Table 2 Policy merit and healthcare worker knowledge related facilitators and barriers to UTT policy and same-day ART initiation implementation

Facilitators

 Policy value in the context of South Africa

"…like I say, the aim [of the policy changes] is to put everyone on [treatment], everybody who is positive so that there must not be any transmission”—PN

 Knowledge of policy objectives

“I like it [UTT] because some people they say we are going to see, like if the CD4 count is less than 500 they start to initiate. But if it’s more than 500 they don’t initiate that person, and that person they get sick. They get sick even though their CD4 count is high. So, that is not right. To start initiate the person who is very sick, because the side effects worse in that person, it is going to be worse for the person. So, it’s better to test and treat while they’re still healthy”—LHC

Barriers

 Exclusion of facility-level stakeholders in policy formulation

“For me, it would have worked very better if before a policy is being designed for the facility, even before the level of the operations manager, they call their workshop. So, that they’ve got buy-in and understanding. Because sometimes you will try to explain a policy that you, yourself don’t understand…”—PN

 Perceived contradictions between ART guidelines and proposed process for ART initiation

“I think again patients’ readiness, there’s subjective readiness and there’s objective readiness. My being readiness to [initiate] doesn’t necessarily meaning I qualify for you to initiate, we still have those patients that we will need to fast-track, the guidelines remains the same, antenatal, TB patients. I might be ready to take but then we have to exclude other conditions. You find out I’m ready, I’m saying yes, I’m ready, probably because… when you get deeper into literature, you know those patients, there’s certain categories of patients that you know such patients are better ready compared to these patients.:—PN

 Lack of clear operational guidance to implementers

“Like when you attended meetings… they kept saying you can initiate patients immediately. But, you know the clinicians [nurses] were not that confident because they were saying they don’t have anything written in black and white that guides them.”—PN

“…what I noticed especially with the nurses at our clinic is that they were also resistant to the very UTT because it was not implemented like when NIMART implemented, people went for training, you know, expensive training. But with UTT, just a memo came and said from now on you can do this, and you don’t have to wait for this, and you don’t have to wait for that.”—PN