Table 6.

Facilitators and barriers to ART adherence for patients not stable on treatment or not adhering to care eligible for Enhanced Adherence Counselling or Early Tracing interventions 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 Perceive EAC to be better than previous counselling [IDI] See advantage of tracing to get missed visit patients back [IDI] Believe adherence guidelines are more structured and comprehensive than previous SOPs [IDI]	Intervention characteristics: Complexity Perceive degree of difficulty in implementing the interventions [IDI] Safety concerns surrounding tracing – encounter angry patients, only men answer the door, no transport, homes that have aggressive dogs [IDI] Design quality No social media or phone outreach [IDI]	Intervention characteristics: Design quality Having a routine clinic visit is helpful [FGD] Believe individual counselling gives privacy, educates and reassures patients [IDI]	Intervention characteristics: Complexity Challenging to trace patients because of wrong addresses and perceive as dangerous for women (can be harassed or attacked) [IDI] Challenging to recruit patients for support groups [IDI] Costs – providers use money out of pocket [IDI] Design quality ART communication material is insufficient [FGD] No support groups available for unstable patients [FGD] No social media or phone outreach [IDI] No support groups [IDI]
Outer setting: Patient needs Perceive benefits of taking ARVs [FGD] Support groups helpful because providers give inadequate attention [FGD] Perceive benefits of assigned dates to collect medication [FGD] Perceive benefits of SMS reminders for appointments and medication collection [FGD] Believe support groups, EAC and home visits are addressing patient needs; implementers emphasize ensuring patients understands the benefits of ART [IDI] Believe counsellors are now better trained and can address patient concerns [IDI] External policy Facility managers more motivated because they know they are being monitored by the district [IDI]	Outer setting: Patient needs Perceive needs and concerns not met by clinic, given inadequate information [FGD] Not aware of SMS/phone reminder system, believe that it would be useful [FGD] Dislike support groups and prefer individual counselling for privacy, not ready to disclose status [FGD] Patients complain about and do not attend support groups because of length of stay and lack of food [IDI] Challenges with tracing because patients often move or are scared to come back to the clinic because of missed appointment [IDI] Cosmopolitanism Challenges with home visits, because many other NGOs do the same [IDI]	Outer setting: Patient needs Encouraged to take ARVs and write down appointment dates [FGD] Find support group beneficial and comforting, easier to collect medication [FGD and IDI] Feel providers are attentive during medication collection [FGD] Missed visit tracing works when clinics work with community committees [FGD] Perceive benefits of assigned dates to collect medication [FGD] See benefits of counselling [IDI] Aware of why patients default: no food to take with ARVs, status disclosure, cannot come to clinic because of work or have to look after children [IDI] Peer pressure Aware of other facilities conducting home visits, believe it could be helpful [IDI]	Outer setting: Patient needs No encouragement from clinics [FGD] Perceive group counselling as not helpful, prefer individual counselling [FGD] Feel that providers do not listen to their suggestions [FGD] Challenges of tracing because of migrant populations [IDI] Have support groups but are aware that patients do not attend for many reasons: work, look after children, lack of food [IDI]
Inner setting: Readiness for implementation Access to resources and materials, training [IDI] Relative priority Recognize and believe in the importance of EAC and tracing [IDI] Prioritize patients who have been traced and return to the clinic [IDI] Goals and feedback Implementers are open to suggestions; ensure interventions work with clinic workflows [IDI] Culture Providers work with each other to help the patient [IDI]	Inner setting: Structural characteristics Perceive clinics to be overcrowded and inefficient [FGD] Challenges with tracing and long wait times at clinic because of staff or resource shortage [IDI] Relative priority Perceive clinics prioritize money over patient care, feel neglected by providers [FGD] Compatibility Challenge with integrating intervention activities into workflow, especially EAC and tracing – need to communicate interventions to patients [IDI]	Inner setting: Relative priority Perceive that if providers care, clinic will be efficient and patients cared for [FGD] Recognize and believe in the importance of the interventions, especially individual counselling, tracing and support groups [IDI] Available resources Have resources and materials to execute adherence activities [IDI]	Inner setting: Structural characteristics Challenges with tracing and patients returning to the clinic form tracing, because the clinic itself is overcrowded, cannot handle volume of patients [FGD and IDI] Relative priority Perceive poor encouragement from providers and feel neglected since initiation into treatment [FGD]
Characteristics of providers: Personal attributes Perceive helpful providers to be friendly, respectful, and who listen to patients [FGD] Beliefs Interested in interventions and value patient relationship [IDI] Implementers strongly believe in patient education at initiation [IDI] Self‐efficacy Believe providers are better trained now and are confident in executing the interventions [IDI]	Characteristics of providers: Personal attributes Perceive provider bad attitude and not interested in interventions, providers often shout at patients [FGD and IDI] Negative experiences with home visit – feel disrespected [FGD] Self‐efficacy Counsellors feel they lack training to give patients medication [IDI] Beliefs Not confident in tracing because of challenges [IDI]	Characteristics of providers: Personal attributes Perceive some providers to be considerate and listen to patients [FGD] Beliefs Believe adherence activities have been successful and can motivate patients to adhere [IDI] See advantages of tracing [IDI]	Characteristics of providers: Personal attributes Perceive provider bad attitude, providers often shout at patients [FGD] Perceive providers do not work hard or care about patients [FGD] Perceive poor quality service [FGD] Perceive counsellors as judgmental [FGD] Beliefs Not confident in tracing because of challenges [IDI]
Process: Execution Received counselling and saw benefits [FGD] Received HIV and nutrition education [FGD] Interventions executed and patients have responded well [IDI] Engagement Designated people to trace patients [IDI] Reflection Perceive SMS/phone calls and appointment cards to be helpful reminders [FGD] Perceive high quality of service at clinic, given adequate information [FGD] Perceive home visits to be helpful when the clinic is too far to collect medication, also receive HIV education [FGD] Implementers believe the intervention is constantly evolving; challenges at first but improved when AGL was streamlined into implementation plans [IDI]	Process: Execution Heard of support groups but have not actually seen them [FGD] Perceive that providers do not explain test results to patients [FGD] Intervention activities not happening according to plan [IDI] Reflection Perceive inadequate counselling, counsellors provide no guidance [FGD] Some patients do not like tracing and give wrong addresses – fear of status disclosure [IDI]	Process: Execution Home‐based caregivers visit households to deliver medications and check‐in [FGD] Received HIV and nutrition education [FGD] Received assigned dates to collect medication [FGD] Engagement Designated people to trace, do home visits, call and remind patients [IDI] Reflection Perceive interventions to be helpful and informational [FGD] Perceive benefits to receiving counselling [FGD] Attend support groups and find them helpful, would like to create one if it does not currently exist [FGD] See patients respond well to adherence activities ‐–counselling, reminders, tracing and support groups [IDI]	Process: Execution Perceive clinic visit process is not explained clearly [FGD] Patients not understanding importance of taking medication [FGD] Adherence activities not happening according to plan [IDI] Reflection Perceive inconsistent system for reminders of clinic visits and outreach, some feel clinic may have lost contact information [FGD] Perceive inadequate counselling, only received counselling once [FGD] Mixed feelings on home visits, some believe it may be helpful, while some would feel embarrassed [FGD] Patients dislike tracing and give wrong addresses and phone numbers – fear of status disclosure [IDI]

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