Table 2.

Quotes Related to Recommended Strategies to Improve Antiretroviral Therapy Initiation and Adherence

Reducing stigma from healthcare providers and family members through education
1	“I think the change that can be made regarding collection of treatment… I wish they [clinic staff] can make them [HIV patients] stick together with the sick people and not be separated from others. Only the patient must know while sitting in the queue which side are they going to when getting inside [with] the nurses to collect treatment, without being discriminated from the outside.”
2	“I had a complaint that I raised at one clinic… When it was the day for the ART treatment collection, the patients that were coming to collect their treatment would be kept aside on their own, and those that are coming to see the [regular] doctor would be kept separate too. People of the community were complaining about that arrangement, that it did not feel right for them to be separated from the others… They were made to sit on the veranda. There was even a saying from other patients that when it was the day for the ART treatment collection, other [HIV-negative] patients would say, ‘I am not going to the clinic today because it is the day for the ART’, in an insulting manner. I requested a meeting with the [head nurse] sister… We had to tell her everything about it. In that way the issue was sorted. Now when they are coming to collect their treatment, they sit with everyone and follow the same queue like everyone else in the clinic and take their treatment without others knowing what they are there for… The clinic became a better place. Really we do appreciate the acknowledgement of that issue.”
3	“My suggestions, like raising the three fingers [to indicate that a patient is coming to collect ART], if those [staff members] that are doing it can stop, because I think it is not done in all the clinics.”
4	“The people [patients] who are already on treatment… are doing well so they [counselors] also assume that they [new patients] will eventually be alright too with the help of the homebased caregivers. I would not say all the counselors are like that but I have seen on many occasions things like that happening. That is also the cause of why people are defaulting after being initiated on the ART programme…”

Reducing competition by collaborating with alternative medicine providers and establishing HIV/ART community support groups
1	“It is bad because… the treatment does not work properly because of the traditional medicine. These traditional medicines cause running stomach (diarrhea) and people lose weight; they [traditional healers] ask people to use the syringe (enema) and they [patients] lose weight and become weak.”
2	“You will start feeling sick even after taking the ART treatment, then you will think otherwise—that ‘this is not the disease I am suffering from so let me just go and see the traditional healer so that I can be told what I am suffering from.’… When you go to the traditional herbalists, they do not advise you to continue taking your treatment given at the clinic and see as the days go by if you will be getting any better, because they are also in business—they want money. The traditional healer will tell that person that they need to perform some traditional ritual, this and that… It depends on that person, how committed is the person going to be to their treatment without getting the ideas that it is something else [causing their symptoms] rather than the disease. If the person has gotten in their minds that it is something else [other than HIV], it becomes difficult to talk to that person out of that idea.”
3	“The situations that we come across… [patients] being lied to and accepting things that they hear from people… telling you to ‘Stop taking your treatment. We are going to lay hands on you, in the name of Jesus.’ You will stop taking your treatment but after a while the sickness will come again. It does not care about laying of hands, [the] illness will be back… When others hear about the [herbal remedy] bottles, they just stop taking treatment and follow those bottles, while we have seen that the ART [medications] are the ones that are important.”
4	“If there can be some way to try and teach the traditional herbalists [and] healers that if a person is sick they need to try and tell the person the real truth that the person needs to go to the clinic. They [the traditional healers] will still get the money, even if they are telling this truth, because the patient will leave the consultation fee. They need to direct the person to the right place at the clinic and tell them to go to the clinic, they will get that little money for consultation, they should not be worried about the money.”
5	“It would be better if they [the traditional healers and church members] are educated. Even themselves they are dying of this disease—how come they are not cured themselves?”
6	“Can we not have the awareness campaigns? Where we can educate the community that has been infected and those that are not infected but [need to] be made aware that this disease is there… Just to encourage them that if you find yourself in that situation or your child is infected, you must have knowledge of the processes to be followed.”
7	“I think it would help that, [for] those that have certain [traditional] beliefs, we should have some support groups for them in the area. They should encourage each other about adhering to the treatment… It would also help [with adherence]. Maybe some patients will realize, when they see the other people getting better [on ART], those patients will realize that ‘I will also get well.’ So it would be better if they encourage each other.”

Reducing transportation barriers to healthcare access
1	“Sometimes you find that you called in the morning around 8:00 but the ambulance will only arrive at 3:30 and the person is sick. If it was someone in labour, the ambulance will arrive after the patient has given birth at home. I would please like to ask if they can keep the time, not to keep on telling lies that they are closer when they are not. You will wait and wait until the sunset.”
2	“I have a big problem… a patient that is very ill. I have to push him with a wheelbarrow to the clinic. It is very difficult for me because the clinics are too far away from homes. I see a need for a clinic car so that, if there is someone who is very ill and unable to reach the clinic, that patient should be able to get the car assistance that is going to come and fetch the patient. It becomes difficult when the patient does not have money. You do not know how you will travel with that patient. Even you [the CHW]… do not have money to hire the car to take that patient to the clinic. It costs a lot of money to hire a car.”
3	“To add on the point that was raised by my sister about the small cars… We started going to the clinic. At the clinic they said it was too much for them, the patient needs to go to the hospital… I was forced to take the last money in my pocket and stop the cars that were passing by to assist me with this patient.”
4	“If [the hospital] can assist each and every clinic by arranging some cars that are always going to be there to assist in the case of emergencies at night.”
5	“We are also having some problems on that issue of what needs to be done… Some people need to come back and collect the treatment [on] this side while working [on] that other side… I do not know what needs to be done… if you have to start and be given a letter to use [at] the other side… there are so many of them who call and ask us to collect the treatment on their behalf [at] a certain time, like after three months. And then [they] come back for a check-up. I have a problem—I do not know about the others—because I do not know how that process goes.”

Promoting patient-centered care by mitigating food insecurity and triaging patients based on socioeconomic and medical need
1	“They brought the woman here to the hospital. She was not attended to. They just made her sleep on the benches and suffer until she went to the traditional healer.”
2	“In most cases we are taught that if the person has a problem we must not encourage that person to go to the traditional healers but to go to the clinics and the hospitals. This is making us liars in front of the community.”
3	“The government, or it is the hospital, they need to get involved in the situation at the clinics. There are clinics that are not working on Saturday and Sunday… When you are bringing a person to the hospital, you need to bring the referral letter from the clinic. If the person is sick on a Saturday and you take him to the hospital, they will tell you to go to the clinic but the clinics are closed on Sunday until Monday. Some people are dying while you are taking them to the hospital, the person will die on the benches while you are still waiting because you did not bring the [clinic] referral letter. We have lost a lot of people through that process… the person can really die just because of this clinic letter.”
4	“Some patients, sometimes even if they are critically ill, the hospital will not admit the patient and you get confused about how are you going to manage at night as the patient has to go back home.”
5	“I wish when looking at the patient [that] they [could] differentiate the needy person and understand that person's situation and get involved in helping.”
6	“The clinic needs to look closer at the wellbeing of the patients, things like the background of the patients, where they are coming from.”
7	“The patient should not just be given the treatment without [the clinic] knowing about their background, not knowing if the person is coming from the bush, where does the patient sleep. They should also enquire about the children, how many children does the patient provide for in the family.”
8	“They complain to us about how they are supposed to take treatment on empty stomach. Like some are not working and not getting a [disability] grant, but they are sick. That makes it hard for them as they have to adhere to treatment, even after following all the processes. But it is hard to take treatment without eating anything.”
9	“If they [healthcare staff] are coming [to see the patients], they should please bring food parcels. The patients [think], ‘Why did they come to see me if they are not bringing something for me?’ If you are bringing something it shows the love to the patient.”

ART, antiretroviral therapy; CHW, community health worker.