus required to investigate such community-based support within its context.The aim of this study is to address this research gap by examining the way in which HIV/AIDS competence in the household hampers or facilitates community-based treatmentadherence support. The data was analyzed carefully in accordance with the Grounded Theoryprocedures, using Nvivo 10. More specifically, we analyzed field notes from participatoryobservations conducted during 48 community-based treatment adherence supportsessions in townships on the outskirts of Cape Town, transcripts of 32 audio-recorded indepthinterviews with PLWHA and transcripts of 4 focus group discussions with 36 communityhealth workers (CHWs). Despite the fact that the CHWs try to present themselves asnot being openly associated with HIV/AIDS services, results show that the presence of aCHW is often seen as a marker of the disease. Depending on the HIV/AIDS competence inthe household, this association can challenge the patient’s hybrid identity management andhis/her attempt to regulate the interference of the household in the disease management.The results deepen our understanding of how the degree of HIV/AIDS competence presentin a PLWHA’s household affects the manner in which the CHW can perform his or her job and the associated benefits for the patient and his/her household members. In this respect,a household with a high level of HIV/AIDS competence will be more receptive to treatmentadherence support, as the patient is more likely to allow interaction between the CHW andthe household. In contrast, in a household which exhibits limited characteristics of HIV/AIDS competence, interaction with the treatment adherence supporter may be difficult inthe beginning. In such a situation, visits from the CHW threaten the hybrid identity management.If the CHWhandles this situation cautiously and the patient–acting as a gate keeper–allows interaction, the CHW may be able to help the household develop towards HIV/AIDScompetence. This would have a more added value compared to a household which wasmore HIV/AIDS competent from the outset. This study indicates that pre-existing dynamicsin a patient’s social environment, such as the HIV/AIDS competence of the household,should be taken into account when designing community-based treatment adherence programsin order to provide long-term quality care, treatment and support in the context ofhuman resource shortages.