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Table 5 Stages of the PITC implementation process and key factors shaping the deployment of the intervention during each stage

From: Implementing a provider-initiated testing and counselling (PITC) intervention in Cape town, South Africa: a process evaluation using the normalisation process model

Stages of the PITC implementation process Key factors shaping the deployment of the PITC intervention
Stage 1 (August to October 2005)  
Project initiation and preparation Credibility, ownership and framing the project by top management
• The HIV manager of the municipal health department identified a gap in HIV testing uptake for STI patients. She rallied managerial colleagues to motivate for the implementing of the PITC intervention in a demonstration project. • The project was initiated by the health department itself and not by an external research organisation.
• The person who initiated the project was a senior manager (the HIV/TB manager) with a track record of achieving quality improvements in the TB/HIV and STI programmes.
• The project aim was to assess the feasibility, effectiveness and efficiency of the PITC intervention in an operational setting. • The PITC intervention was based on recommendations made in the WHO draft guideline for PITC in 2006.
  • The PITC intervention was promoted as being necessary to enhance comprehensive STI care and in response to real human resource constraints.
Governance accountability structure established Governance, leadership and accountability mechanisms were in place
• A project governance structure, the Project Steering Committee (PSC), provided oversight of the planning, implementation, monitoring and evaluation of the PITC project. • The PSC provided a structured governance mechanism for the participation, collaboration and accountability of relevant stakeholders, including managing conflicting views.
• The PSC was chaired by HIV manager, who was the initiator, project leader, and who acted as the champion for the project.
• The PSC comprised frontline clinical staff (nurses and lay counsellors), clinical supervisors, clinic management, HIV counselling trainers, project management and the project leader. • The PSC met at quarterly intervals and provided meetings of the PSC, provided opportunity for continuous monitoring and evaluation, regular feedback and motivation.
Stage 2 (October 2005 to March 2006)  
Planning and project management mechanisms Detailed planning, flexibility and management support provided
• There was a lengthy planning process spanning nearly nine months prior to implementation as well a detailed operational planning. • Planning was a ‘start and stop’ process due to disagreements among stakeholders about the acceptability and relevance of the PITC intervention.
• Facility managers and frontline staff had the flexibility to re-design patient flows in their clinics that would best accommodate the integration of the HIV offer into the STI consultation.
• Staff requested the support of a project manager to ensure effective implementation and monitoring and evaluation. Management responded positively (contextual integration).
• To strengthen the project management, a project manager was allocated on a part-time basis to be responsible for coordinating the operational level implementation and monitoring.  
Stage 3 (January to April 2006)  
Design of the PITC intervention Local adaptation, contestation and compromise enhancing the acceptability and feasibility of the PITC intervention
• The WHO version of the PITC intervention had to be adapted on several levels to fit with the local requirements. • The adaptation of the PITC in intervention was done on several levels geared towards improving the feasibility and acceptability of the intervention. (Upwards task shifting and task sharing).
• The intervention involved re-allocation of roles between clinical staff and lay health workers.
• There were several areas of disagreement amongst stakeholders in the PSC regarding the design of the intervention, task re-allocation, and training. The clinical guideline was lengthened to accommodate concerns among HIV trainers regarding ethical implementation of PITC.
• A clinical guideline for nurses was developed to guide their practice in the consultation. • The above conflicts threatened the feasibility of implementing the project.
• The conflict resolution and leadership skills shown by the project leader were largely responsible for the successful resolution of conflicts: using compromise and executive decision-making.
Training Training coverage and feasibility
• The frontline STI nurses and lay counsellors, as well as a few clinical supervisors, were trained on the PITC intervention by trainers from an HIV counselling training unit within the health department. • Training was well attended not only by the STI nurses responsible for implementation, but also by their immediate clinical supervisors (district HIV/TB coordinators).
  • Training course for nurses was 2.5 days (reduced from 5 days initially suggested by trainers).
  • Lay counsellors received training to provide more in-depth post-test counselling over two to three counselling sessions per patient.
Stage 4 (April 2006 to December 2007)  
• Health facility-based implementation and monitoring and evaluation Early and continuous monitoring, feedback and support provided
• Implementation started April 2006 in seven health facilities • Monitoring and evaluation mechanisms were in place from the start and were continuous throughout the duration of the intervention.
• The monitoring and evaluation systems were planned from the start, including the outcome indicators and the data sources. • Project support was provided through quarterly ‘cluster’ monitoring meetings that were conducted by staff from two or three clinics at time.
• A quarterly review meeting of the PSC was conducted where all facilities were provided with feedback on progress. • In cluster meetings and in quarterly PSC meetings, nurses and facility managers reviewed progress (based on routine health information), shared best practices, and addressed practical problems (e.g., ensuring supplies of test-kits, testing registers and clinical guideline sheets).
Evaluation of staff and patient experiences Evaluation of multiple dimensions provided information on perspectives and experiences of important stakeholders.
• Evaluations of patient and staff perspective and experience were conducted through various qualitative research methods. • Patient satisfaction surveys and patient exit interviews were done midway to explore the acceptability of the PITC intervention.
  • Evaluation of staff perspective was conducted via focus groups, to explore the acceptability of and the barriers and facilitators to implementation.
  • STI clinical consultations of nurses were observed to examine the delivery of the intervention in terms of efficiency of integration and the quality of informed consent processes.