1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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%]

12. 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

13. 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”

14. 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

15. 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
LRU 15
38.5
Stigma 4
10.3
Waiting time at PC 2
5.1
Bad experiences

16. 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”

17. 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”

18. 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

19. 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

20. Thank You!