Clients Perceptions of HIV/AIDS Supportive Counseling in Botswana: A Qualitative Study

The United Nations has created the Sustainable Development Goals (SDG) initiative in an attempt to end the HIV/AIDS epidemic worldwide by the year 2030. In an effort to assist in the SDG cause, the current study sought to obtain data from clients in Botswana regarding the perceptions of their experiences with HIV/AIDS counseling from 25 randomly selected hospitals/clinics. Clients were then sequentially offered the opportunity to participate in the study. Volunteers were then provided with the survey and data was collected through 5 survey questions that elicited qualitative feedback from participants. Once data was collected, thematic analysis was utilized to determine major themes found within participants’ responses. The themes found within these responses are presented along with their implications for future research and practice.

Keywords: HIV/AIDS; Counseling; Botswana

The United Nations has created the Sustainable Development Goals (SDGs) initiative that aims to ultimately end the AIDS epidemic worldwide by 2030 [1,2]. In this concerted effort to end AIDS, sub-Saharan Africa must be of primary focus as it represents the priority countries in eliminating child contraction of the HIV virus and keeping mothers alive [3] and due to the large numbers of individuals living with HIV/AIDS in these countries [3,4]. Among the many goals of the SDG initiatives is the aim to deliver mental health services to individuals living with HIV/AIDS [2]. With increased availability of ARV treatment [1] it is now possible for individuals to live with HIV as long as they adhere to medication protocols.

Although this route provides a means to live, contraction of HIV still results in living with a chronic disease. Individuals afflicted with HIV/AIDS suffer from psychological hardships such as emotional distress, uncertainty, helplessness, anxiety, depression, anger, thoughts of suicide, revenge, and negative social stigma perceived from others [1,5]. These psychological stressors may lead to impulsive or destructive behaviors (e.g., substance abuse) that interfere with medication adherence [6] and risky health behaviors that undermine treatment and contribute to the spread of HIVAIDS. In order to decrease the chances of psychological stressors leading to the spread of HIV/AIDS, counseling and mental health services are of primary importance in treating individuals afflicted with HIV/AIDS. Given the prevalence of HIV/AIDS in sub-Saharan Africa, the United Nations’ SDG initiative, and the importance of mental health care in preventing the spread of HIV/AIDs, this article will explore the perceptions of HIV-positive clients about the counseling services provided to them in sub-Saharan Africa, specifically, Botswana.

The majority of early research in this area has focused on counselors providing services. For example, in Zimbabwe counselors reported receiving minimal support and supervision as well as being undertrained [7]. Additionally, counselors indicated that the beginning and later stages of counseling were difficult (with the beginning stages being most difficult) and that working with serodiscordant couples (one partner HIV-positive, one HIV-negative) was problematic along with working with couples wanting to have children. In Kenya and Tanzania [8] counselors reported feeling pressured to be good role models in their communities and to provide information to their communities as they were perceived to be very knowledgeable. Moreover, counselors indicated that they felt work stress from both external contributors (e.g., economic conditions in their country), job structure contributors (e.g., heavy and unpredictable workload, compensation), and job duties (e.g., fear of clients). It is worth mentioning that although these counselors reported psychological stress due to their role as counselors, many of them found their work satisfying and gratifying [7,8].

More recently there have been a number of studies relating to voluntary AIDS testing and counseling, the majority of the studies focus on the barriers in reaching out to the counseling and testing services, especially underserved communities. Typically there is a one-time counseling session after the voluntary test; however, particularly noteworthy is the idea of having mobile voluntary and counseling services (MVCT), an innovation that has proved quite successful in several countries [9,10]. The stigma associated with having HIV/AIDS and how counseling has proven to be helpful in this regard is also discussed by Mall, Middlekoop, Mark, Wood & Becker (2013) [11].

A few studies of HIV-positive clients in Sub-Saharan Africa who participated in group counseling have also been reported. Schacham and colleagues [12] administered questionnaires to 397 clients in western Kenya who were HIV-positive and had self-enrolled in one or more psychosocial support groups. The questionnaire was designed to collect data related to participants’ demographic and HIV-related characteristics and also included assessments of psychological distress. The authors reported that participants were primarily female (72%), that 70% were unemployed, and that participants had been living with HIV for an average of 2.5 years. They also reported that, across all participants, HIV status was rarely shared with sex partners, family members, or friends and that psychological distress was more prevalent among women on measures of depression, anxiety, paranoid ideation, interpersonal sensitivity, and somatization.

Edwards and Edwards [13] studied 30 HIV positive clients in South Africa who received six one-hour sessions of person centered group counseling. Compared to a student control group, the HIV positive clients showed improvements in perceptions of autonomy, personal growth, environmental mastery, positive relations with others, and self-acceptance. Specific to Botswana, Stockton, Paul, Morran, & Mokalake (2016) [4] surveyed clients’ perception of their experiences with counseling services and found quantitative data to provide evidence that a majority of HIV/AIDS clients reported a positive experience with counseling in Botswana. The current study goes into considerable depth regarding the counseling experienced by the participants taking into account not only the social stigma but multiple other aspects that counseling sessions focus on, such as medication adherence, safe sex practices, alcohol and drug issues and knowledge about HIV/AIDS, self-acceptance, disclosure to family, fear of future and many others. One important component of the current study is preventing mother to child transmission (PMTCT) and how counseling has helped in preventing infants from getting infected. Finally, the study also aims at understanding additional services clients want from the counseling and information centers.

One country in sub-Saharan Africa where the HIV/AIDS epidemic has been especially prevalent is Botswana, where 21.9% of adults ages 15-49 were infected with HIV in 2013 [2]. Although career guidance counseling existed in Botswana as early as 1963, it was not until the 1990’s that counseling centers with a focus on mental health began to emerge [15]. These counseling centers provide services directly related to HIV/AIDS concerns, such as pre-ARV therapy, as a response to the epidemic. Counseling centers are located in hospitals, counseling clinics, and non-governmental organizations.

Stockton and his colleagues explored the experiences of 181 HIV/AIDS counselors in Botswana, through the use of both quantitative and qualitative data [5,16]. The majority of counselors were lay counselors (i.e., persons with two years or less of training) or other allied health professionals such as nurses and doctors [5]. This data indicated that the majority of these counselors were very satisfied with their training and perceived themselves to be effective in working with clients [16]. That being said, a large majority of counselors reported 8-weeks or less of formal training and field experience and no on-the-job supervision during an average month [16]. Both quantitative and qualitative data yielded results that participants desired much more education and training in order to be more effective counselors. In addition to expressing a desire for greater training, counselors expressed frustration for the often unclear and temporary role of lay counselors. They provided suggestions for systemic changes such as greater dissemination and coordination of services within and between hospitals and other treatment providers [5]. Although the work is stressful and can lead to burnout, the majority of counselors found their work satisfying and gratifying [5,16]. The data these counselors provided served as a sparkplug to improve the training and work conditions of counselors in Botswana.

With improvements implemented in the training of counselors providing services to HIV/AIDS clients in Botswana, Stockton, et al. [4] sought to obtain quantitative data on the benefits HIV/AIDS clients gain from these services in addition to qualitative data. Their study included 319 adult HIV/AIDS clients who had received counseling services in Botswana.

Among the numerous benefits observed, the authors noted that clients were positive about the benefits they received from counseling (e.g., education on practicing safe sex, the importance of taking medication regularly), the majority of participants perceived a positive relationship with their counselor, indicated a high level of satisfaction with educational materials they had received, had positive perceptions about the goal setting process in counseling, often felt that they could depend on family and friends for help when needed, and a majority of participants had positive feelings toward their present quality of life. One particularly important finding was that participants felt there was a social stigma with being HIV-positive and that others treated them differently when they knew they were HIV-positive. Although these data were helpful to elicit responses to specific questions and quantify clients’ experiences, richer data may allow for a more in-depth understanding of the experiences clients have had while receiving counseling services in Botswana.

The current study sought to build upon the quantitative research by Stockton, et al. [4] by exploring HIV/AIDS clients’ perceptions of counseling services in Botswana through the use of qualitative data. As such, the central research question was: what are patients’ (clients’) perceptions of HIV/AIDS counseling services in Botswana? In order to explore this central question, participants were asked to answer five open-ended questions with sub-questions in surveys assessing their experiences with counseling services. These five questions addressed: (1) topics typically addressed during counseling sessions (2) what impact being HIV- positive had on clients (3) experiences related to counseling while being pregnant with HIV/AIDS (4) the effects of disclosing HIV status to others and (5) how counseling has been most valuable to clients and their suggested improvements.

Participants for the study were 328 adult clients (i.e., 18 years-old or older) who were HIV positive and receiving supportive counseling during the study. Clients were sequentially offered the opportunity to participate in the study and those who volunteered were added as participants.

Data collection began in April 2013. After the data was collected, it was found that there were some data integrity issues (it was discovered that the study protocol was not properly followed in two regions) and contaminated data had to be discarded in those regions necessitating re-submission to IRB to collect additional data. Permission was obtained and additional data was collected from new volunteers in March and April 2014.

On average, participants had known about their HIV status for several years (M = 6.92, SD = 3.61). In the sample, 57.32% of participants identified as female (n = 188), 39.94% identified as male (n = 131), and 2.74% did not indicate their gender (n = 9). (Refer to Table 1 for further details on demographics.)

A survey instrument was created and pilot tested for this study. After consulting with Botswana colleagues and officials, the survey was written in English as it is one of two national languages in Botswana and English is also taught in schools in Botswana. The responses obtained from the surveys were broken into units and those units were categorized in themes. The authors followed the recommendations of Braun and Clarke 2006 [17] relating to thematic analysis. The relative independence of the themes is established by the judges’ ability to reliably categorize units into the various themes [17]. The survey contained five open-ended questions that were used to generate qualitative data. The questions used were as follows:

1. What aspects of your life does your typical counseling session focus on?
2. What impact has being HIV positive had on you?
3. If you are or have been pregnant since you have been HIV positive, please discuss your experiences with regards to your pregnancy and HIV/AIDS supportive counseling that you have received.
4. Have you disclosed your HIV status to significant people in your life? If so, please write about the experience and/or consequences of disclosing your status to them. If not, please explain what has kept you from doing so.
5. In what ways has counseling been most valuable you, and what additional help are you most in need from your counselor?

This study received approval from the Ministry of Health in Botswana. Population centers in Botswana chosen for this study were: Gaborone, Francistown, Masunga, Tutume, Mann, Mahalapye, Palapye, Selibe-Phikwe, Molepolole, Loabtse, and Kanye.

After randomly determining the 25 hospitals/clinics under study, volunteers who met the study’s inclusion criteria were then recruited from these sites. Employees from the Institute for Development Management (the major institution in Botswana that trains HIV/AIDS paraprofessional counselors), then went to each site and explained the research study and consent procedures to potential participants. Individuals who wished to participate in the study were given a consent form to sign and complete and then given a survey to complete.

Ultimately, 329 participants signed the consent form and completed the survey, but one participant’s data was excluded due to completing less than half of the survey, leaving 328 usable surveys. As noted earlier during initial data collection, it was found that the study protocol was not followed in two of the study’s population centers, therefore this data was excluded from study, and data was recollected at sites in these areas, following the study’s protocol.

In order to analyze the qualitative responses, thematic analysis was utilized [18]. Data was approached with a realist epistemology in that the responses of the participants were taken at face value in order to understand their experiences with counseling [17]. In order to carry out this epistemology, researchers used deductive analysis by breaking down responses to survey questions into separate units based on semantic themes. Semantic themes are explicit themes found at the surface level within the data that explicitly address survey questions being asked [17]. Coinciding with recommendations by Braun and Clarke [17] semantic themes were determined once all researchers on the research team had a chance to familiarize themselves with the data. Once familiar with the data, responses were broken down (i.e., coded) into units that shared similarities with one another. After units had been determined, the research team met to define themes that would be used to categorize units the research team had extracted from the data.

Finally, once themes had been identified, each member of the research team paired up with a partner on the research team and each pair was assigned a survey question to analyze. Pairs then split up and examined all response units to the question they had been assigned. Researchers categorized units into the semantic themes that had been identified during the research team meeting. After individuals categorized units, they reconvened with their partner and compared their categorization of units to their partner’s categorization. If both members of the pair had separately categorized a unit into the same theme, they were determined to be in “agreement.” If partners did not categorize a unit into the same theme initially, but were able to agree on categorization after reconvening, they were determined to be in “consensus”. If partners were not able to come to a consensus on how a unit should be categorized, it was considered that partners had reached a point of “no consensus,” for that unit. If there was no consensus reached amongst pairs, then that unit was brought back to the full team, and if the team could not reach a consensus, the unit was categorized as having no consensus. For a summary of the agreement on themes between raters, Table 2,3,4,5 and 6.

Although thematic analysis generated many themes to each question (Table 2,3,4,5 and 6 for a complete list of themes), this section will only include the top three themes found for each question. Additionally, all quotes have been corrected for spelling and/or grammar error.

For the purposes of this report, u will refer to the number of units in a given theme or subtheme and n will refer to the number of participants that generated those units.

The first open-ended question of the survey used in this study asked participants, “What aspects of your life does your typical counseling session focus on?” A total of 242 participants responded to this question; responses were then broken down into 853 units of responses, which were then coded according to common themes. Of the 853 units of responses, team members were in agreement on the coding of 821 units, 26 units were coded by consensus between team members, and consensus could not be reached on 6 units. On coding participants’ responses, several major themes emerged. By far the number one major theme that was produced in response to this question was education, which was exemplified in 723 units generated by 233 participants. Responses in this domain were then broken into six sub-themes: safe sex practices (u = 272, n = 178), medication adherence (u = 207, n = 162), alcohol and drug issues ( u = 76, n = 64), nutritional needs (u = 66, n = 65), available resources (u = 10, n = 9), and the remaining 158 units (n =122) that fell under the theme of education but could not be categorized into one of the five previous sub- themes were categorized as general education (see Table 2 ).

The first education sub-theme was safe sex practices. Safe sex practices referred to the use of condoms, reducing the number of sexual partners, and how to handle situations with sexual partners who did not want to practice safe sex. Additionally, general education about how HIV/AIDS is contracted and spread and general prevention information was also grouped into this domain. Answers like “safe sex practices,” “stick to one partner,” “always use a condom,” and “A-abstinence, B- be faithful, C- condomize” were common throughout.

The second sub-theme was medication adherence. “Always take medication on time,” “attend doctor’s appointments regularly,” “avoid traditional herbs/medicines,” “do not share medication,” and “these medications will be taken for the rest of my life” were common responses detailing the comp1iance of medication adherence and ongoing medical treatment. The third sub-theme - alcohol and drug issues -noted that issues related to alcohol, drug, and tobacco use were often discussed in counseling sessions. Typical responses included “avoid drugs,” “no drinking alcohol,” and “no tobacco use during this treatment.” The forth sub-theme was nutritional needs, which referred to units of responses where participants acknowledge that counseling sessions relayed the importance of diet and eating healthy foods.

The smallest sub-theme identified under education was labeled available resources. This sub-theme referred to the information participants received regarding resources available to them during counseling sessions. Examples of the available resources cited by participants were “HIV/AIDS counseling,” and “introduction to PMTCT program.” Typical responses in the general education sub-theme were, “behavior change,” “exercise,” “HIV/AIDS issues,” “secondary infection,” and “health issues.” Perhaps this subtheme is best described as a “catch-all” for general, if not vague, responses related to educational topics discussed in counseling.

The second greatest distinct, major theme found by the research team was acceptance of status/self (u = 26, n = 24). Participants primarily identified “self-acceptance,” acceptance of status and medical needs, and the importance of “coping” and “acceptance” as topics discussed with their counselor. To supplement the theme of acceptance of status/self, 14 respondents’ answers were coded under the third major, distinct theme of responses to this question - instillation of hope (u = 15). Instillation of hope included statements about “living positively” and embracing the belief that, “this is not the end of life.”

The second open-ended question of the survey asked participants, “What impact has being HIV-positive had on you?” This question was designed to elicit personal experiences of those living with a positive HIV status in Botswana. The purpose of identifying these experiences is to educate counselors with hopes it will improve practice and also to demonstrate the need for counseling within the population. A total of 666 units of responses, across 296 participants, were identified for this question about the impact of being HIV-positive. Of the 666, total units, 611 were coded in agreement, 54 reached consensus, and only 1 unit was not able to reach agreement or consensus. A number of themes that emerged from this question were related to the negative impact of being HIV positive. The top 3 themes that this data produced were: discrimination encountered (u =102, n = 73), psychological distress (u = 91, n = 64), and fear (u = 66, n = 54; Table 3). The top theme coded for the impact of being HIV-positive related to participants’ experiences of encountering discrimination. Participants encountered discrimination from a broad range of individuals in their lives including family members, employers, partners, friends and society in general. Discrimination included being a subject of gossip, receiving dirty looks, individuals being persecuted for their status and having assumptions made about how they became HIV positive. Furthermore, many responses included phrases that indicated important people in participants’ lives had left them and would no longer speak to those with a positive status, such as, “My girlfriend dumped me,” “... my family stopped giving me the love they used to give me,” and, “All my friends walked away from me when they knew I was positive.”

The second-most frequently coded theme to question 2 was psychological distress. Respondents described feeling guilty, stressed about their new status, depressed, and alone. Examples of units that were coded under this theme were statements such as, “. . . I feel like there is no hope in life,” Being HIV positive has shattered a lot of dreams and plans I had for my life,” and “When I came to the reality that I was HIV positive I could not accept myself.”

The third theme, fear, was a theme that respondents wrote about extensively. The respondents identified experiencing fear in many ways such as being afraid of death, isolation, discrimination, and the future. Respondents feared discrimination from their family, employers, partners, and social groups, and rightfully so considering the top-coded theme for this question. Fear of the future was categorized by fear for their current or potential children (mainly if they will be infected or experience a negative impact from their parent’s status), fear of the future of a relationship with a significant other or partner, fear of the well-being of one’s family, and fear of securing/maintaining a job in the future.

Examples of units that were coded under the theme of fear are, “Being HIV positive children,” “Big impact because I fear my friend would isolate me if they know I am HIV positive,” and, “The first thing that came to mind was death, I was, and still am, afraid to die.”

Question three of the survey asked: “If you are or have been pregnant since you have been HIV positive, please discuss your experiences with regards to your pregnancy and HIV/AIDS supportive counseling that you have received.” There were 215 units of responses generated by 67 participants who responded to this question. Popular themes that were reported were Preventing Mother to Child Transmission (PMTCT) helping to have HIV-negative children (u = 92, n = 43), education (u = 19, n = 17), and counseling and the benefits of counseling (u=11, n = 10; Table 4). Of the 215 total units coded, 200 were in agreement and 15 reached consensus, leaving no units in a state of no consensus.