**3.1.1 Variety in optimal settings for public health care**

Respondents identify two principal and linked dynamics in the impact of rurality on HIV/AIDS care. Interestingly, public health care is perceived to be both a 'place' and a 'service'. Public knowledge in rural areas about HIV/AIDS is low, as it is for many health problems in a traditional rural environment. Negative community attitudes and stigma around HIV/AIDS have a profound impact in small, cohesive rural communities such that a more distant 'place' for testing is preferable to many community members. However, such attitudes also result in late recognition of HIV and delayed decisions to be tested. As the disease progresses, the capacity for ill people to travel declines further. At this point, and as HIV status becomes known to neighbours, a 'service' approach to public health is more preferred by community members. However, lack of transport for health care workers in remote areas affects HIV/AIDS awareness building, case identification, and follow-up services. Further, a service approach might alleviate the problem of limited space at hospitals, as noted below.

#### **3.1.2 Limitations in quantity and scope of practice of professional personnel**

The extreme conditions of HIV/AIDS clearly affect the adequacy of rural health care.

Nurses and VCT counselors are very overloaded and underpaid. Adding nursing staff is often considered to be a solution, but there are also practical barriers such as the need to share accommodation. As well, the limitation in types of South African health human resources is a severe problem. Marriage counselors and social workers are particularly

town of Edendale. From these locations, a sample of 46 key informants was drawn that included doctors, nurses, and VCT counselors. Semi-structured interviews were taped and administered by trained medical students, in Zulu, English or Xhosa, as appropriate. Interviews were done with fully informed consent and the right to refuse consistent with Research Ethics Board approval of universities in Canada (Queen's University) and South Africa (University of KwaZulu-Natal). The overall purpose of the interviews was to understand health workers' attitudes towards HIV/AIDS and GBV and how it affected their own work. However, a subset of questions focused on their experiences and roles, responsibilities and capacities in HIV/AIDS-GBV service delivery, which are reported here. In addition, relevant material was utilized from other interviews done for a larger study

Transcripts were analyzed and categorized according to concepts and issues derived from

Respondents identify two principal and linked dynamics in the impact of rurality on HIV/AIDS care. Interestingly, public health care is perceived to be both a 'place' and a 'service'. Public knowledge in rural areas about HIV/AIDS is low, as it is for many health problems in a traditional rural environment. Negative community attitudes and stigma around HIV/AIDS have a profound impact in small, cohesive rural communities such that a more distant 'place' for testing is preferable to many community members. However, such attitudes also result in late recognition of HIV and delayed decisions to be tested. As the disease progresses, the capacity for ill people to travel declines further. At this point, and as HIV status becomes known to neighbours, a 'service' approach to public health is more preferred by community members. However, lack of transport for health care workers in remote areas affects HIV/AIDS awareness building, case identification, and follow-up services. Further, a service approach might alleviate the problem of limited space at

**3.1.2 Limitations in quantity and scope of practice of professional personnel**  The extreme conditions of HIV/AIDS clearly affect the adequacy of rural health care.

Nurses and VCT counselors are very overloaded and underpaid. Adding nursing staff is often considered to be a solution, but there are also practical barriers such as the need to share accommodation. As well, the limitation in types of South African health human resources is a severe problem. Marriage counselors and social workers are particularly

with local women, men, faith leaders and traditional healers.


**3.1.1 Variety in optimal settings for public health care** 

the literature review.



**3.1 Issues of availability** 

hospitals, as noted below.

**3. Results** 


lacking. Doctors are not only in short supply, but many are temporary. South African medical practitioner licensing requires a one year community residency [Republic of South Africa 1997] which has increased the number of young doctors in rural areas, but often leaves gaps in service:

*Doctors here are very nice but very junior. I think for them it's "let's stick some chest drains in, put a CVP line in and do a 'caesar'. It's because we are only here for a year …let's turn it into an educational experience. I'm going to do all these courses and come up with these skills."* 

Distinctions between various medical professions and their scope of practice also creates service lacunae:

*These patients need to have their bloods taken for CD4 counts, as a nurse I have to do that but it's not within my scope.* 

Additionally, strict clinical guidelines for administering ART and considerable job stress creates problems in quality of care:

*When I'm giving everybody else their medication usually at 1800h, the HIV patient won't take it because they have to take it at 2000h. Who is going to sit down and wait for 2000h to give them their treatment? So they must remember for themselves because if they don't then they won't be taking their medication properly.* 

#### **3.1.3 Lack of physical space, resources and confidentiality**

Having sufficient working space is a concern for all hospital and clinic staff:

*Our ward accommodates 26, especially female medical, so we have floor beds and there we nurse some conditions, and now you as a nurse will have to be on your knees, and how can you put up a drip on the floor?* 

However, respondents hold differing views regarding the treatment of patients within the physical space of clinics. Some value the use of physical space for purposes of 'integration' of HIV/AIDS patients, while others value it for the purpose of 'separation'. Both views are linked to issues of ethics. Integration of HIV/AIDS patients with the general outpatient population is recommended by some respondents for the purpose of maintaining privacy of HIV status. Integration is also preferred to maintain equity of service for non-AIDS patients. For others, separation of HIV/AIDS outpatients is desirable for confidentiality of information. Most respondents recommend the separation of inpatients to ensure such privacy:

*The sad thing with HIV positive patients is that they are not protected. We don't have an isolation ward for them, the medical patients are mixed with them … There is no confidentiality for the HIV patients.* 

Numerous respondents identify problems related to the lack of essential medical equipment and supplies for HIV/AIDS care. First, there is a basic lack of equipment (e.g., suction machines, blood pressure instruments) for various clinic locations and needs. Further, existing equipment is not well maintained, or may be lost or stolen. Second, protective supplies (e.g., masks, gloves) that are necessary for working in a HIV/AIDS environment are lacking, especially in the communities. Basic supplies such as HIV test kits, oxygen and medications are not always available. Third, preventive immunizations (e.g., for hepatitis) are not routinely provided to health workers without cost. Although PEP is provided adequately to health workers, it is not necessarily provided to members of the public who might be exposed to the virus through caring for an HIV positive person. Finally, there is lack of coordination in using the available resources. A significant example is the lack of transport for delivery of blood samples to regional laboratories.

An Institutional Analysis of Access to

**3.3.2 Appropriate social care** 

the community, as noted by one volunteer:

*catastrophic (i.e., contracting HIV/AIDS).* 

*for my drugs and I must' absorb' a lot.* 

*just talking.* 

GBV/HIV Services in Rural KwaZulu-Natal, South Africa 97

Counseling is considered to be a lynch pin in HIV/AIDS and GBV social care. It is an evolving practice that originated in the West and is a common response to post-traumatic stress disorder. In rural South Africa, confidential counseling is increasingly intended to minimize the risks of HIV transmission, to prepare people for medical and social consequences of the disease and to increase treatment compliance. However, counseling

*Our people do not understand the idea behind the concept of counseling. Even when you explain it to them they don't see the benefit of going there. People do not see how their problems can be solved by* 

Community based volunteers for public education, support or home care are often an essential adjunct in integrated HIV/AIDS care. It is rare for adult men or younger women to volunteer, however, as they are usually pre-occupied with wage labor and subsistence activities. In the rural area, the HIV/AIDS volunteers are often older women or unemployed youth, that is, groups having lower community status. Such secondary status and varying concepts of privacy can affect the effectiveness of these volunteers and their acceptance by

*The problem is that we wouldn't be able to tell the community members what to do…they will say we think we are better. People who do counseling are those that you are close to, you come from the same neighbourhood, so it becomes hard to open up to them; especially if the families are not on good speaking terms. You go and share your story and the counselor will share it with everyone she knows, those are the reasons we fear going for counseling. People who do counseling are not well trained.* 

Rural communities, in turn, may not be supportive of women who experience violence. Fear of stigma and rejection by partners, family and community members inhibit women from disclosing rape to others and seeking out health care. Lack of knowledge of the risk of contracting HIV and other sexually transmitted infections (STIs) through rape means women do not necessarily consider health care an urgent priority following sexual assault: *She will not go to the police station because she might be afraid that her neighbours will laugh at her…. I think that she wouldn't go. Before a woman can go for medical help she has to tell certain people. If she does not want her rape ordeal to be known in the area, she can just let it slip. It is difficult for women to go to hospital without telling their mothers first. Moreover, if the raped woman lives with her partner and has not told him about the rape, it would be impossible to seek help. Also, not all women know the dangers inherent in rape. Some forget that the long term effects of rape can be* 

Even violence towards young children elicits contradictory responses. On the one hand, there is a feeling that child rape should be hidden to maintain a girl's reputation for future marriage. At the same time, children are considered to be especially vulnerable to the psychological consequences of rape, particularly stranger rape, and are in need of

*Look, you know, I'm unemployed. I'm the one without a job and my boyfriend is paying for me too,* 

Even with a broad understanding of GBV-HIV links and their effects on communities, rural

*So hunger is first, violence and a fear of violence is second, generalized poverty is third, ("How am I even going to get to the clinic to get care? I don't have bus fare.") and then fourthly HIV. So* 

counseling. Women's susceptibility to GBV and HIV/AIDS due to poverty is clear:

community women often have more immediate priorities than HIV testing and care:

may not be viewed in the same way by rural people themselves:

**3.3.3 Acceptability of health care in the context of violence** 

### **3.2 Issues of affordability**
