Table 3 Supporting quotes for each theme and sub-theme
Factors that influence prevention of diabetes and hypertension in PLWH | ||
|---|---|---|
Organisational and healthcare system factors | Education on lifestyle behaviours | “in the morning before starting the clinic we give education about diet and we have a nutritional officer in here that helps to plan diet with the client … We also tell them about cigarette smoking and alcohol using and we have people that have already stopped.” (HIV doctor; P6) |
“we were also told to do some exercises … exercises like walking … You can go and return by not using car. Other exercises include doing your usual activities.” (PLWH; P24) | ||
Counselling on ARV adherence | “it’s counselling, they all receive this … adherence counselling, they all receive.” (HIV nurse; P8) | |
“they [CTC HCPs] are the ones that got us to this point because we gave up before when we didn’t have any hope of living, but they gave us education, do this, take this medication, ‘if you adhere to treatment you’ll have life like any other person’.” (PLWH; P21) | ||
Individual factors | HCP knowledge of NCDs | “if the patient has hypertension it is easy for them to have diabetes or if they have diabetes it is easy to have hypertension. But on the side of HIV and diabetes or hypertension, from what I know, if the patient’s immunity is low then they can easily get diabetes or hypertension.” (HIV nurse; P2) |
“To me I think no there is no association [between HIV, diabetes and hypertension], it just happens coincidently.” (HIV doctor; P3) | ||
PLWH knowledge of NCDs | “we normally receive health education here [at the CTC] and even in the media when we watch TV we may find that a doctor is explaining the risk of getting other infections for people living with HIV … opportunistic infection, for example TB [tuberculosis] and pandemic diseases. If your immunity is weak then you can easily get infected.” (PLWH; P23) | |
“they [CTC HCPs] never give me that education [on NCDs]. They just give me the HIV education.” (PLWH; P32) | ||
Syndemic factors | Poverty of PLWH | “I also advise what is available near their home because it may differ on economic. For me I can eat anything I want but for some patients they can’t eat anything they want.” (HIV doctor; P3) |
“one of the things that they told me, first of all is nutrition, good nutrition, to eat a lot of fruits, vegetables, doing exercises, things like that, having a good diet. But you may find some of us we don’t do that because of our economic issues. For example, myself I just eat ugali [porridge made from cornmeal or corn flour], and hard work. Because I cannot afford to take all the things they say I should eat.” (PLWH; P33) | ||
Mental health and wellbeing of PLWH | “sometimes when we take the viral load of patients and you find he is having high viral loads and you’ve been counselling on medication adherence in different sessions and still fail to adhere then you can think that the patient is not stable mentally.” (HIV nurse; P2) | |
“they told me to avoid overthinking, ‘if someone hurts you, do not take it serious, just take it easy and it will reduce overthinking. You have to take problems as a normal life thing. If you take it very serious, your blood pressure will be high.’.” (PLWH; P26) | ||
Factors that influence early diagnosis of diabetes and hypertension in PLWH | ||
Organisational and healthcare system factors | Fragmented HIV and NCD services | “we may give this medication and believe that when they go to a specific clinic they will be given certain medication. So you may find that the patient does not go to the clinic or they go to the clinic and find there’s a lot of patients waiting on the service and the patient gives up and decides to go home.” (HIV nurse; P5) |
“usually they [CTC] refer with a document that says ‘attend so so and so with this diagnosis’.” (NCD doctor; P11) | ||
No protocols on NCD screening | “someone who comes sometimes has symptoms or doesn’t have symptoms. They have [high blood] pressure and they don’t know. If they tell me the symptoms, what I would do, I will provide the CTC care but I will link them with other people in the clinic for hypertension or diabetes.” (HIV doctor; P1) | |
“we need to have the ability to diagnose early because we may find that the patient has diabetes for a long time or hypertension for a long time without knowing so it is important that we diagnose these patients early.” (HIV nurse; P2) | ||
Lack of access to diagnostic equipment | “we take blood pressure if we have the equipment, if the equipment is not functioning you can just lose them until you suspect that they have hypertension because of their history or their presenting complaints.” (HIV doctor; P6) | |
“the challenge is on diagnostic tests. You may wish the patient would go for a certain diagnostic test but you may find there is no diagnostic test or you may find the reagent has finished or something like that … it forces you to tell the patient to go outside the facility to look for diagnostic tests.” (NCD doctor; P20) | ||
Individual factors | HCPs’ knowledge of NCDs | “You may find the signs and symptoms of diabetes or hypertension, for example he is urinating a lot at night, he is having a lot of thirst, [then] you know exactly that this patient is having diabetes, but to do a confirmation test, they have to go to the lab.” (HIV nurse; P8) |
“for example if the client comes and explains ‘I have headache’. For example, yesterday, a client complained with shoulder pain and she just shows us the direction of the pain, that the pain is running across the neck and that is a certain sign that shows you that this needs more investigation so I took her for investigation, they have checked her and they found the blood pressure is high, like 165 over 190.” (HIV doctor; P6) | ||
HCPs’ personal practice | “we must escort them because you can find a client is in line for a long time and if they are going alone to the OPD they have to follow a line again so to avoid that disturbance, we just assist them.” (HIV doctor; P7) | |
“Then the patient be like ‘ok I have to go home to get money and then come back.’ … remember the blood pressure is already high then he’s telling you he has to go home to find money. So that patient may collapse on the way home. So sometimes us healthcare providers take our money to assist these types of patients.” (HIV nurse; P2) | ||
Syndemic factors | HIV stigma | “most of them run to avoid contact with other people. Because we normally tell them when you go to the reception at OPD show them your CTC card [but] you may find they go there and they meet with other patients that are residents of the same place of the HIV patient so the HIV patient may decide to not continue with care at the OPD.” (HIV doctor; P9) |
“for big diagnostic tests … it’s just outside the CTC … but there are people who are shy here, they are scared to go from here to the laboratory. They feel that people are seeing them.” (PLWH; P33) | ||
Poverty of PLWH | “The challenge comes when you tell the client ‘now I’m going to take you to another department for the continue of your care’ and some just refuse and some don’t have the money because not all of them have health insurance so the big challenge is money … so when you tell them ‘we are now going to the OPD’, just opening the file is 8,000 TSH. They tell you ‘I don’t have that money’.” (HIV doctor; P7) | |
“sometimes I want them to take some investigations in the laboratory. And most of them they don’t have money … and if you ask them to take the investigation in another laboratory outside of the hospital, you can see they are disappointed. And even they can tell you that the bus fare they had to borrow from their neighbour. So that is the challenge we are facing.” (NCD doctor; P17) | ||
Factors that influence safe and effective care | ||
Organisational and healthcare system factors | Fragmented NCD and HIV services | “feedback mechanism is one of the big challenges. We find we send a patient to the specific clinic, it would be a clinic for diabetes or hypertension but to give the feedback that ‘we have received this patient’ normally they don’t give feedback. Therefore to receive feedback and to put the notes at the back of the file that this patient also has this problem, they usually don’t do that. Because until the patient comes and explains by himself, that’s when you can know, but apart from that you may find that we never know [about comorbidities].” (HIV nurse; P5) |
“so you see they can [suspect] the disease in the CTC but they have to wait for the clinic day in the OPD and by waiting for the clinic day, there can be complications so there is a problem. If there’s a way to improve it, we should start the treatment right after they have been diagnosed.” (NCD doctor; P11) | ||
Lack of NCD continuity of care | “at the hypertension clinic, we meet with different doctors. Today we may meet with this doctor and tomorrow we will meet with a different doctor. But when you meet with different doctors and according to the blood pressure on that particular day they end up changing my medication … they say ‘no you don’t have to use these medications, use these ones’. Now in my opinion, this is what led me to get a stroke, because … I’ve never used a single medication for a long time.” (PLWH; P25) | |
“clients are used to a certain kind of doctor or healthcare provider but due to scarcity of healthcare workers, they are shifted so you may find one is complaining that I want to be cared for by my doctor or to get a certain room. So it is difficult to convince them to be cared by another doctor or in a different room.” (NCD nurse; P16) | ||
Individual factors | PLWH knowledge of NCDs | “they can come from the CTC and take their ARVs and when they come to the NCD clinic [we] give them medication. If you ask them ‘do you have any other problem’ they don’t normally talk. So they just think they are two separate clinics and there’s no need to share their status.” (NCD doctor; P17) |
“I don’t know, why should they ask [about HIV]? Like how am I going with my HIV status, how does that concern them? I think they are special for diabetes. Because when you go to the diabetes clinic, what they have to do is check my diabetes status so that I can go home.” (PLWH; P27) | ||
HCPs’ personal practice | “if we find the patient has higher blood pressure for example we normally prefer to start with those patients that have a higher blood pressure compared to those that do not have and we do that because we know these types of patients have to move to another clinic so that is why we prefer to start with them.” (HIV nurse; P2) | |
“after finishing of taking care on my side for a diabetic patient I do communication with the doctors of CTC either by calling through the phone or escorting the patient … and the CTC doctor will give their advice that is associated with HIV.” (NCD doctor; P19) | ||
Self-monitoring of NCDs | “we normally advise them to take their blood pressure at home and keep a record so that we can know if the prognosis of the client is in line with the medication that we give them.” (NCD doctor; P11) | |
“I take medication only at night, 2 tablets every night and I test for blood sugar myself at home because I have the diagnostic machine because they say you have to test your blood sugar yourself every day.” (PLWH; P27) | ||
Syndemic factors | Poverty of PLWH | “when they are told ‘we don’t have this medication, you have to buy’ the patient comes back to me and says ‘sister, that medication has finished, what should I do, I don’t have money’ so that is one of the challenges. Some of them they don’t have money, even the small amount of 30,000 [TSH] you may encourage the patient to contribute or to pay for a community health fund [insurance]. You find some they don’t have.” (HIV nurse; P8) |
“we use medication that is expensive and for many, money is a problem so you may find others that fail to get medication because they don’t have money.” (NCD doctor; P11) | ||
“medication for fever or headache, you’ll find there are no medication and they write for me to buy and I have no money. The diabetic medication, as I have told you I buy when I have money. If I don’t have money, I leave it.” (PLWH; P32) | ||
HIV stigma | “I never told them [OPD staff] I have HIV. They ask but I’m not ready to open up because I know I attend the clinic and I get my medication so there is no need to open up.” (PLWH; P24) | |
“even if I explain to the diabetes doctor that I have HIV, I don’t think it would help me … if it could be something that was talked about from everyone, maybe we would have more freedom to talk about it.” (PLWH; P29) | ||