Subtheme 1.1: The meaning of HIV management guidelines

Literature refers to guidelines as directions or principles presenting current or future rules of policy that can be developed by government or by the convening of expert panels (Blackwell’s Nurses Dictionary 2014b:260). The national consolidated guidelines for the prevention of mother to child transmission and the management of HIV in children, adolescents and adults provides guidelines on how to respond to and to manage HIV infected individuals (NDoH 2015:1). However, the consolidated guidelines of 2015 show no modifications or new provisions regarding mental health screening (NDoH 2015).

The nurses subjectively shared their views and understanding of what the guidelines meant to them as professionals and their work with HIV infected individuals. The impression gained from findings show that nurses interpreted these guidelines as professionals using their nursing background and experience. There were various interpretations of the HIV guidelines. Participants understood the guidelines as strategies to manage HIV infected clients effectively, while others described them as ethical obligations regulating their practice on management of HIV and mental health.

Therefore, participants’ explanations do concur with the broader definition of the concept from the literature.

The policies relating to HIV and AIDS have risen out of the necessity to develop a more organised, formalised response to the increasing epidemic (Du Toit 2008:6). Countries in sub-Saharan Africa empowered nurses by training them to initiate antiretroviral

Bateman 2012). The nurses also described the HIV management guidelines as empowerment of nurses, information on initiation of antiretroviral drugs (ARVs) and as provision for proper assessment. They felt empowered to effectively manage HIV as they had a framework to guide their practice.

In support of the findings, reports from small-scale Task Shifting Demonstration Project confirm that task shifting of ART initiation from doctors to nurses in Namibia is an appropriate, indeed vital, initiative in continuing the scale-up of life-saving HIV clinical services (O’Malley, Asrat, Sharma, Hamunime, Stephanus, Brandt, Ali, Kaindjee-Tjituka, Natanael, Gweshe, Feldacker & Shihepo 2014:9).

It was further revealed that HIV management guidelines provided them with broad questions to respond to in order to complete assessment of HIV clients and others. The assessment of HIV infected individuals includes mental health, physical health and social functioning, these components are interdependent and complex (Uys & Middleton 2014:16). The various forms of understanding of these guidelines provided insights into how they would implement them.

The guidelines play an important role in ensuring uniformity of treatment. They also provide nurses with standards and procedures regarding criteria for initiation of ART and regime, follow-up visits, adherence, patient management and diagnosis and management of side-effects.

The findings give evidence that it is very crucial for the nurses to have similar understandings regarding the guidelines to be able to implement HIV programmes effectively.

4.3.1.2 Subtheme 1.2: Meaning of mental health screening for HIV positive infected individuals

Literature defines mental health screening as a form of mental health assessment which requires nurses to use self-reporting questionnaires to screen for clients suspected of mental disorders (Uys & Middleton 2014:16, 39). Screening for mental health among HIV clients is given reasonable consideration in the SA health policy. This is due to a growing burden of mental, neurological, and substance use (MNS) disorders, which are

often co-morbid with HIV and other chronic diseases, indicating that considerable mental health treatment gap exists, especially in rural areas (Jack, Wagner, Petersen, Thom, Newton, Stein, Kahn, Tollman & Hofman 2014:8).

Nurses understood mental health assessment in HIV infected individuals as necessary steps that must be carried in order to identify clients who show symptoms of common mental health problems associated with HIV. Uys and Middleton (2014:198) describe mental health assessment as the conversational spaces in which the nurse and the client create a version of client’s life history through the process of asking and answering. It involves the description of the patient’s appearance, speech, actions, and thoughts during the interview. It was evident from findings that mental health screening requires specific skills; hence their interpretation of what was required indicated the need for specific knowledge and skills to be able to assess and record mental status accurately. Nurses also lamented the lack a resourceful screening tool to support their understanding of what they needed to do. Presently, they indicated that they use the HIV form that does not provide them with the necessary or adequate information to know how to identify CMD. They acknowledged the importance of mental health screening among HIV positive individuals, and they were also aware of side-effects of drugs such as hallucinations that needed to be assessed.

South African nurses providing HIV care at clinics attended training and workshops on:

Highly Active Antiretroviral Treatment (HAART); Prevention of Mother-To-Child Transmission (PMTCT); HIV Counselling and Testing (HCT); Nurse Initiated and Managed Antiretroviral Treatment (NIMART), Provider-Initiated HIV Counselling and Testing (PICT) and Integrated Management of Childhood Illnesses (IMCI) (own experience). However, there is no specific training on mental health and HIV to guide nurses on how to screen for mental health. Thus, nurses believed that mental health screening is not given prominence in professional development programmes, and this led them to concentrate only on the physical assessments and furthermore rely on their nursing background to screen for mental health, when the need arose. The need for

4.3.2 Theme 2: Implementation of the guidelines

Literature describes implementation as the process of converting the divisional human resources into action, which is accomplished through the practical application of the programmes (Booyens 2008:21).

In theme 2: Implementation of the guidelines, three subthemes emerged from collected data. Participants described their practices and experiences with regard to mental health screening. The three subthemes, namely; mental health screening practices, management of known mental disorders and evaluation of implementation of the guidelines emerged from data.