The referral system between the VCT centre and HIV treatment clinic enabled us to monitor trends in the uptake of referral appointments and assess the effectiveness of the VCT service in linking diagnosed patients to available treatment services. Overall, we observed a high referral rate over the three-year period, with close to 100% of men and women receiving a referral following their diagnosis at VCT. High proportions of referred clients subsequently registered at the HIV clinic within six months of their referral, with no statistically significant difference in uptake rates between men and women (72%, 84/117 versus 66%, 153/232; p = 0.27).
Over the three-year period, there was a steady increase in the overall number of HIV-infected persons who were referred, as well as the number who subsequently registered at the HIV clinic within six months of referral (from 22 to 114, and 15 to 64, respectively). During the first 18 months of the referral programme, the proportion of patients who registered at the HIV treatment clinic within a week of their referral more than tripled from 18% to 64%, although the proportion who remained unregistered after six months never went lower than 17%.
Between September 2007 and February 2008, the number of clients who were referred increased by 70% compared with the preceding six months, coinciding with a national HIV testing campaign. However, over the same period, the proportion of referred persons who did not subsequently register at the HIV treatment clinic also increased by 7% compared with the preceding six months.
The provision of a transportation allowance was widely acknowledged by the patients to facilitate uptake of referral appointments at the HIV treatment clinic. As one woman explained, accessing this modest financial support enabled her to overcome the financial barriers to attending the clinic that she had been facing:
The problem that I had was about transport, that is what was troubling me. And at that time I didn’t have money that I could pay for my fare… therefore I was not going there constantly…. But afterwards when I got a sponsor, they were giving me an allowance and I attended (adherence) training continuously ... [Roadside, woman, in-depth interview]
However, there were also a few reports of patients facing pressure from their families to spend the transport allowance on other items, including food, reflecting the precarious economic situation of some HIV patients. One HBC worker explained the competing priorities faced by some patients who had received transport money:
[They say]...without food I will die. So why not die tomorrow because I have no fare rather than today because I have no food. [HBC worker, in-depth interview]
High levels of alcohol dependency were reported in the study setting both by HIV patients and health care workers, and there were some reports that the transport allowance was used to purchase local alcohol instead of paying the bus fare.
These problems were generally overcome once a volunteer from the HBC programme became available to escort patients during their first visit to the HIV treatment clinic. Additional reported benefits of the escort included having someone on hand to provide encouragement, as well as physical support for those in poor health. The presence of an escort was seen to be particularly important for patients who were unfamiliar with the journey to Mwanza City, or who felt intimidated by attending a big hospital and could reduce the delay in taking up the referral appointment, as one of the HBC volunteers explained:
Right now what we do once he/she gets that green [referral] card, you go with him direct. At least during the first trip you take them to Bugando [hospital] there. After he/she arrives there they are comforted in their heart to see that it’s so many people ... But during first trip you have to take him/her there. If you don’t, he/she can take that green [referral] sheet and stay with it at home! [HBC worker, in-depth interview]
The provision of referral forms also played an important role in facilitating patients’ entry into the hospital, or ensured that they were directed to the right clinic. Furthermore, patients from Kisesa were not required to repeat VCT on arrival at the HIV clinic in the hospital, because the referral forms included the signature of a recognized VCT provider and would be difficult to duplicate due to their design and green colour. Avoiding the need for these rural patients to repeat VCT at the hospital reduced the time that they needed to spend at the HIV clinic completing the registration requirements:
We receive patients at the reception there and talk with them. Patients coming from TAZAMA bearing those green referral forms we don’t take them to VCT because we know that VCT done at Kisesa there is similar to the one done here at Bugando [hospital]. [HIV clinic staff, in-depth interview]
The referral forms were also perceived by the nurses to be a useful tool that aided the registration process because they included key background information about the patient. Finally, the referral forms acted as an indicator to the nurses of the general level of preparedness of the patients, particularly in terms of their knowledge about the clinic procedures and need for follow-up appointments:
Those green forms are good because they show his/her history, so even before we interview him/her we have got more of his/her information already ... It also helps to know the services they get there [from TAZAMA] ... we even know that the patient is willing. Other patients come to clinic without fare or whatever, so they are fearful. But for the patients coming from Kisesa we are sure that this one will follow our services. [HIV clinic staff, in-depth interview]
Although most patients reported that the referral system facilitated their initial access to HIV treatment, many expressed a desire for HIV treatment clinics to be in closer proximity to their homes:
So I request services to begin at the [health] centres in each area. It’s easy to go, and perhaps we can succeed on this problem, to be known early and treated early before the infection advances. [Roadside, male, in-depth interview]