South African TB nurses' experiences of provider-initiated HIV counseling and testing in the Eastern Cape Province: a qualitative study

This study addressed factors that played a role in the limited but effective implementation of provider-initiated HIV counseling in tuberculosis (TB) clinics in the Eastern Cape Province, South Africa, as part of a clinical trial. The Eastern Cape is a region with some of the highest TB and HIV rates in the world. The parent study was a pragmatic, cluster-randomized trial designed to measure the impact of provider-initiated ("opt-out'') counseling on the uptake of HIV counseling and testing in newly registered TB patients. Key informants were interviewed and clinic nurses who participated in the study were invited to participate in focus group discussions (FGDs). Thematic content analysis of transcriptions was conducted on data collected during interviews and FGDs. Three major themes regarding nurse experiences were derived from analysis, indicating that multiple structural and personal factors influence the success of provider-initiated HIV counseling of TB patients in primary care settings: (1) chronic frustration with knowing what TB tasks need to be accomplished but not having the resources, including staff, to accomplish them; (2) conflict between the appreciation of the need and importance of HIV counseling and testing and the health system's recognition of their difficulties implementing it; and (3) ambivalence in their roles as care providers and educators in the context of HIV counseling and testing. Innovative and coordinated strategies are needed in this environment to facilitate greater number of patients receiving HIV counseling and testing services.