Table 5.

Facilitators and barriers to ART adherence for stable patients eligible for Repeat Prescription Collection Strategies under the South African National Adherence Guidelines mapped to relevant Consolidated Framework for Implementation Research constructs

Intervention		Control
Facilitators	Barriers	Facilitators	Barriers
Intervention characteristics: Relative advantage Reduced queues and waiting time [FGD & IDI] Perceive service as fast, fewer trips to the facility and more convenient times for those who work [IDI] ACs easier to manage compared to DMD and pickup is quick [IDI] Speed and convenience of DMD pickups is helpful [IDI] Adaptability Implementers able to adapt ACs – number of and types of patients [IDI] Existing ACs being aligned to the AGL – used to be collection points previously [IDI]	Intervention characteristics: Relative advantage Not all stable patients are eligible for ACs due to comorbidities [FGD] DMD not convenient for patients who desire health checks or want >1 month of medication [FGD] Risk of defaulters or data gaps as the system is streamlined between DMD and clinics [IDI] Design quality Routine collection excludes adherence activities unless patient is sick [FGD] Some confusion surrounding context of the intervention [IDI] Intervention source Challenges with the authority of implementation – clinic, pharmacy, or DOH Care and Support [IDI] Complexity Difficulty establishing cohorts early on when creating ACs [IDI]	Intervention characteristics: Relative advantage Believe reduced queues are an advantage of DMD [FGD] Found SMS reminders for DMD collection helpful [FGD] Perceive that ACs save time and money [FGD] Perceive DMDs as fast and convenient [IDI] Adaptability Believe DMD is flexible, especially if clinic has a stock‐out [FGD]	Intervention characteristics: Relative advantage Potential loss of connection between patients and providers [FGD] Design quality Routine collection excludes adherence activities unless patient is sick [FGD]
Outer setting: Patient needs Helpful for those who work [FGD] Patient privacy protected [FGD] Addresses issues of stigma [IDI] Reduces burden of distance because of fewer clinic visits [IDI]	Outer setting: Patient needs Clubs not convenient because of distance and association with HIV‐positive people, i.e. stigma, despite accommodation for all chronic medication pickup at club visit [FGD and IDI] Some desire to still have regular health checks [FGD]	Outer setting: Patient needs DMD is helpful for those who work because the hours are accessible and lack of queues [FGD] Report of dismantling DMD in favour of clubs as patients want to come in groups [IDI]	Outer setting: No codes mapped to this CFIR domain
Inner setting: Implementation climate Aware of the intervention options [FGD] Those not in ACs/DMD can be motivated to qualify through adherence; felt empowered and encourage to adhere [FGD] Perceive patients welcoming the various RPCS interventions [IDI]	Inner setting: Implementation climate Felt interventions were NOT compatible with clinic‐based services for chronic diseases such as hypertension or diabetes [FGD] Some felt not well informed about the interventions [FGD] Implementers perceive staff shortages [FGD] Challenges with resistance and buy‐in to the new interventions from providers [IDI] Difficulty of implementing RPCS in the context of other programmes [IDI] Limited available space for AC meetings [IDI] Perception that DMD was designed to chase patients from facility [IDI]	Inner setting: Implementation climate Felt the intervention was compatible with chronic diseases for patients who have diabetes, for example and still need regular clinic visits [FGD] Reports of non‐adherence to Viral Load Protocol [IDI]	Inner setting: Implementation climate Some felt the interventions were NOT compatible with chronic disease management [FGD] Some felt not well informed about DMD availability (ambiguity at control sites) [FGD] Believe that waiting a year for eligibility is too long [FGD] Concerns for patient files getting lost [FGD] Clinics are overcrowded [FGD]
Characteristics of providers: No codes mapped to this CFIR domain	Characteristics of providers: Personal attributes Some felt punished by providers if missed their appointment [FGD] Perceive bad attitude among providers [FGD and IDI] Fear that patients will default if they are left to pick up at DMDs [IDI]	Characteristics of providers: No codes mapped to this CFIR domain	Characteristics of providers: Personal attributes Some felt punished by providers if missed their appointment [FGD] Felt little support from providers unless sick [FGD]
Process: Engagement Some patients given a choice between AC and DMD [FGD] Execution Some preferred ACs because DMD only provided one month of medication [FGD] DMD generally described as an easy process [FGD] Partnerships between development partners and DOH [IDI] ACs running smoothly [IDI] Tracing loss to follow‐up is easier for clinic based RPCS [IDI] Reflection Implementers perceive need for more training at all levels of the facility [IDI] Implementers perceive lack of accountability and ownership [IDI]	Process: Engagement Some patients not given a choice between AC or DMD [FGD] Planning and engagement Early implementation challenges with DMD [IDI] DMD was not well introduced to facilities or health care providers [IDI] Multiple directorates guiding care, treatment and pharmaceutical services [IDI] No ownership of DMD by the facility staff; perceived as led by pharmaceutical services [IDI] Execution Felt implementation was going slowly [FGD] Not consulted or counselled about medication change [FGD] Some have not seen a change since the implementation of the AGL [FGD] Late or no delivery of medication at DMDs [IDI] Patients lose trust because of stock‐outs at DMDs [IDI] Perceived increase in lost to follow up because of communication gaps between facility and DMD [IDI] Illegible prescriptions and errors [IDI] Challenges monitoring DMD patients’ health and medication pickup [IDI]	Process: Execution Generally described as an easy process [FGD]	Process: Engagement Some patients not given a choice between AC or DMD [FGD] Execution Notable challenges with early implementation of DMD, including shut‐down DMD points and general problems with collecting at pharmacies (illegible prescriptions and errors) [FGD and IDI]

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