Table 3.

Tangible Barriers to Care from the Perspectives of 11 Healthcare Providers and 51 Patients

Row	Barrier	Stakeholder Characteristics	Representative Quote
1	Cost	Counselor	If the service is free, they can come back, but if they need to pay then they have to think about…how they’re going to pay. Some are brought here by their relatives, so they need to rely on those people for them to give them money so they can come back again.
2		Patient; Female (Interview)	I did not come back when I was supposed to come back because I didn’t have money to come because they told me to bring 200 Rand down there and from there to collect my results.
3		Patient; Male (Focus Group)	It is a problem especially if you are not working and there is no one to support you financially. And even if you try to get some money at home you can see that it is not easy because it means that they must not buy food so that you can go to the clinic.
4	Cost – Not a Barrier	Counselor	Fortunately now the government is providing antiretroviral drugs. Cost is no longer a problem… if and when the time comes where they feel they have run out of funds, they can easily be transferred…to a place where they can get the medication free of charge.
5		Patient; Male (Interview)	If you have medical appointment and you know that you are going to a hospital on this date, you could budget because it’s your life at the end of the day. You can do your budget and take out things that are not necessary.
6	Transportation	Counselor	Taxis are there, buses are there, trains are there, but money to take them and those kinds of transport to the hospital or any institution. You have to have money for transport and money to pay for meals.
7		Patient; Male; 41 (Interview)	When I arrived in town, I must get a taxi from town to [the hospital]. You find that I do not have food. I only have transport money to get into the hospital only. This is the major challenge for many people. You may find that they have money to get here, but they do not have money to buy something to eat/food while they are here. He/she will wait until he/she gets home later on and cook his/her samp at home.
8		Patient; Male (Focus Group)	And at some point, there was a report that blood drawn for doing tests get lost. And we were supposed to get CD4 count test results. Then, there was a delay and we were forced to back on the following day. But we could not afford to come back…we were forced to wait for about a week because we did not have money to go back…people do not have money to go to the clinics and also to pay for the service when they get to the hospitals. You find that some people have discovered their HIV status and they have a desire to receive HIV care but they do not have money to do so,
9	Transportation – Not a Barrier	Doctor	There are numerous taxis…and buses and trains coming from every point. I don’t think transportation is a problem…I worked in a rural hospital and people used donkey carts to get to my ARV clinic, so I don’t think transportation should be a barrier. It’s just a stupid excuse.
10		Patient; Male (Focus Group)	There is a lot of transport out there and even if you have challenges of transport in your community, you know where to get transport and you know when it’s the right time to get transport. So, you can make sure you are ready and you get transport if you are serious about going to the clinic.
11	Employment	Doctor	A lot of patients cannot get time off work to come to clinic visits, to see a doctor, and our care is structured such that every month for the first three months they have to come and see a doctor. And you know, monthly clinic visits.
12		Patient; Male; 24 (Interview)	I am only free on Thursdays and that is why I am here today. I also have to attend here next Thursday…If I decide to attend on Mondays, it means that I must negotiate with my employer…if my employer does not agree or allow me to do that, it means I have to accept that…the disease would continue to affect me as I would not be getting an opportunity to go to the clinics. I have also noticed that White people undermine this disease, they do not take it seriously and they do not take care of us when we are sick. They just do not care about us. They say that if you start coughing, they would employ another person.
13		Patient; Male (Focus Group)	Let’s say you are at the clinic today and they tell you to come back next month…So, you compare the two, you think about work and you think about the clinic, then you decide not to go back to the clinic because you cannot miss work. You may think that you have missed work a couple of times in a month and then you decide not to miss work in the following month.
14	Employment – Not a Barrier	Counselor	A person comes just once a month to the clinic. Even if you are working, everybody who is working is entitled to at least one day off a month in their annual leave. That won’t be a problem. It can be a problem if the employer does not know that the person needs to come to the clinic every month. It comes back to that issue of disclosure.
15	Patient Experience: Delays	Counselor	Surely…there will be times where not everybody will get the help that they need at the clinics…because maybe the clinic is short staffed, or maybe the clinic is too busy, or maybe the people who are in the clinic at that time even if there’s not many of them but they need extra care so they need extra time to be spent with them by the clinicians or by the health worker at the time.
16		Patient; Female; 44 (Interview)	There are problems especially in the clinics. You find that you have done you CD4 count test and you have already received your results of CD4 count. However, you find that you wait for a very long time; maybe you wait for about six months, without getting your treatment…This means that the disease continues to destroy you while are waiting for [antiretroviral treatment].
17		Patient; Female (Focus Group)	At first, I came with the child and I was in the queue for a very long time and I ended up going back home without any assistance. I was also hungry and the child was also hungry and there was so much delay. So, when I came back the other day, I did not get help and they said they told me that I must return in March. It means I spent transport costs for nothing…So, there are always problems in government hospitals and medical centers where it is free of charge.
18	Patient Experience: Queues	Nurse	But a barrier in government sectors might be time spent in the clinic or time spent in the hospital…They get there very early in the morning, stay for the whole day and maybe get attention late during the day because all those places are full, always full.
19		Patient; Female; 44 (Interview)	Sometimes you sit in a wrong queue because you do not know where to sit. You find that when it is your turn to be seen, they tell you that you are in a wrong queue, and that breaks your heart. Sometimes it breaks your heart in such a way you just decide to go home and tell yourself that you will come back some other time.
20		Patient; Female (Focus Group)	For example, you may find that we are sitting and waiting in the queues, and we have arrived early in the morning, but you find that there is not even a single staff member who is there to help you… You find that the room is full of patients who are waiting and there is no one to help us… the clinic staff keeps on passing by.
21	Patient Experience: Staff	Nurse	Healthcare worker staff attitude - the negative attitude… might cause a barrier for the HIV positive people to access that medical care.
22		Patient; Female	You get [to the government clinic] and wait for the clerk to register you but they’ll sit and discuss their stories… the clerk will pay attention to a friend and discuss their stories not us. They’ll not pay attention to us… they don’t care… if there’s an incoming call, they’ll answer that, yes! They’ll answer their personal calls, talking, laughing… They’ll sit and even if another call or three calls come in while you’re standing there in front of them.
23		Patient; Male (Focus Group)	Okay, usually you go early in the morning when you go to the clinic and you wait for the whole day in the queues for help. And sometimes you find that the clinic staff is taking tea break at 9AM. And you have been waiting since 7AM till late, but you find that they are just sitting and discussing personal matters whereas we are waiting for their help… You find that you spend the whole day at the clinic but you do not get help in the end.
24		Patient; Female; 44 (Interview)	Some of the health care workers speak in a nagging way. Therefore, some people get annoyed and stop going to the clinic as they feel that they are going to deal with such health care workers who talk in a nagging way… It could be better if they can stop scolding at patients… I think the doctors should be more caring.
25		Patient; Male (Focus Group)	I think there is lack of communication between the clinic staff and patients. For example, we could be sitting and waiting in the queues and we see staff members passing by, and we do not understand what is going on… there is a wall between the staff members and patients. For example, they could only say, “next or the next patient, or they say you must wait for few minutes we have a tea break.” … It is frustrating … Sometimes, you wait for a very long time and then you decide to go back home because they are not helping you. And you do not even understand why you did not get help.
26	Patient Experience – Not a Barrier	Doctor	We have a waiting list of about three weeks now. I don’t think that that would be an excuse because getting an appointment as a first initial visit it’s a walk-in system in this clinic. So number one, that’s not a problem. And number two, is if you are on treatment here in this clinic and you do want to see a doctor then you are allowed to make an appointment to come in and see a doctor. And if you can’t, there are always government casualties, provincial hospitals, private doctors, you can go to anyone if you have a problem and you can always get advice. So not necessarily with us.
27		Patient; Male (Interview)	You cannot leave without getting help at the clinic. It never happened.