The Perspectives of Key Informants on Programs and Policies Pertaining to HIV Prevention and Treatment for Farm Workers in Rural South Africa
Abstract
Introduction: Farm workers are one of the subpopulations with poor progress toward the 95-95-95 targets in South Africa. The transient nature of farm workers results in treatment disruptions and affects the continuity of care. This study aimed to explore program implementers’ and program experts’ perspectives on the challenges and opportunities in providing HIV prevention and care to people working on farms.
Methods: The study was conducted in three provinces of South Africa, using an exploratory qualitative study design. Policy document analysis was performed followed by key informant interviews with HIV program implementers and program experts. Key informants were purposively selected based on their roles in the HIV program at health facilities and other settings. An inductive approach was used to analyze data.
Results: Eight policy documents were analyzed, and eight key informants were interviewed. Emerging themes included challenges in providing HIV services to farm workers, effective strategies employed by service providers, and program and policy recommendations. Several challenges in providing HIV care to farm workers were presented, including their high mobility which leads to treatment interruptions and loss to follow-up. As a result, farm workers easily get lost to follow-up and are likely to have poor treatment outcomes. Some of the effective strategies included community-based prevention, treatment and support services, and the use of health passports to improve linkages to care. Community health workers, mobile clinics, and community-based pick-up points improve access to HIV counselling and testing, adherence to antiretroviral therapy, and retention in care. Program and policy recommendations included customized HIV services and designing sector-specific HIV policies.
Conclusion: The study reveals ongoing structural barriers that limit sufficient HIV prevention and retention in care for farm workers who are on treatment. Models of care that include patient-held records, workplace-provided services, and mobile healthcare are recommended.
1. Introduction
Ending HIV calls for optimal HIV prevention and care for all and prompt address of barriers to such, by ensuring that no one is left behind, especially among the most at-risk and vulnerable populations [1]. Although there is enormous progress toward ensuring the achievement of the UNAIDS 95-95-95 targets, such progress is uneven across populations between and within countries, both globally and in South Africa [2–4]. Realizing the success of the 95-95-95 strategy relies on reaching all marginalized subpopulations to HIV prevention and care and on ensuring retention in care for such populations.
Migrant and highly mobile persons are one of the most at-risk and marginalized subpopulations [5–7]. High mobility is associated with an increased risk of nonadherence to antiretroviral therapy (ART), loss to follow-up (LTFU), and noncontinuity in care [8–12]. For the purpose of this study, continuity of care is defined as successful care visits, ART refills, ART adherence, and HIV viral load suppression [13], while LTFU is when a patient has not had ART drugs for three consecutive calendar months [14]. Migration and mobility are not adequately covered in current HIV prevention and treatment programs and policies in South Africa [9, 11]. According to Camlin et al. [2], strategies that fail to account for the complex dynamics of mobility in specific settings will fail to successfully engage with the magnitude of populations necessary to end the epidemic. Farm workers are one of the highly mobile populations, and they have been found to be one of the subpopulations with poor progress in achieving 95-95-95 targets in South Africa [15]. They are mostly in seasonal employment, and whether they are migrants or not, they are likely to be highly mobile between different farms, as they mostly depend on seasonal work [16–18].
The transient nature of farm workers results in treatment disruptions and affects the continuity of care [19]. As a result, farm workers generally fare worse in the HIV treatment cascade, which is exacerbated by their further proximity to health facilities. Closing the gap in HIV prevention and treatment coverage across subpopulation groups requires targeted interventions. While much research has been done among farm workers to understand their barriers to HIV prevention and treatment, little is known about how health workers have experienced engaging with farm workers in the HIV treatment cascade and what strategies they have used to improve this engagement. The aim of this study was therefore to explore healthcare workers’ and program experts’ perspectives on the challenges and opportunities in providing HIV prevention and care to people who are farm workers and to gain insight into current program and policy gaps.
2. Methods
2.1. Ethical Considerations
The study was approved by the Research Ethics Committee of the Faculty of Health Sciences, Stellenbosch University (Ref no. S21/143). Written informed consent was obtained from all participants, and to maintain confidentiality, codes were used instead of participant names.
2.2. Study Design
This was an exploratory qualitative study design nested in a larger mixed methods doctoral study. An exploratory design was most suitable for this study aims to investigate areas that remain mostly unexamined and which have little pre-existing knowledge [20].
2.3. Study Setting
Participants were invited from different parts of South Africa and those who accepted and consented to participate were from Limpopo, Gauteng, and Western Cape. The setting included public health facilities in two districts in Limpopo province, which have been previously reported to attend to a higher number of migrant farm workers [21]; national public health institutions; and academic institutions and organizations that are directly involved in HIV programs for agricultural workers, identified through their work, and snowballing. Additionally, document analysis involved national policies that covered the HIV program for farmworkers countrywide.
2.4. Document Analysis
The purpose of the document analysis was threefold. Firstly, it was to examine the content of HIV policies, guidelines, and reports about farm workers, who could also be grouped as migrant or highly mobile populations and vulnerable populations. Secondly, it was to guide the in-depth interview discussions, and lastly, it was to facilitate data triangulation from various data sources. Document analysis concentrated on documents from 2004 (with the start of the HIV treatment program in South Africa), to date.
The ready materials, extract data, analyze data, distill data (READ) approach [22], one of the policy document analysis methods, was used to conduct the document review. The steps followed included searching for policy documents from various sources including the National Department of Health website, the Department of Employment and Labor, and the Department of Agriculture. The inclusion criteria for policy documents were that they should be policy document(s) that address HIV, and they should explicitly mention migrant populations and/or farmworkers (as farmworkers can be addressed under migrant populations). The exclusion criteria were any policy documents that do not include HIV among farmworkers or migrant populations.
A total of eight documents were identified (Table 1). Out of the eight documents, two were excluded as they did not address policy matter pertaining to HIV program for farm workers. Data extraction was performed on six eligible documents, where data were entered into a word document table that was guided by the research aim (Supporting Information file (1)). Two researchers extracted data that pertained to policy matters regarding HIV prevention, treatment, and/or care for farm workers, migrant and mobile populations, and vulnerable or priority populations. The next step was to analyze the extracted data using thematic approach [23] and distilling the findings into the overall study findings from key informant interviews (KIIs).
| Document title | Document type | Summary of key findings |
|---|---|---|
| National HIV counselling and testing policy guidelines | Policy guideline | Community-based HCT services and the role of the workplace in facilitating access |
| Acknowledgment of farm workers as a vulnerable population requiring services at convenient locations | ||
| National HIV testing services: Policy | Policy document | Provide outreach/mobile services to mobile populations, including farm workers |
| Offer prevention services at convenient locations | ||
| National Strategic Plan on HIV, TB, and STIs 2023–2028 | Policy document | Maximize equitable access to HIV, TB, and STI services |
| Strengthen community-led responses and decentralized service delivery for HIV, etc. | ||
| Increase the availability of migrant-friendly HIV prevention, screening, testing, and treatment facilities | ||
| HIV/AIDS technical assistance guidelines | Guideline | Access to treatment: Employers are encouraged to support employees in accessing HIV treatment, including information on available health services and providing a supportive environment |
| SADC HIV and AIDS Strategic Framework 2010–2015 | Framework | Achieving universal access to HIV and AIDS treatment for all who need it |
| Facilitating cross-border initiatives for universal access | ||
| Developing HIV-related regional harmonized policies for migrant and mobile labor | ||
| Integration of HIV and AIDS in ministries of agriculture | ||
| National Strategic Plan 2017–2022 | Policy document | Customized services and information to the unique needs of key and vulnerable populations and differentiated service delivery approaches |
| Innovative ways to link mobile populations to care | ||
| Rollout of unique identifier for those on ART | ||
| Cross-border collaboration on HIV, TB, and STI policy and programming | ||
2.5. KIIs
2.5.1. Study Population
The study population consisted of key informants from the HIV and AIDS/STI/TB (HAST) program who are implementers of the program at the health facility level and program experts from non-governmental organizations (NGOs) and academic institutions. Key informants varied from a range of backgrounds and experiences within the HIV subject, from health workers to program experts (Table 2).
| Description | Number |
|---|---|
|
|
|
|
| Average number of years in the field | 10 years |
|
|
2.5.2. Sampling
Key informants were selected through purposive sampling. Informants were selected based on their roles in the HIV program for farm workers, including first-hand knowledge and substantial experience in either implementing or overseeing HIV programs, policy, or research. The selection of key informants was firstly at the health facility level, where health workers who provided HIV prevention and care services to the farm workers were purposively selected. The inclusion criteria for key informants were the following: experience in implementing the HIV program for farm workers, expertise in the design of HIV programs or policies, and thus, their understanding of the program and policy implementation. The exclusion criteria were HIV program implementers or experts who have never worked with farm workers. Thereafter, the selection was at a national level, where key informants identified as subject experts through experience or knowledge were purposively selected. The district and provincial levels were deliberately not included in the sample, because although they play a senior role in the HIV program, they are neither program implementers nor policymakers; thus, they were not deemed as having substantial first-hand knowledge in policy formulation or direct implementation. Furthermore, snow-bowling sampling was done where the identified key informants would recommend more appropriate experts for the study.
2.5.3. Sample Size
The final sample comprised eight participants, four from the Department of Health, three from nongovernmental/intergovernmental organizations, and one from academia. Six invited people declined to participate, with no reason provided.
2.5.4. Data Collection Tools
Two interview guides were developed, one for program implementers and the other for program experts. The principal investigator (PI) who is an experienced qualitative researcher with a master’s degree in public health (MPH) conducted the interviews. Semistructured KIIs were conducted using an interview guide that explored challenges, gaps, and best strategies in current HIV programs and policies for farm workers. The interview guides were reviewed by three senior researchers, possessing PhD in public health, for content validity and clarity of questions.
2.5.5. Data Collection
Data collection was from November 2022 to October 2023. Key informants were recruited through email, with follow-up telephone conversations where necessary. Fourteen participants were invited from the government (implementers and high-level national program managers), intergovernmental and nongovernmental organizations, and researchers. Three senior government officials, two NGO officials, and one from academia did not accept the invitation, with no reasons stated. The interview began with an introduction to the study and an explanation of the voluntary nature of participation. All consenting participants signed a written informed consent, which included consent to the digital recording of the interviews. Five interviews were held face-to-face, and three were held online through Zoom meetings by the PI, who is a female researcher experienced in qualitative in-depth interviews and is a PhD candidate with a MPH. Interviews were conducted in English, which is one of the main official languages in South Africa, and they took between 30 and 60 min. The interviews took place in enclosed spaces either in the interviewers’ office (for online interviews) or the participants’ office (for face-to-face interviews), involving only the researcher and participant. The researcher ensured reflexivity by continuously keeping a journal to note and reflect on the data collected after each interview.
2.5.6. Data Analysis
At the end of each interview, digital audiotape files were labeled with a unique identifier and uploaded to a secure password-protected server. The audio files were then transcribed verbatim. The data analysis process started with open coding emerging from the data by two independent researchers, following an inductive approach. Codes were grouped into categories. Through a continuous consultative process, a thematic analysis approach was used to modify and refine the codes and organize them according to emerging themes and subthemes. Moreover, findings from the document analysis (Table 1) were distilled into emerging themes and subthemes from KIIs.
3. Results
3.1. Characteristics of Key Informants
A total of eight key informants were interviewed (Table 2), which were grouped into program implementers (n = 4), program experts (n = 3), and research experts (n = 1).
3.2. Emerging Themes
Following data analysis, three themes and nine subthemes emerged from the document analysis and KIIs, as shown in Table 3.
| Theme | Subthemes |
|---|---|
| Challenges in providing HIV services to farm workers | Individual farm worker challenges |
| Service-level challenges | |
| Program and policy shortfalls | |
| Effective strategies employed by service providers: what has worked | Community-based support |
| HIV prevention and awareness strategies | |
| Improving treatment access and linkage to care | |
| Program and policy recommendations: looking ahead | Health promotion and awareness strategies |
| Comprehensive and multifaceted HIV program | |
| Customized HIV services to address the needs of vulnerable populations | |
| Policy and governance | |
| The role of farm owners/employers | |
3.3. Challenges in HIV Programs and Policies for Farm Workers
Respondents presented several challenges encountered while rendering the HIV program to farm workers, either as program implementers, researchers, or policymakers. These challenges were mainly related to individual farm workers, the employed service delivery models, and/or shortfalls in programs and policies.
3.3.1. Individual Farm Worker Challenges
Almost all respondents said that farm workers are mainly seasonal workers, and therefore, it is difficult to provide them with consistent treatment and follow-up care. As seasonal workers, most farm workers only work at peak seasons, and then they move to other areas when the season is over. As a result, those on ART are not able to continue attending the same clinic, as they either go back to their hometown/country or move to other farms. Most farm workers leave without informing their treatment clinic, making it hard for the clinic to trace them, as described in the following narrative:
It is very difficult …. We have got seasonal workers, and a lot of them are from Mozambique or Zimbabwe. So, they come for testing, and we start them with medication. When the season ends, they don’t come to get a referral letter, even though we explain that they need to get a transfer letter, they just disappear for six or eight months. When the season starts again 11 months later, or whatever it is, when they get a job again, they come back, and they want to start afresh or they want to pick up where they left off. (KI 003-implementer)
Cross-border mobility poses a challenge for continuous HIV care. (KI 007-program expert)
Most respondents mentioned that since farms are usually far from clinics, workers encounter transport challenges, which affects their clinic attendance. Furthermore, commuting to health facilities is not safe for female farm workers, as some have been mugged and sexually molested while walking a long distance to the health facility, as indicated in the following quotes:
You can say… Maybe like 10 to 20 kilometers. It’s quite very far……. One of the main barriers would be accessibility in terms of transportation, because it is within a rural setting, you know, places are far from farms. So, accessibility and transportation are the main challenges. (KI 006-program expert)
They need our support because they are going through a lot. It is so painful. Some of them when they come this side they get abused, they get raped, you know, it is painful. Even the pregnant ones. They are trying to come here then they get raped on their way to the clinic. Yes, last week we were having another one, she was in her twenties, she was coming to this side and on her way, she met three guys who all raped her. (KI 002-implementer)
Another challenge faced by farm workers is their work schedules. Sometimes, their clinic dates conflict with their work time, and some employers refuse workers the time to go to their clinic appointments during working hours. Certain employers do not accept sick notes from government health facilities. This then affects the worker’s ability to keep their clinic appointments, as related by an informant:
Some of them, their employers don’t allow them to come to collect the treatment on the exact date, they issue them, their dates… You find that most of the time we’ll issue dates, and you’ll find that on the very same date, it’s also during the weekdays, you find that it’s not easy for the employer, but they will come at the end of the day without requesting sick leave. We will give them the sick notes and you’ll find that some farms say they don’t consider clinic sick notes. (KI 002-implementer)
3.3.2. Service-Level Challenges
Respondents who render mobile health services to different farms reported that sometimes they cannot provide services due to insufficient mobile clinic vehicles. They also experience a shortage of human resources, which limits the provision of mobile health services. Most of the respondents mentioned the difficulty of establishing and maintaining follow-up care for farm workers:
We are working in the mobile clinic; sometimes we have a challenge of transport wherein we fail to access the farm … Sometimes you find that we run short of staff and that becomes a challenge as we end up not reaching some of the areas, we need to reach with mobile health services. (KI 001-implementer)
Then, a second barrier would be facilities and lack of resources. So, there aren’t sufficient facilities as such, if you look at a rural context. In an urban context, there are so many HIV facilities and support centers, but if you look within the context of rural farm workers, there is a lack of centers of support and HIV facilities. (KI 006-program expert)
Poor communication between health facilities affects continuity of care, as most government clinics do not have email addresses. One of the respondents explained that this was a program limitation, as clinics could be able to communicate and track patients who have self-transferred to other health facilities:
Clinics should have an email address, even if it’s controlled by the operational manager so that we can quickly email information to and from each other. (KI 003-implementer)
Farm workers on ART easily get lost in follow-up as they do not alert the clinic when they change location. It is difficult to trace those farm workers who have missed their clinic visits. Usually, workers change addresses after the peak season, and they cannot be reached by phone. Thus, adherence to ART is an ongoing challenge to farm workers, and eventually, it affects their treatment outcomes. Harmonized regional HIV policies for migrant and mobile labor were mentioned in one of the policy documents [24]. This was described by some key informants as follows:
When we deal with farm workers, we are dealing with mobile patients. It is not easy to collaborate with them because sometimes you find that they just disappear. You will look for them and they are nowhere to be found. Somewhere, somehow, they cross the border, and you will remain here with loss to follow-ups. (KI 001-implementer)
Tracing them is difficult because you find that even the contact phone number is not there… sometimes someone will respond and say the person you are looking for is now living in another town. (KI 004-implementer)
We have had patients whose viral loads were undetectable, who were doing so well. Then they go and come back, and the viral loads are in the millions. (KI 003-implementer)
facilitation of collaboration between member states in the development of harmonized policies on cross-border and internal migrants and mobile populations. (Policy document [24])
Some of the respondents also mentioned the persistent HIV stigma and discrimination in the farms, which potentially interferes with the use of mobile health services by farm workers.
3.3.3. Program- and Policy-Level Challenges and Shortfalls
Respondents reported a challenge of farm workers visiting multiple health facilities to collect similar medication, which they suspect gets resold to the public. While there were overall concerns about the lack of policies that address HIV in farm workers, which one of the respondents said was the greatest shortfall for the HIV program for farm workers, other respondents said it is rather the implementation of policies that is a shortfall, as facilities can apply existing policies in the context of farm workers:
I think we do not have a national strategy. I mean, the agricultural sector is such a large sector in South Africa and not having a clear plan, you know, at the national level as to how HIV could be addressed. I think for me, that’s the greatest shortfall because at least even at the local level if they have a point of reference, you know, that is, that informs them at that level. (KI 005-program expert)
Two respondents further expressed concern that farm workers are not well recognized as key populations in health policies, leading to neglect in resource allocation. Discussions highlighted the discrepancy in policy attention, emphasizing the need for a nuanced approach to healthcare for farmworkers. One informant narrated:
Farmworkers are overlooked as key populations in the HIV policies. Current policies focus on urban migrants; farmworkers’ unique challenges are ignored. (KI 007-researcher)
HIV epidemic control hinges on how well we include key and other priority populations in the national response. (Policy document)
3.4. Effective Strategies Employed by Service Providers: What Has Worked
The second theme was derived from both document review and interviews. Key informants provided several approaches that they have employed at the service delivery and program level, which they found effective in HIV service delivery for farm workers. The document reviews detailed policy directives concerning HIV prevention, treatment, and care for vulnerable populations, which include migrants, highly mobile populations, and highly mobile populations [25].
3.4.1. Community-Based Support
Some respondents emphasized the significance of building strong and trustful relationships with farm owners and farming communities. This approach not only facilitates support from the employer/farm owner but also ensures that farm workers have access to the necessary health services. Informants explained that:
Models of community-based HCT - outreach or mobile HCT can be provided in a variety of settings including mobile vans and workplace. (Policy document [26])
The issue of having a good relationship with the farmers was the most effective strength … just because of that good relationship with the farmers, it makes it easy, and this also makes the farmers give us support. (KI 001-implementer)
Firstly, working within that space, if you do not involve the farm owners themselves, you are doomed for failure. So bring them on board, showing them the business case for allowing such interventions to be implemented within their workplaces… also working with farm workers themselves so that they are the ones who design and are part of the planning and implementation, especially when it comes to outreach campaigns. They know the landscape and allowing them to be change agents and lead in terms of what needs to be done is important. (KI 005-program expert)
Respondents also mentioned the successful role played by peer educators, community health workers (CHWs), and change agents in supporting the HIV program in farms and farming communities. Change agents and peer educators are recruited among farm workers themselves. They get trained on HIV and HIV prevention, and their role is to influence workers on positive behavior change. Other settings have trained “activists” from farming areas whose role is to provide ongoing education to farm workers, and they also act as first respondents in patient tracing, particularly where there are no CHWs. The policy documents mentioned the provision of outreach or mobile HCT programs at convenient locations such as community-based locations and workplaces, to reach mobile populations [24–26]. One informant said:
We trained farm workers to be change agents and mobilizers of their peers. So, we provided a range of training for them to be able to deliver HIV prevention messages, and to also link their peers to services that are around the farm. (KI 005-program expert)
Respondents also reflected on the community outreach and engagement approach, where health providers engaged existing community organizations or representatives in providing HIV and support services to the community. Adherence clubs were also mentioned to be a successful approach in providing treatment adherence support for farm workers who are on ART. Adherence club members were able to get their follow-up treatment from the club, and when it was their clinic day, they were placed on fast-track queues so that they did not spend much time in the clinic, as explained in the quote below:
We’ve created this program, called the adherence club, whereby we only give them two months’ medication… so that they mustn’t queue because if they are queuing transport, it will leave them behind……. We also have this pick-up point whereby we choose different pharmacists. We register them so they can go to the pharmacy to collect their medication at time… (KI 002-implementer)
CHWs also play a role in delivering medication to those who cannot attend health facilities themselves. However, a challenge observed in some settings was that there were limitations with their services due to communication gaps between them and farm workers:
They CHWs provide counseling and testing, they give HIV information in the farms, and they do all the follow-ups … they are very productive in such a way that I think even in other provinces, or other sites, it is going to be good for CHWs to be empowered to do the same job because it makes the job easier, even for the nurses. (KI 001-implementer)
Empowerment and capacity building of migrant workers were also reported to be effective in HIV prevention and education among farm workers:
We do capacity building workshops and one of our main focus concepts is HIV and AIDS… So, we have women who are our activists on the grassroots level, and these women play the role of active activists within the farming areas. (KI 006-program expert)
3.4.2. HIV Prevention and Awareness
Some of the best approaches to teaching and educating about HIV to farm workers were shared. These include ongoing awareness campaigns, which were always rendered during the peak season when farm workers are working, with constant provision of condoms during those seasons. One of the respondents mentioned that visual aid has been more effective in providing HIV prevention education to farm workers:
When I show the visual aid it’s like a light that clicks on. So, more visual aids are effective, as they can see it visually, and not just hear the information. (KI 003-implementer)
3.4.3. Improving Treatment Access and Linkage to Care
Several interventions were reported to have been effective in improving access to HIV services. These included mobile health services, provision of treatment pick-up points, and use of health passports. Pick-up points included prepackaging follow-up medications for those who have suppressed viral loads, and they collected their medications from locations such as pharmacies and private companies. Health passports were reported to have been very useful for this highly mobile population. The passport has all the treatment details of the patient, so when they move to new locations, they can produce the passport in the new health facility, and they easily continue treatment. The experiences are narrated as follows:
We also have pick-up points, where we register them to collect their medication at any time. They only receive a message when the pick-up medication has been issued to the pharmacy, and then they collect their medication there. (KI 002-implementer)
I remember we were trying to formulate something like a treatment passport, which gave all information from initiation up to the present, with details of blood tests done and medication changes. I think having a common document makes it easy for everyone. (KI 001-implementer)
Some respondents explained the importance of the farm owner’s involvement in the HIV program. They explained the successes of employers promoting HIV awareness, providing access to testing and treatment services, and implementing workplace policies that support employee health and wellness. In other settings, farm owners have provided clinic structures that can be used by health providers when they visit the farm:
I think for me, what I found to be one of the strengths was when you know, you were able to have a structure endorsed by the farm owners. And by that I mean, if they were able to include HIV programs… I think that then becomes institutionalized within that farm. And include that as a program within the workplace in their institution, because then they can account for it. They know they have milestones; they know that by the end of the year, these are the things they should have done … having them as part of the program also was the strength of the program. (KI 005-program expert)
Change of facility operational hours was also discussed as a best practice to accommodate farm workers, in ensuring that they can be able to access the clinic after their work hours, as narrated by one informant:
Us staying open longer, so we open from 7 am to 6 pm, which helps as they can come after work. (KI 003-implementer)
3.5. Program and Policy Recommendations: Looking Ahead
Respondents provided their views on what would work best in ensuring successful HIV programs and policies for farm workers.
3.5.1. Health Promotion and Awareness Strategies
Some of the respondents raised concerns that many farmworkers lack basic knowledge and understanding of HIV and AIDS, including transmission and prevention methods, testing, and treatment options, and they still have myths and misconceptions about HIV. They recommended that prevention strategies, especially HIV/AIDS awareness campaigns, should still be reinforced in the farms, as described in this quote:
Actively disseminating, you know, the correct information, awareness campaigns, some HIV and AIDS drives or exhibitions, whereby people can get tested regularly… just that basic education and understanding of the virus itself, how to actually obtain medical assistance, and also education around the myths regarding the virus. (KI 006-program expert)
Some of the respondents emphasized the need for integration of HIV awareness and prevention efforts within broader health promotion activities. Suggesting that instead of treating HIV prevention as a standalone initiative, it should be integrated into general health promotion campaigns. This integration approach ensures that HIV awareness and prevention become part of overall community health initiatives including the engagement of farming communities through community mobilization efforts:
And also, the health promotion aspects like having broader health promotion activities happen so that we can locate HIV with that, rather than having it as a separate vertical program. Also having amenities available, having condoms, and consistent provision of condoms. And then community mobilization, engagement of communities, you know, farming communities. So, if you have also reached them from the communities where they come from, then by the time they go to the farms, they would be more equipped, more aware, and probably trying to take more precautions, you know, starting there would be one of the keys. (KI 005-program expert)
Recommendations also included the establishment of specialized units or clinics in rural areas, employing dedicated staff and conducting regular awareness campaigns to improve HIV program effectiveness. Respondents also mentioned a need to increase the mobile health services, so that they reach all farm/farm workers. Other respondents raised a need to take HIV counseling and testing services on the farms:
Accessibility to dedicated HIV service centers within farm communities is a critical factor. Establishing centralized points for health services can significantly improve the reach and effectiveness of HIV programs… In rural settings, mobile health clinics within farms can bridge the gap in healthcare accessibility. These clinics can address transportation challenges and bring essential services closer to farmworkers. (KI 006-program expert)
Mobile clinics act as lifelines, reaching migrant farmworkers where they are. It’s not just about tests; it’s about bridging the gap between distance and care. (KI 007-academic)
Three policy documents mentioned a need for HIV prevention services to be rendered at convenient locations for mobile populations, such as community-based locations and workplaces [25–28].
3.5.2. Comprehensive and Multifaceted HIV Program
One of the respondents emphasized a need to ensure that HIV programs are not only comprehensive but also accessible and affordable for farm workers. Social factors that might hinder access to healthcare services for farm workers need to be addressed, especially those from marginalized communities:
I think a program for HIV, should be multifaceted and look at the social aspect, access issues, are there accessible, services and affordable that are accessible to farm workers. (KI 005-program expert)
HIV interventions can also be integrated within broader wellness programs to address behavioral issues and social aspects effectively, as explained in the following quote:
We need a very comprehensive health program that also addresses other health issues, other social determinants … a much broader wellness approach than just an HIV intervention so that we can also address other factors. But also, I think it makes people feel much more receptive because if it’s just an HIV program, some people feel like it’s for those, you know, those who go, there are the ones that have issues with HIV… (KI 005-program expert)
Addressing gender dynamics and key populations within the farm working population was also highlighted. Women and children have special needs as farm workers. There are also key populations that live and work in farming communities that need specialized HIV services. This was described in the following narrative:
Also addressing the gender dynamics, we know that there’s a high incidence of gender-based violence in the farms, you know, having all those other aspects of gender-based violence and addressing the underlying causes of gender-based violence… (KI 005-program expert)
Within farmworkers, there are also key populations. So, you also need to segment and make sure that other vulnerable groups and other key populations within that community are also receiving special attention. You have children who are most likely going to grow to be farmworkers … I remember that in some of the farms we used to find very young girls, because sometimes there are homes within the farms, so, they start engaging in sexual activities at a very young age, you also need to have programs that are mindful of the fact that there are young people within the farms. (KI 005-program expert)
3.5.3. Customized HIV Services to Address the Needs of Vulnerable Populations
One of the program experts recommended a revised service delivery model. The service delivery model for farm workers should consider tailor-made and targeted HIV programs that consider the nature of their work, their high mobility, and their geographic mobility.
This agrees with one policy document that addresses the increase of access to health services for vulnerable populations through service delivery approaches that are tailored for vulnerable populations. The policy document continues to outline considerations for flexible service delivery options and cross-border collaboration against HIV and other communicable diseases for highly mobile and migrant populations [25]:
There will be increased access to health services through differentiated service delivery approaches tailored for the populations served. Innovative methods will be used to deliver these services, including comprehensive and holistic one-stop-shop approaches, dedicated services, and alternative hours and days. (Policy document [25])
services and information will be customized to address the unique needs of key and vulnerable populations. (Policy document [25])
3.5.4. Policies and Governance
Some respondents emphasized the importance of implementing current HIV policies at a clinic level, mentioning that no matter how great policies may be, they remain on paper unless actual service providers interpret and implement them accordingly:
More about the poor implementation and the failures of the Department of Health’s decentralization… Decisions are still taken at the top, and then they just trickle down. (KI 007-academic)
Some respondents recommended a database that connects all healthcare facilities, allowing for easy access to patient information across clinics. The need to have unique patient identifiers and to establish a national database system that can streamline patient information was emphasized by most respondents. The database would be useful to connect all healthcare facilities, thus allowing easy access to patient information across clinics. It would also prevent the misuse or exploitation of healthcare services. The database is also mentioned in the National Strategic Plan 2017–2022 policy document [25]. This is echoed in the following sentiments:
We spoke about the unique identifier for a very long time, and it never happened. However, without that, it’s very difficult because every time they move to a new site, it becomes difficult to know where to continue their treatment. So, if they carry something, or if they have something that allows them to go in, when they move to the next farm, far away from where they were before, they’re able to go to the clinic and produce something that will allow them to get in and continue with treatment without question. (KI 005-program expert)
I know it has been in the plan for years and years, but a database that connects everybody, where you can tag a patient using their identifier would help. We can be able to see which clinic the patient has already been to and when last they collected their medication. This would avoid patients going from clinic to clinic, and those who collect and sell HIV medication. (KI 003-implementer)
It is not easy, but I think they can link the system between countries so that if the patient comes in, if we punch in their name on the computer, we can get their information and where the patient was treated previously. But we are still waiting for that. (KI 002-implementer)
Fast-tracking the integration of Tier.Net with ETR.Net as a first step while the unique identifier is being rolled out. (Policy document [25])
However, another respondent had a different view regarding national databases, explaining the challenges that such a system would raise as facilities would need to have computers, Internet connection, data security, and protection. This raised the question of how realistic it would be to attain a national database:
There’s a big push now for e-records, or electronic records, which I think is a nice idea. I do not know how that works in practice, when like, you know, many primary health care facilities do not have a working computer … I think that is a lovely idea, but I do not think it is super attainable, right? But giving people their health records in a digestible format like help passport would be quite nice and effective. (KI 007-researcher)
Some respondents emphasized the need for comprehensive and inclusive HIV and AIDS policies that specifically address the needs and vulnerabilities of farmworkers. They also elaborated on the necessity of explicit policies about farm employers’ duty to ensure workers have access to healthcare. One informant narrated:
The issue of improving the way the information goes to workers… the policy or whatever that pushes the farms or farmers to make sure that the workers have access to information should be compulsory. (KI 001-implementer)
Although it was recommended that in the absence of HIV policies for farm workers the HIV programs must be integrated within existing health forums such as the mining sector and malaria programs, we identified a challenge that farm workers have unique health needs that may not be fully catered for within other population groups:
I think we definitely should integrate, and it makes sense to integrate, and for SADC I think it needs to be part of the broader conversation that is happening with other sectors like the mining sector, so that we don’t have all these you know, splits in conversations. You know, there’s the mining sector, if there are SADC meetings on malaria, it needs to integrate the farming sector because it’s mainly on the farm in those communities where you will find cases of imported malaria. And then we can include issues of HIV within that. (KI 005-program expert)
3.5.5. Role of Farm Owners/Employers
Some respondents raised the issue of the employer’s role in improving access to HIV care for workers. They deliberated that employers should have an obligation toward farm workers as part of their corporate social responsibility, emphasizing that certain accountability and responsibility should come from the employers’ end rather than workers working long hours with no proper care. The employer can provide resources such as transport for workers attending health facilities. Moreover, collaboration between service providers and employers was recommended as one of the strategies to improve farmworker access to healthcare:
…as we know, all businesses have a corporate social responsibility. So now you ask yourself, what is the agricultural department’s responsibility towards farm workers?… So that an obligation needs to be placed there, a certain responsibility and accountability should come to their end, rather than having farm workers work extended hours with no proper healthcare… (KI 006-program expert)
Employers should also support HIV workplace programs, which do not only benefit workers but employers as well as shorten the time spent traveling to health facilities. Providing clinic structures in farms can facilitate HIV outreach services, especially where mobile clinic units are limited, but other modes of transport to deliver HIV services in the farms are available. One policy document states that employers should support employees in accessing treatment for HIV/AIDS, which includes the provision of information about available medical services and creating an environment that supports employees in managing their health [29]:
Employers are encouraged to support employees in accessing treatment for HIV/AIDS, including providing information about available services and creating an environment that supports employees in managing their health. (Policy document [29])
4. Discussion
This study explored key informants’ perspectives on current farm workers’ HIV programs and policies in South Africa. The findings indicate that despite the progress made in expanding the HIV testing and treatment services in South Africa, there are still several challenges in the HIV program and policies for farm working populations. However, due to their experience in program design and implementation, key informants shared best practices that have been successful in strengthening the program and provided recommendations for HIV programs and policies.
A clear majority of key informants attested to the difficulty in rendering HIV services to farm workers, where being seasonal workers combined with high mobility results in treatment interruptions and high LTFU. Several studies have found challenges in retaining highly mobile and migrant populations in care [2, 6, 8, 11, 30]. Self-transfer of workers to new facilities as they move to new farms or change work was reported as a major setback in managing farm workers on ART. Silent transfer poses a challenge as it can lead to double counting the number of people initiated on ART, which would result in overestimates of the program coverage [31]. Existing national policies have sought to address HIV prevention and treatment for highly mobile and migrant populations, which include farm workers, with emphasis on providing such services at convenient locations [24–27, 32]. However, discussions with key informants indicate a lack of implementation of such policy directives at the facility level.
Some of the most effective interventions that were implemented by key informants to mitigate treatment interruptions included the use of treatment passports and transfer letters. Interventions including health passports, electronic medical records (EMRs), and centralized ART databases have been reported to improve the continuum of care between health facilities and between countries for those patients who are cross-border migrants [6, 12, 33–35]. However, the provision of transfer letters depends on patients informing health workers of their relocation, which is not always the case. Distance was also mentioned as a challenge to rendering HIV services to farm workers, particularly making it difficult to trace workers who are defaulting on treatment. In previous studies, farm workers reported that distance to health facilities is one of the main barriers to accessing health services [5, 36, 37]. To counter distance challenges, policy documents made provisions for customized services that meet the unique needs of populations similar to or inclusive of farm workers [25], including outreach and mobile health services [38], as well as community-led and decentralized service delivery approaches [27].
There was consensus from most key informants on the lack of standard policies and programs that specifically addressed farm workers. Policies would act as a point of reference at a facility level, and thus, a more standardized approach to HIV programs for farm workers would be attained. Although farm workers are catered for in some national policies [25, 39], having sector-specific policies and guidelines for the population may better facilitate the implementation of HIV programs at a district and health facility level. One of the policy frameworks [24] addresses a need for regional harmonized HIV policies; however, it is unclear whether this framework has been adopted or implemented by member countries. Although farm workers are also closely linked to migrant populations, they differ from most migrants in the sense that they are in remote areas. On the other hand, other migrants tend to be closer to the cities and thus may not have similar experiences to farm workers regarding HIV healthcare.
It is worth noting that in the past, HIV services to farm workers in certain districts were mostly provided by donor-funded NGOs, and when funding stopped, the NGOs exited the farm areas they were servicing [34]. Thus, the government had to take over those services, and maintaining the gains from NGO programs largely depended on resource availability from the government side. Previous studies have reported that careful transition planning is necessary when external funding withdraws, to ensure that the exit of donors does not leave a vacuum for those populations that benefited from their funding [34, 40].
Some of the best practices echoed by almost all key informants include community-based services, which mainly cater to prevention, counseling and testing, treatment support, and defaulter tracing. Bringing HIV services to where farm workers are, including the involvement of CHWs, was found to bridge the distance gap for farm workers as facility visits for those who needed HIV services were reduced. Although our findings suggest that CHW enables prevention and treatment access for some workers, the challenge is that the CHW program does not reach all farming communities, as it is not properly integrated into any existing agricultural sector guideline or policy. Therefore, the success of this program does not benefit all farm workers. Some of the successful community services include treatment pick-up points, mobile health services, adherence clubs, and CHWs. This aligns with previous studies that have reported higher success rates of community-based interventions such as peer support and support groups in improving adherence [41–43]. Previous studies have shown the success of adherence clubs in reducing patient LTFU, as the clubs shorten the time and cost it takes to reach health facilities [44]. Our findings also affirm the effectiveness of CHW in improving treatment access for farm workers. Community Health Workers are effective not only in supporting those who are on treatment but also in providing counseling and testing, especially among vulnerable groups [45]. Mobile health services have long been found to close the access gap and contribute toward universal health coverage, which has also been the case in some South African settings.
EMRs, such as the use of a national electronic database, were recommended by our key informants. Several studies have investigated the successes of EMR in improving patient care, reporting on the benefits that cannot be disputed [33, 35]. Although such benefits would contribute positively to the HIV program in South Africa, the main concern of infrastructure to maintain an electronic record system was raised. This is in light of the current challenges with network coverage, where most rural areas could struggle with network connections.
Given policy document analysis, it is apparent that there are current policies that address the plight of farm workers regarding HIV healthcare, albeit they are grouped with other similar subpopulations, as mentioned by key informants. The reported experiences at the service level also allude to the lack of implementation of these crucial policies. This highlights a gap in the monitoring and evaluation of policy implementation. Moreover, this may underscore a need for specific policies that would address farm workers as a stand-alone population rather than within the context of other related populations.
Based on our findings, we recommend that more practical and feasible solutions in the case of South Africa should be considered in attempts to better HIV service delivery for highly mobile populations. These solutions include patient-held records or treatment passports, improving community-based services and strengthening mobile health services to cover all hard-to-reach populations. Implementing community-based models of care, such as nonconventional and/or convenient locations, as per the current policy stipulations [27], would improve access and retention in care for farm workers.
A further recommendation that cannot be overemphasized is the employer’s role in improving access to HIV prevention and treatment. Although HIV and wellness policies may exist at the local level in different farms, there is a call for the agricultural sector to have a more standard HIV workplace policy that outlines the employers’ responsibilities based on the existing laws and regulations of managing HIV in the workplace [29, 46].
4.1. Strengths and Limitations of the Study
The main limitation of this study was the nonparticipation of government policy experts, who declined the invitation to participate. Although their inputs would have added value to this study, those who participated provided important insights into current HIV programs and policies for farm workers in South Africa. The second limitation was that there are not many researchers in South Africa who are focused on this study population, particularly on this subject. This was also the case with programmatic interventions, where most NGOs who had worked in this field had closed down. This limited the number of possible participants from both the NGOs and the academia. This study’s main strength is the policy document analysis, which not only acts as an extra data source but underscores most of the program and policy gaps identified by the key informants, thus strengthening the validity of this study’s findings.
5. Conclusion
Key informants highlighted several HIV program challenges that face health providers and the health system. To the best of our knowledge, this is the first study that sought to understand the HIV services and policies for farm workers from healthcare workers’ and experts’ perspectives. Although there are studies that have reported on the lack of targeted HIV policies for farm workers in the past [2, 9], this is one of the first studies to report on the content of national HIV policy documents pertaining to farm workers in the South African context. Furthermore, this is the first study to report on the role of farm owners in improving access to HIV care, as established by our findings. The views and experiences shared provide a strong basis for engaging current policies and developing a model of care that will ensure that no one is left behind in the quest to end HIV and achieve the 2030 developmental goals.
Conflicts of Interest
The authors declare no conflicts of interest.
Author Contributions
Nosimilo Mlangeni: conceptualization of methodology, development of interview tools, data analysis, methodology, writing–original draft, writing–review and editing. Martina Lembani: review of interview tools, methodology, writing–review and editing. Olatunji Adetokunboh: review of interview tools, methodology, writing–review and editing. Peter S. Nyasulu: review of interview tools, methodology, writing–review and editing. All authors read and approved the final manuscript.
Funding
This research was funded by the National Research Foundation (NRF) in South Africa (grant number 138261) and the Harry Crossley Foundation funding through Stellenbosch University.
Acknowledgments
The authors acknowledge Ms. Mahlatse Maeko for participating as a second researcher in the data analysis process. We also acknowledge all key informants who agreed to participate in our study. Special thanks are due to the National Institute for Occupational Health for providing resources, physical space, and valuable support to execute this study.
Supporting Information
Additional supporting information can be found online in the Supporting Information section.
Open Research
Data Availability Statement
Due to the sensitive nature of this study, restrictions apply.
