In Summer 2018, we piloted the TRHC with 18 persons aged 50+ in Khayelitsha and 12 in the rural HIV40 study site. The aim of the pilot was to test the feasibility of using the TRHC with those living and not living with HIV. The research team’s formative qualitative study, and the literature on LHCs, HIV risk and testing, and NCD risk and treatment provided a basis for the instrument. The TRHC was developed to capture when and why older South Africans do or do not test for HIV and how that relates to their risk histories. The domains (outlined below) reflected the types of risk correlated with older persons’ HIV acquisition and testing that were in the limited extant research.17,38,59
Like other LHCs, the TRHC was formatted as a large, fold-out paper grid (See Appendix A),89,131,160 with months across the top and domains of interest (e.g., HIV testing, partnerships) down the left side. Because of the potentially protracted nature of older persons’ risk profiles, the decade of ART rollout, and the age, period, and cohort effects on risk, the TRHC was designed to include a 10-year retrospective period. Based on a life-course approach, in addition to socio-demographic timelines (details on age, residence, education, marital status, employment, and social grant status), the TRHC had three key domains with multiple timelines:
- Relationships and sexual risk: Relationship dimensions and sexual behaviors for each relationship over the past 10 years, which included reporting on all partnerships and various types of sexual risk.
- Health status and health care utilization: This section tracked the timing of illness, diagnosis, and care for all chronic conditions, and routine and acute engagement with the health system.
- HIV testing: Respondents placed each HIV test in the past 10 years on the calendar and answered a series of survey questions about each test.
In the pilot, a set of public reference points (e.g., World Cup in June–July 2010, Marikana Massacre in August 2012, Mandela’s death in December 2013) were pre-printed on the calendar; fieldworkers added respondents’ salient personal reference points at the beginning of the interview. As the interview progressed, information from one timeline was used to cross-check and resolve inconsistencies in others.81,87 The fluid form of the interview allowed fieldworkers to ask participants about HIV testing both as part of the HIV testing timeline and when risk was mentioned in any other timeline. Detailed margin comments and debriefing notes provided extremely valuable context to the data that allowed for deeper understanding of decision-making.87 The findings show that older study participants were able to recall key events and place them on the TRHC, such as when they had tested for HIV, when sexual and romantic relationships occurred, and information related to their health conditions. They were able to specify which components of each changed over time and which were static.