At the Maun, Serowe and Mahalapye study sites, patients gather at the IDCC clinics for their ARV consultations, adherence counselling, laboratory schedules and collection of their medications. These clinics are largely separate from the rest of the units within the hospital. In contrast, at the Molepolole study site, all outpatients were received at the hospital outpatients unit, which had two consulting rooms for people on ART. Two of the health facilities (Serowe and Maun), which happened to be first generation sites, had adequate space. The structures provided for adequate confidentiality, good counselling, laboratory services with adequate shade, and seats provided for the patients in the waiting area. However, in Mahalapye and Molepolole there was a lack of space, seats and shade in the waiting areas, and patients resorted to sitting in makeshift waiting areas. The little cover and shade that is available is inadequate to shelter patients if the weather is bad. In all four facilities the environment was found to be clean. At each of the facilities posters were strategically placed within the IDCC clinics, mainly explaining the importance of adherence to ARVs and the fact that these medicines suppress the virus but are not a cure for the disease. Some of the posters were in English and others in Setswana.

The service and staffing details are outlined in Tables 5.1 and 5.2.

Table 5.1: Service details of each participating facility, as of May/June 2005

Table 5.2: Summary of staffing for the IDCC at the time of data collection

5.3.2 Service provision

All facilities operated Monday to Friday, with the exception of Molepolole which opened only four days per week. The eligibility criteria were the same in all the facilities since they followed the national guidelines for commencement of therapy. The patients were encouraged to come with adherence support partners but the lack of a partner did not disqualify anyone from being put on ART.

At the Maun, Molepolole and Mahalapye sites, pre-treatment adherence counselling was done in a group session, whereas in Serowe this was done on a one-to-one basis. At Mahalapye, adherence counselling was done by a team of health workers consisting of a nurse, pharmacy staff, social worker, and dietician, while at the other sites it was done by one health worker at a time with a group of patients.

Seeking shade from the sun in Molepolole: patients wait for their appointments in the hospital grounds, outside the hospital chapel.

The adherence support mechanisms varied between the sites, in both the method of counselling used and in the follow-up of patients who were not achieving optimal adherence or who had stopped taking the ARVs. The similarities included the use of pill counts (with the exception of Serowe), encouraging patients to bring an "adherence buddy" at the start of therapy, and the use of cell phone alarm settings to remind them to take their medicines. A basket of food rations was also available for patients who were unemployed or no longer working because of illness and who did not have any other source of income. This was determined on the basis of an assessment by social workers, which included home visits.

At the time of the study, equipment for measuring CD4 counts and viral load was not available at any of the facilities. Maun, for instance, sends its viral load and CD4 samples to reference facilities by air courier and the other sites transport their samples by road to their tertiary referral hospitals. Other laboratory investigations, such as haematology, cultures and urine analysis were done on site. Since the completion of the study, Serowe has acquired the capacity for CD4 testing.

Language barriers were observed to be a problem during interactions between some expatriate health workers and patients.