Stages of the PITC implementation process | Key factors shaping the deployment of the PITC intervention |
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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. |