Table 2.
Summary Themes Identified from the Focus Group Discussions with Health Providers
| Major themes | Subthemes | Representative quote | |
|---|---|---|---|
| Barriers to ART for all patients, regardless of sexual orientation | |||
| 1 | Information and AIDS literacy | Lack of knowledge on HIV prognosis, ART, and ART adherence | “When you tell somebody that they have a low CD4 and they have to take medication, they do not understand, because it does not align with what they are saying out there…” (Male clinician, age 28 years) |
| Belief in traditional medicine | “… There are those who have gone for faith healing, others are using herbal medicines…” (Female clinician, age 47 years) | ||
| 2 | HIV stigma | Delayed health seeking | “They really have a lot of stigma, and I think they fear to come out” (Female clinician, age 53 years) |
| Irregular clinic attendance | “You want to go the hospital but you do not want to say where you are going, so you end up missing your visit” (Female clinician, age 45 years) | ||
| Lack of disclosure and psychosocial support | “If there is no disclosure you cannot adhere… You may take the drugs late, or even forget, because you fear your partner might see” (Female clinician, age 45 years) | ||
| 3 | Economic challenges | Inability to afford transport, nonsubsidized medical expenses | “Sometimes they have money to come to the clinic, sometimes they do not have and they miss their appointments” (Male clinician, age 28 years) |
| Lack of adequate nutrition | “In terms of nutrition, sometimes they get supplemental food, but when the programme stops, they come to you and say ‘how can I take this medicine, and I have not even been able to get breakfast, and even lunch?’” (Female counselor, age 43 years) | ||
| 4 | Mental health and substance abuse | Overcoming severe anxiety, guilt, and depression | “I think it is because of desperation, some of them do not have money, they do not have anything so they resort to taking drugs, which helps them feel good about themselves. The drugs themselves: when they overdrink they forget to take their medication, they forget to come to the clinic, they do not keep the time, and so will not be doing as well as per the treatment” (Male clinician, age 28 years) |
| Forgetfulness | |||
| Barriers to ART adherence considered specific to MSM HIV patients | |||
| 1 | Biased clinical environments | Lack of MSM friendly services | “Many had complaints about the staff and how they treated them and this is what had made them default” (Male clinician, age 59 years) |
| Provider inaptitude | “Another issue is that they are not certain; they do not know who is a good person for them, who will understand them” (Male clinician, age 59 years) | ||
| Secondary stigma | “… we were told to be careful because we were going to be beaten for supporting this group” (Female clinician, age 47 years) | ||
| Lack of structural support | “…there is that mentality, especially from the administration, that these people, it's like they are sinners, they are evil, they have done all the evils they should not be getting services from here…” (Male clinician, age 35 years) | ||
| 2 | Prejudiced patient–provider relationships | MSM-related stigma | “… Initially I was very against them, because I wanted them to change and be the right way, you know?” (Male clinician, age 37 years) |
| Anticipatory stigma | “We see sometimes almost 200 patients, and we are so busy… you know they do not have labels on their foreheads… and if I tell you that you are being out of line, it is not because I have phobia… Do not start using words like homophobia with me, there is no place that you will go to that does not have rules, you know?” (Female clinician, age 47 years) | ||
| 3 | Impeded access to social and financial capital | Economic challenges secondary to social ostracism | “…For those who openly say that they are MSM, you find that they have many challenges. For one, they cannot move out during the day because… some have weaves, have plaited their hair, have nail polish… you know the way they present themselves, they cannot walk freely daytime… you find that when they are out doing their work, they are arrested, they are harassed, so on and off they are in prison…” (Female counselor, age 39 years) |
| Unsustainable expectations of support from health workers and facilities | “They also say that taking ARV's on an empty stomach is hectic, so they would rather not take them. And they tell you that if you give me food, I will eat and I will take them, but if you don't, then it is difficult for me to take them” (Female counselor, age 39 years) | ||
| Interventions to improve care | |||
| 1 | HCW sensitization | HCW training | “…through training you come to feel, you come to understand them, you come to understand their suffering… at least you know, what are the things they are getting out there, what are the things that are making them not swallow these drugs, what are that things that are making them not to attend to the clinic, what are the things that are making him, sometimes come in annoyed, so you feel that you want to know more” (Male clinician, age 35 years) |
| Structural support | “The administration is also important … our bosses should be called, and be informed, be educated…” (Male counselor, age 35 years) | ||
| 2 | Peer navigators | Peer mentorship | “To support MSM adherence, I think you need to use an MSM doing pretty well to support the others” (Female counselor, age 36 years) |
| Support to HCW | “We have an MSM peer working with us, sometimes they call him and he calls us” (Female clinician, age 53 years) | ||
ART, antiretroviral therapy; ARV, antiretroviral; HCW, healthcare worker; MSM, men who have sex with men.