Expansion and Decentralisation of HIV Services in Barbados: The Client’s Perspective D. Babb1, S. Forde1, A. Gumbs1, W. Sealy2, T. Carmichael1, S. Crichlow1, N. Adomakoh1   Ladymeade Reference Unit, Ministry of Health1 CHART Barbados, National HIV/AIDS Programme, Ministry of Health2

Background As the National HIV/AIDS Programme moves toward the goal of Universal Access by 2010, its scale up initiatives will encompass expansion of HIV services (including decentralisation), scale- up of HIV testing, integration of HIV and SRH/MCH services, strengthening of HIV surveillance systems and accelerated training and capacity building The client numbers at the Ladymeade Reference Unit (LRU) are steadily increasing and as a result of this there is a growing pressure to initiate the decentralisation process

Study Objectives To determine the client’s level of satisfaction with the existing HIV treatment services To explore client’s views about possible expansion and decentralisation of these services in Barbados

Design & Methods This study began in October 2009 and is ongoing. The data presented is preliminary and was collected over a period of eight (8) weeks The study was conducted with clients attending the LRU and presenting for services during stated time period Clients were randomly selected and invited to participate Informed consent was obtained Interviews were conducted using a semi-structured questionnaire Pertinent clinical information was obtained from patient files Data was entered and analysed using Epi Info 2008, Version 3.5.1

Design & Methods The questionnaire used was designed with six (6) Sections: I: Demographics II: Confidentiality III: Standard of Care IV: Accessibility and Convenience V: Support Systems VI: Clinical Information

Demographics 60 participants Ages ranged from 19-73; mean 44.5 yrs/ SD (11.5) 55% [33/60] female; 45% [27/60] male 12 [20%] primary, 31[51.7%] secondary, 17[28.3%] tertiary education 39 [65%] employed; 21[35%] unemployed 56 [93.3%] Barbadian, 3 [5.0%] Guyanese, 1 [1.7%] Vincentian

Geographical location Parish Female Male Total Percentage St. Michael 15 12 27 45.0 Christ Church 7 4 11 18.3 St. Peter 3 11.7 St. Philip 1 6.7 St. James 2 5.0 St. Thomas St. Lucy 3.3 St. Joseph St. George 1.7 33 60 100.0

Results: Confidentiality How would you like to be addressed for your care? 15 [25.0%] by name, 11[18.3%] by number, 34[56.7%], does not matter Over time how would you rate the level of confidentiality at this facility? Very good 40[66.7%] Good 12[20.0%] Satisfactory 7[11.7%] Fair 1[1.7%] Poor 0[0.0%] Do you trust the staff of the LRU? 60[100%] responded yes

Results: Standard of Care How long have you been attending this facility? Would you recommend the LRU to someone else that needs similar care? 60[100%] responded yes Length of time Frequency Percentage 0-6 months 2 3.3 6 months-1 year 3 5.0 1-2 years 11 18.3 2-5 years 13 21.7 > 5 years 31 51.7

Results: Standard of Care How would you rate the level of medical care received at LRU? Response Frequency Percentage Excellent 41 68.3 Very good 12 20.0 Good 5 8.3 Satisfactory 2 3.3 Fair 0.0 Total 60 100.0

Results: Accessibility and Convenience Have you ever received care from the polyclinic in your area? Yes-40[66.7%] No-20[33.3%] When was the last time you received medical care from a polyclinic? Last month 2[3.3%] Within last 3-6 months 3[5.0%] Within the last yr 8[13.3%] Within the last 5 yrs 6[10.0%] 5-10 yrs ago 9[15.0%] More than 10 yrs ago 15[25.0%] Never attended 17[28.3%]

Accessibility and Convenience I do not attend the polyclinic in my area because of: Reason Frequency Fear of breach in confidentiality 16 Long waiting time 13 No reason to go there/don’t need services offered 10 Lack of privacy during interview prior to consultation 8 Overcrowding 3 Close proximity to home 2 Far proximity from home Poor availability of doctor Other 4

Accessibility and Convenience I do not attend the polyclinic in my area because of: “Because if I have a problem I come here or go to the hospital” I do not feel comfortable discussing my business with the people up there” “I never considered it for my healthcare”

Results: Accessibility and Convenience Would you like to have the medical care you receive here transferred to the polyclinic in your district? Response Frequency Percentage Yes 4 6.7 No 53 88.3 I don’t know 3 5.0 Total 60 100

Please explain you answer.......... 71.7% (43/60) of respondents provided an explanation for their answer Of those who gave an explanation, (39/43) did not want to have their medical care transferred to a polyclinic Some of the reasons cited are as follows Reason Frequency n= 39 Percentage Confidentiality 16 41.0 Satisfaction/Comfort @ LRU 15 38.5 Stigma 4 10.3 Waiting time at PC 2 5.1 Bad experiences

Would you like to have the medical care you receive here transferred to the polyclinic in your district? Please explain you answer.......... “Too many people that I don’t mix with go up at the polyclinic and are too malicious. I am more comfortable here. If it comes to that (transfer) please make it the GP clinic or it wont make any sense!!” “The staff at the polyclinic don’t know of my situation and I would prefer it to stay that way” “The LRU is more private” “I will see too many people from my area” “I think that the fewer persons that are aware of my condition the better” “Because then people would know 'bout ya and you don’t want certain people to know” “I prefer to come here because this is the place for it” “I am extremely comfortable where I am” “I feel there is more confidentiality here at the LRU. At polyclinics it would be more open” “Level of confidentiality is not there. LRU is like an extended family. The polyclinic is like a stranger coming into the family. I am not interested”

Would you like to have the medical care you receive here transferred to the polyclinic in your district? Please explain you answer.......... (4/43) gave an affirmative response with the following explanations: “Because it is close to my workplace” “I believe a person living in the north of the island would be at an advantage if the services are available at the clinic in their area” “I would like to be close to home - in terms of transportation, then I would be able to take less time from work” “If it could happen, I would save taxi fare and just take a ZR”

Clinical information Viral load ranged from <40 to 677,000 copies/ml; median VL 40 CD4 counts ranged from 21 to 1609 cells/mm3; median CD4 523 53 (88.3%) participants on ART 44 on 1st line;7 on 2nd line and 2 on 3rd line 48 (80.0%) of clients interviewed classified as needing “routine” care 12 (20.0%) deemed “complicated” as a result of stage of infection, complexity of regimen, adherence concerns 15 (25.0%) clients also had other chronic illnesses besides HIV infection

Conclusions & Recommendations Majority of clients surveyed do not wish to attend a polyclinic for HIV care Majority of clients surveyed are stable clients needing routine care Clients who have never attended a polyclinic based their decision on their perception of the polyclinic system Clients are satisfied with care received at LRU Survey should be continued Pilot of HIV care at two (2) polyclinic sites The profile of client who will access care at polyclinic needs to carefully considered Option of private care should be explored

Thank You!