Table 4 Clinical management of HIV positive patients related facilitators and barriers to UTT policy and same-day ART initiation implementation

Facilitators

 Knowledgeable patients and ART-ready patients

“Today we live with people who are HIV positive. Although we may speak of people who are in a remote place…and you know…this person…you may give us cues relating to that. But for somebody who is living in CBDs and all that urban life, and all that stuff. They should know about [HIV], even at workplace, I think that’s something…on TVs we talk about HIV…you know…or related things.”—PN

“It doesn’t necessarily mean transmission will only be stopped by treatment. I think these days were just talking about treatment, treatment—we don’t talk about condoms anymore, we don’t talk about healthy lifestyle anymore. We just want treatment, treatment…”- PN

 Reduced system barriers to ART

“… because like I say, the aim is to put everyone on treatment, everybody who is positive so that there must not be any transmission, and that’s how we deal with AIDS…”—PN

Barriers

 Counsellor skill limitations

“… we came up with this (policy), and now we are ready for UTT, but did we go back and look at the cadres of counselling that we have? To say, when they need to communicate that to the patients, how much intense can they go in order for the patients to be able to say “okay I can be motivated” [to initiate ART] or “no give me a chance [to think about initiating ART]”.”—PN

“… I used to strongly believe that in issues where you do adherence counselling, there’s a certain length that the counsellor can go up to. Beyond that it needs a professional person.”—PN

“We have got adherence counselling, but our non- suppressing patients, their levels [viral load] are very high. Which says to you that maybe the content or the counselling that is done is not getting through to the patients.”—PN

 Limited patient ART demand creation efforts

“…people expected people will come in numbers to say, yah we want ARVs. But it’s not really happening like that because I think people are still exercising their right to choose whatever is that they want. Much as they said UTT…and then they thought the following day people will just come and say yah I want ARVs. It’s not…I don’t see it happening…”—PN

“[Uptake of SDI]is very low. I think maybe it’s our mentality because some of the patients have been tested. They know the policy said “you will be initiated after the blood results”, but now all of a sudden something came up.”—PN

 Patient and clinical readiness for ART

“No, I don’t think same-day ART initiation will work, the person has to accept that this is what is happening when he/she comes back from the clinic he/she shouldn’t be surprised… we will be able to assist him/her better than initiating him/her whilst still shocked, whilst crying. What is he/she going to do with the treatment? On the other hand, the husband tells her that he doesn’t want someone that takes a treatment. You see those kind of things? So that is no.”—LHC

“… I think that it is fine if we allow a person to go and think about taking ARVs then if he/she has processed it and feels that he/she is ready that is when they can come back and say I am ready for starting on ARVs…”—LHC

“Ask the patient to give you back the information that you have just told him/her, you will see that okay, and this person has heard what you said or he/she was not listening. That’s how I can tell that this one can initiate.”—LHC

 Excess emphasis on ART targets, need to report ART deferral reasons

“now I’m doing my stats…and if I say my positivity rate…I tested twenty and my initiation rate for the week, this week, was 35%, I will be asked, why is it 35%. What do I say? It’s 35%, I initiated five out of the twenty and there’s nothing that I can do. It’s just a name-and-shame…and whatever reason you can come up with […] what you are saying, me I always write on the Treatment Retention Acceleration Program (TRAP) the reasons, but it doesn’t change the fact that I am at 35%, so I am pulling the region down. It’s not like these things we don’t say, and sometime if you talk, it’s like you are negative, you are not open to UTT, but those are the realities that we deal with at facility level, those are issues that are there at facility level and we need to talk about them”—PN