Patient and health provider perspectives after implementation of the “treat all” guidelines in Namibia

The Government of Namibia started implementing the "treat all" guidelines as national policy in April 2017. To cope with the critical shortage of medical doctors, the Namibian government officially adopted ART task shifting and decentralization guidelines in 2015. The government started decentralizing ART services to community-based health facilities and devolving care responsibilities from physicians to nurses under USAID's HIV Clinical Technical Assistance Project (UTAP). The Namibian government also started utilizing community-based ART delivery models (CBART), especially community ART-refill groups (CARGs) for stable ART clients. This approach aimed to reduce overcrowding in clinics and overburdening staff. A study was conducted to determine the perspectives of clients and providers regarding ART service delivery six and twelve months into Namibia's implementation of the treat all guidelines. The study selected six district-level hospitals and four community-based health facilities from six northern districts to participate. The study collected qualitative data from ART clients and ART providers across the ten study facilities at baseline, six months, and twelve months after implementation of the guidelines. The information gathered related to service quality, changes in service delivery, and recommendations for service improvements. The study found that ART clients remained satisfied with their HIV doctor or nurse, but wait times continued to be a concern for ART clients at most facilities. Despite the introduction of the treat all guidelines, human resources for health remained a challenge, but neither providers nor clients felt that the introduction of treat all exacerbated long wait times at ART clinics. ART clients continued to face many ART adherence barriers, independent of treat all, such as missing work to obtain drug refills, side effects due to lack of food, and alcohol use. However, decentralization and community service models can make drug refills easier, thereby improving ART adherence. Most ART clients and health providers still felt that their health facilities were noticeably understaffed, and health providers also felt that increased training, especially on the treat all guidelines, could improve efficiency and competency among all staff members. Health providers were divided as to whether client loads had increased or decreased because of the treat all guidelines. Many providers noticed an increase in client loads after implementing the treat all guidelines, which was attributed to provider-initiated HIV testing and counseling (PITC). However, some providers noticed no change, and some noticed a decrease in client loads after the implementation of the treat all guidelines. Additionally, with the implementation of CBART and/or CARG, many health providers noticed a decrease in overcrowding and workload at their facilities. Health providers noted that decentralization and CBART/CARGs improved ART adherence for clients. Since ART care was decentralized, ART clients did not need to travel as far to retrieve medication and see an HIV health provider, thus making it easier to attend appointments and adhere to ART medication. Health providers also felt that CBART or CARGs were beneficial to ART clients since ART medication was either delivered to community doorsteps or only one person in a CARG needed to travel to the health facility to retrieve medication for their group. Awareness of the treat all guidelines was low among ART clients, suggesting the need for more education. When asked about the treat all guidelines, most ART clients were unaware that such guidelines existed. While all health providers were aware of the guidelines, some health providers noticed that CARGs did not noticeably decrease existing long wait times at ART clinics.