Table 4.

Facilitators and barriers to ART initiation and adherence for new patients eligible for the Fast track Initiation Counselling intervention under the South African National Adherence Guidelines mapped to relevant Consolidated Framework for Implementation Research constructs

Intervention		Control
Facilitators	Barriers	Facilitators	Barriers
Intervention characteristics: Design quality Importance of counselling in UTT climate [IDI] Relative advantage FTIC was identified as faster and started patients on ART earlier than before [IDI]	Intervention characteristics: Complexity Some providers conflated UTT with FTIC, focusing on same‐day ART initiation [IDI] Intervention source Confusion around intervention source especially in UTT context [IDI] Relative advantage Some believe starting patients earlier is not beneficial for treatment outcomes [IDI]	Intervention characteristics: Design quality HIV education after testing [FGD] Home visits for HIV education and testing [FGD] Relative advantage UTT makes ART initiation faster [IDI] Advantage of treating patients before they are sick [IDI]	Intervention characteristics: Complexity Complexity of UTT in some cases resulted in patients not being initiated or potential defaulters [IDI]
Outer setting: Patient needs Eager to be informed of HIV status due to knowing someone with HIV [FGD] Received encouragement from friends to get tested [FGD] Openness with partner about HIV status [FGD] Belief that everyone should not be afraid and get tested [FGD] Addresses patient challenges with transport, as fewer visits are required before starting [IDI]	Outer setting: Patient needs Misinformed about HIV testing – only need testing if ill [FGD] Fear of getting tested because of stigma and knowledge of status [FGD] Fear of initiation because of stigma and side effects [FGD] Perceive lack of counselling and neglect after initiation [FGD] External policy Belief that pressure of rolling out UTT may de‐emphasize counselling during FTIC [IDI]	Outer setting: Patient needs Perceive a need for the government to change policy regarding HIV testing – everyone should be tested [FGD] Privacy when getting tested [FGD] Reduced trips to the clinic minimizes stigma [IDI] External policy Due to UTT push, increased testing and initiation is vital to reach 90‐90‐90 [IDI]	Outer setting: Patient needs Perceive that patients are not ready to start ARVs [IDI] External policy Belief that pressure of rolling out UTT may de‐emphasize counselling during FTIC [IDI]
Inner setting: Implementation climate Received ART education [FGD] Treatment collection dates were set up for patients [FGD] Perceive that patients like”fast‐tracking” because it is important to know your status and start treatment [IDI]	Inner setting: Implementation climate Lack of ART education [FGD] Perceive the clinic to be overcrowded and have long wait times [FGD] Unfamiliarity with the intervention [IDI] Readiness for implementation Unavailable stationery for record keeping [IDI]	Inner setting: Implementation climate Received ART education [FGD] Perceive intervention as important [IDI] Fast‐tracking works hand in hand with DMD [IDI] Readiness for implementation Algorithms or guidelines are available to help with ART initiation, often provided by the district development partner [IDI]	Inner setting: Implementation climate Limited encouragement from providers to take treatment [FGD] Some direct resistance to UTT [IDI] No training for UTT [IDI]
Characteristics of providers: Personal attributes Perceive some providers to be knowledgeable and encouraging [FGD] Expressed excitement about the FTIC intervention [IDI]	Characteristics of providers: Personal attributes Perceive some providers to be unfriendly and judgmental [FGD] Self‐efficacy Low readiness and unawareness of the intervention [IDI]	Characteristics of providers: Knowledge & beliefs Believe that patients are counselled and then are ready to initiate treatment [IDI]	Characteristics of providers: Knowledge & beliefs Perceive that some providers as not well informed/not trained in initiation of treatment [FGD] Perceive that patients are not ready to start ARVs without more counselling or laboratories [IDI] Self‐efficacy Low readiness to implement UTT [IDI]
Process: Execution Received counselling and believe it is beneficial [FGD] Believe in benefits of FTIC and perceive fast turnaround from testing to treatment initiation [FGD] Received support from family members or spouse/partner [FGD] Some providers described FTIC as a streamlined process [IDI]	Process: Execution Perceive a lack of privacy during counselling [FGD] Perceive a lack of counselling after testing [FGD] Perceive neglect from providers after initiation [FGD] Influence of myths from community surrounding side effects of ARVs and misinformation about testing [FGD] Planning and engagement Unclear distinction between and insufficient training on FTIC and UTT [IDI]	Process: Execution Process of HIV testing explained to patients and they were encouraged to take treatment [FGD] Perceive counselling to be helpful for relieving stress and fears [FGD] See benefits of taking ARVs and find it convenient [FGD] High quality of the standard of care for ART initiation including existing algorithms guiding the process [IDI]	Process: Execution Perceive lack of counselling after HIV testing or have only received counselling once [FGD] Perceive receiving a lack of or inconsistent information regarding treatment [FGD] Poor execution of consultation around UTT, the new approach could lead to increased defaulters [IDI] Do not fast track new patients because of belief that baseline labs and counselling is important [IDI] Insufficient training on UTT [IDI]

FGD, focus group discussions with patients; IDI: in‐depth interviews with providers and implementers.