Challenges and enablers faced by HIV/AIDS supporting organizations during COVID-19

The dynamics of multi-sectoral collaborations between HIV/AIDS-supporting non-governmental organizations and public health institutions can significantly affect how programs are implemented, especially during emergencies like the once-in-100-year COVID-19 pandemic. These collaboration dynamics were explored in a South African context in the Western Cape province during COVID-19. Interviews and a focus group discussion were conducted with participants (n=6) from two small-scale HIV/ AIDS-supporting NGOs and one public health institution. Challenges of multi-sectoral collaboration identified included inadequate engagement opportunities, limited opportunities to contribute during engagements, and being forced to innovate to survive. Ena-blers of multi-sectoral collaboration, such as communication, leadership, coordination of responsibilities, and trust and transparency, were found to be crucial for effective and strong working relationships during times of unparalleled disaster. New insights are offered on how enablers of collaboration that apply during normal circumstances should be thought of during times of crisis, and how these can be adapted and augmented to help HIV/AIDS collaborative partnerships survive future potentially disastrous situations like climate change.


Introduction
Multi-sectoral collaboration between HIV/AIDS-supporting non-governmental organizations (NGOs) and public health institutions has a significant influence on the outcomes of implemented programs in South Africa (SA) (Lanford et al., 2022;Mahlangu et al., 2017;Mahlangu et al., 2018;Mahlangu et al., 2019).As an example, in South Africa's Western Cape Province, small-scale HIV/AIDSsupporting NGOs make a vital contribution to curbing the HIV epidemic through multisectoral collaborations with public health institutions and the private sector (Hinton et al., 2021).Outcomes of such collaborations include expanded access and adherence to antiretroviral treatment (ART) through food support and empowerment programs, increased access to healthcare for people living with HIV (PLWH), operations.This recommendation begs the questions: How has the disruptive nature of the COVID-19 pandemic impacted collaboration efforts between small-scale NGOs and public health institutions in the Western Cape Province, and what can we learn from these adaptive processes to help sustain effective collaboration going forward?
As far as we know, South African studies on collaborations between HIV-related NGOs, public health institutions, and other entities have mainly focussed on macro-level collaborations between multiple sectors during relatively predictable and manageable times (see, for example, Lanford et al., 2022;Mahlangu et al., 2017;Mahlangu et al., 2018;Mahlangu et al., 2019).Such earlier studies did not account for complex and dynamic emergencies like the once-in-100-year COVID-19 pandemic and how that affects collaborative processes.It is, therefore, reasonable to conclude that collaborative efforts between organizations may have experienced new or different dynamics since the outbreak.
Moreover, as indicated above, earlier studies into the collaboration between role players in the HIV field in South Africa mainly focussed on macro-level collaborations between multiple sectors.To our knowledge, no comparable research focussing on multisectoral collaborations on a smaller scale, like between public health institutions and HIV/ AIDS support NGOs at a local level, has been conducted in South Africa.This gap may be vital in light of the need to improve HIV/AIDS support at provincial and district levels, with attention at local levels where implementation is key (National Strategic Plan or NSP South Africa, 2017).Given this state of affairs, the present study investigated the dynamics of multi-sectoral collaborations between smallscale HIV/AIDS NGOs and public health institutions in the Western Cape Province of South Africa, while concurrently establishing how these entities adapted their working relationships due to COVID-19.Identification of challenges and enablers associated with these collaborative efforts led to proposed adaptive collaboration principles for the post-pandemic era.Such adaptations could be necessary not only because of COVID-19 but also in light of other looming disastrous situations like climate change and its impact on HIV-related services.
Generally, five elements associated with the collaboration process can help to understand, analyze, or manage collaboration alliances (Thomson & Perry, 2006;Wood & Gray, 1991;Xu & Kim, 2021), also in an HIV context (Jobson et al., 2017).Two of these elements include governance (involving decisionmaking within and across organizations) and administration (including aspects related to shared roles, responsibilities, goals, and implementation plans between collaborating parties).The other three elements are mutuality among collaborating parties, norms of trust and reciprocity between cooperating entities, as well as organizational autonomy (understood as how collaborating partners handle their interests or exert influence over or control the behavior of other organizations).These elements served as theoretical underpinnings in the current study to identify potential challenges and enablers to adaptive collaboration efforts.

Method
A qualitative instrumental case study design was adopted for the study to gain an indepth understanding of the dynamics at play in multi-sectoral collaborations.Telephonic oneon-one interviews were conducted with different participants who worked across collaborative organizations.These interviews were followed up with focus group discussions between these participants to reflect on and explore any issues emanating from the interviews.Before commencing the research, ethics approval for the study was obtained from the relevant authorities.Three organizations located in the southern suburbs of Cape Town which were known to the researchers were selected for inclusion in the study -two small-scale HIV/ AIDS supporting NGOs (referred to as NGO X and NGO Y) and one public health institution (referred to as Public Health Institution H).These entities fit the inclusion criteria of having collaborated on various HIV-related projects in the past as well as during COVID-19.The sample size in qualitative research tends to be small to support the depth of case-oriented analysis (Sandelowski, 2004).Therefore, the sample size of three organizations with two representatives each (n=6) was deemed suitable for the study.
At the participant level, preference for inclusion in the study was given to individuals with administrative duties related to HIV/ AIDS care and who had served for at least one year in that institution.NGO X provides HIV prevention and treatment services and was represented by an HIV and AIDS/STI/ TB (HAST) manager and an HIV counselor.NGO Y provides antenatal support to pregnant mothers, nutrition support, and counseling services for HIV and other social issues.NGO Y was represented by the center manager and the founder CEO.Public Health Institution H is a day hospital and was represented by an HIV and TB nurse practitioner and an acting HIV/ AIDS case manager.Interview questions were developed based on the five elements of the collaboration process discussed earlier.Data triangulation by using interviews and focus group discussions ensured the validity of the study results as well as increasing the reliability and trustworthiness of the research data.
Managers from the three organizations assisted with the recruitment of participants by identifying potential candidates.The managers were provided with a sample letter to send to their colleagues to invite them to take part in the study and to contact the researchers directly via e-mail should they be interested.Consent forms were e-mailed to participants after they had contacted the researcher.A week was given to read, complete, and return the forms.Participants were then allocated their preferred times for the telephonic interviews.It was followed up with a focus group discussion via Zoom with the previously interviewed participants.Both the interviews and focus group discussions were conducted in English.Data analysis used NVIVO 2.0.Transcriptions were imported and coded according to challenges and enablers related to collaboration.

Results and Discussion
The results revealed different challenges impacting collaboration as well as enablers of the collaboration process (Figure 1).The main challenges that impacted collaboration efforts identified in the study included engagement dynamics, a lack of funding, and being 'forced' to innovate due to the circumstances brought on by COVID-19.These challenges are unpacked below.Firstly, considering engagement dynamics, some participants felt that small-scale NGOs could only make minimal inputs/contributions as part of collaborative initiatives.Along the same lines, it was found that representatives from small-scale organizations often felt limited in identifying and raising issues of concern during collaboration meetings.For example, a participant highlighted, "…we need to have a stronger voice within like saying this is wrong…".This limitation may well relate to participants stating that, although small-scale NGOs plan collectively with public health institutions, they often have limited autonomy as their programs are frequently regulated by the very entities they are collaborating with (or by external stakeholders).
A factor as to why NGOs' voices are often quiet during collaborative engagements was mentioned: a lack of resources.A further reference to resources related to the explanation of the dynamics of international partners.Dominance by international partners was thus associated with accumulated resources.Participants from the public health institution indicated that international partners take a leading role in HIV-related programs during collaborations, and they felt decision-making was not always inclusive.This lack of collective engagement creates a complex structure that hampers participation and innovation (Kwibisa & Majzoub, 2018).However, participants indicated that contributions of smaller partners are usually acknowledged as part of collaborations.
All three entities reported limited activity due to physical contact and other related restrictions in effect at the time of the study because of COVID-19.The reported inadequate engagements consequently negatively affect participation and decision-making around routine processes and procedures of joint HIVrelated interventions.Regular engagements are vital platforms for exchanging information in collaboration (Hushie et al., 2016;Mahlangu et al., 2019).Participants stated that before COVID-19, they had been accustomed to a collaboration-integrated planning approach.However, they could only make limited contributions in deciding their action plan during the pandemic.Participation and integrated decision-making are vital for collaborations to work well (Hushie et al., 2016).
A second challenge that impacted collaboration efforts was a lack of funding.Participants from both NGOs received less funding and resources and perceived that their funders might have shifted focus from HIV/ AIDS programs to addressing COVID-19related challenges.Davids (2020) opined that donors diverted funding from HIV support programs to COVID-19 support programs, i.e., at the same time as when the research was conducted.A lack of funds affected the usual collaborative processes of these organizations.For example, public health institutions rely on food support programs provided by small-scale organizations, which became a challenge to fulfill because of funding limitations.
The financial position of an organization is noted by Eftekhari et al. (2014) to determine its relationship with other organizations in a collaboration.Limited financial resources may halt development efforts and subsequent collaborations of small-scale NGOs with other entities, as in the current study.A third challenge identified in the study affecting collaborations was that the pandemic forced partners to innovate with how they used technology.For example, reducing physical contact with clients and other employees by performing their administration duties, such as remote data capturing.This remote interaction impacted collaborative processes as it meant that technical skills had to be transferred among collaborating entities, which ultimately proved problematic.According to Bano (2019), the transfer of technical expertise by NGOs to public sector partners can be challenging as this may imply changing their working ways.
Public health facilities experienced an influx of patients, and workload had increased.Collaborative organizations had to innovate by adapting their working relationships through some shared work responsibilities.For example, the small-scale NGOs had to assist the public health institutions with HIV testing as the public health institutions had to assist the small-scale NGOs with COVID-19 screening of clients and provision of essential resources, including protective gear.The main enablers related to collaboration identified in the study included effective communication, transparency and trust, leadership action, and the effective coordination of responsibilities and roles.These enablers are elaborated on next.
Firstly, effective communication among staff from cooperating organizations was shown to be a strengthening factor of collaboration.Participants perceived communication within and across organizations upheld all processes of collaboration.Staff involved in the collaboration continuously informed each other of any developments that could affect their joint operations, such as changes in fulfilling responsibilities.Participants highlighted that communication was vital, specifically when these organizations became overwhelmed because of the impact of COVID-19.This constant communication assisted collaborating organizations in formulating necessary strategies for stability and progress.Similarly, Bridges et al. (2011) note that communication is a vital aspect of maintaining information flow among collaborating entities.
Clear communication promoted collaboration to remain functional despite COVID-19-related limitations.This finding is comparable to Raharja and Akhmad (2020), who report that communication in HIV-related collaborations maintains togetherness and fills gaps of inability due to lack of resources.Secondly, transparency and trust were identified as enablers of collaboration.Participants iterated that despite having diverse values and cultures, they managed to achieve the set goals of HIV support programs by being transparent.All organizations contributed in different ways to the collaboration during integrated planning meetings.During these meetings, each organization would typically present its organizational structures and the best contributions they all provide (e.g., counseling services, distribution of food, or HIV testing) while being transparent at each step.
Organizations achieved trust by openly sharing their strategies and resources.Resource sharing is seen as a contributory element for successful collaborations (Bridges et al., 2011).
For instance, small-scale organizations could operate from the public health facilities.In a one-on-one interview, one participant opined, "You must trust that the other organization is doing the right thing.At the end of the day, we all have the same goal…" Respondents further highlighted that they shared information about their inability to fulfill certain responsibilities, and that this yielded trust in their collaboration.
The high levels of transparency and trust point to a sense of togetherness in the collaboration which emanates from organizations' dependency on each other (Thomson & Perry, 2006).
Thirdly, the enabler 'leadership action' was identified as being central to boosting collaboration efforts.The public health institution was found to have the position for leading and controlling collaboration initiatives and efficiently perceived.For example, the institution leads by setting up required protocols and procedures to help adapt to changes in the working environment and to adjust to the pressures of dealing with two pandemics at the same time.Developing protocols and procedures were cited by participants as vital for ensuring well-coordinated collaboration.This finding concurred with Mahlangu et al. (2019), who also found that effective leadership facilitates effective progress in HIV-related collaboration.
The fourth enabler of collaboration identified in the study related to the effective coordination of responsibilities and roles.Participants acknowledged that, although collaborating organizations have unique approaches, values, and ethos to address HIV-related support, they all operate under a common framework and that responsibilities must be well coordinated.Entities reported having coordinated roles that were clearly defined to guide their activities, ensuring that roles and responsibilities were not duplicated.Furthermore, collaborating organizations acknowledged the importance of the role played by each organization.Therefore, coordinated efforts in integrating COVID-19 and HIV/ AIDS programs were deemed manageable by participants.
The current study was not without strengths and limitations.A strength of the study was that it employed known elements underpinning the process of collaboration i.e., governance, administration, mutuality, norms of trust and reciprocity, and organizational autonomy.These elements helped to classify and make sense of the challenges and enablers related to the collaborations identified in this study.In doing so, the study findings can be easily incorporated, as part of future related studies.The first limitation of the study was that it did not collect any baseline data on pre-COVID-19 working relationships between the collaborating organizations.It may have been useful to gain deeper insights into the current findings.A second limitation of the study was that it was limited to a small-scale cohort in one province of SA.Funding limitations and restricted time frames did not allow for a broad-based study.
Implications for practice identified in the study were as follows.Based on the challenges identified around collaborative engagement, the development of HIV-related policies that enable an administerial environment promoting inclusive engagement should be encouraged, particularly where small-scale non-state entities and bigger role players such as public health institutions work on joint projects.On a practical level, this could take the form of service-level agreements and contracts that are inclusive of small-scale NGOs' contributions and inputs.It can raise trust, improve transparency, and ultimately lead to more effective collaborations.Furthermore, the findings of this study showed that when collaborating parties are using the same technology, it is vital to make sure all entities involved are clear about utilizing that technology.It may be important for an effective collaboration that enhances the uniform provision of services by all stakeholders.
Overall, our findings confirm the recommendation by Keene et al. (2020) discussed earlier that collaborating actors involved in HIV-related healthcare programs need to adopt sustainable strategies to cope with unprecedented emerging pandemics or comparable disasters in the future.Such actions will serve all role players well as it can help them to adapt and cope better under changing or unexpected working conditions.The current study also identified potential avenues for further research.Using the study's findings as a baseline, future researchers can explore the development of a collaboration process framework to help cooperating partners deal with disastrous or unpredictable situations in the future.Given that the study was relatively small in scale, comparable research on a broader scale, for example, focussing on more organizations and in multiple provinces, can also be considered in future projects.

Conclusion
Overall, the challenges and enablers of multi-sectoral collaboration identified in the current study are, for the most part, attestations of known elements associated with the collaboration process.For example, the challenge around limited contributions during engagements can be linked to the element of governance; the enabler 'sharing of expertise' (to achieve joint programs goals through innovation) can be linked to the element of mutuality.Despite this, our findings provided further support for the position that certain elements of the collaboration process, such as communication, leadership, coordination of responsibilities and roles as well as trust and transparency, are crucial for effective and strong working relationships -and revealed this to especially ring true during times of unparalleled crisis.We also offered insights into how known enablers of collaboration that apply during normal circumstances should be thought of during times of crisis,and how these can be adapted and augmented to help HIV/ AIDS collaborative partnerships survive future potential disastrous situations like climate change.

Figure 1 :
Figure 1: Summary of the Main Challenges and Enablers Related to Collaboration Identified in the Research.