Table 2.

Barriers and Facilitators of Same-Day ART Initiation Using the Transtheoretical Change Model in Ethiopia

Stages of Change	Pre-Contemplation	Contemplation	Preparation	Action	Maintenance
Characteristics of patients	Unwilling to start lifelong ART or do not self-identify as an ART candidate	Willing to start lifelong ART and self-identify as in need of treatment	Have treatment supporters, Prepared for drug adherence	Consulting healthcare workers and has initiated ART	Adhere to ART and return for the next clinical visit
Barriers	Socio-economic factors such as Poverty, being male, young, urban, commercial sex workers (CSW), daily laborers and students; feeling “healthy”/fear of lifelong treatment and ‘psychological importance, Shocked due to the test result (emergence) and hopeless; lack of awareness (disease progression, ways of transmission, the importance of ART); mistrust the test result; fear of disclosure (stigma, discrimination and poor social support); came for other medical service and perceived fear of side effects; professionals attitude towards early ART due to fear of drug resistance, believe in one either (drug/ART or God)	Lack of understanding about HIV/AIDS and ART Demand re-test after holy water Programmatic enforcement (healthcare workers urge patients to initiate ART) Need time to absorb the meanings of the test result, “let me try holy water first”	Lack of continuous social support consult family members, need time to share the experience with fellow patients	Lack of finance for transport, drugs for opportunistic infections, treatment interruption due to holy water, demand re-test after ART along with holy water	Overcrowded clinic Persisting perceived stigma and discrimination
Facilitators	Symptomatic patients especially unexplained weight loss, risk assessment positive patients during pretest counseling, exhausting with all treatment options (traditional, holy water and modern), knew someone on ART, have a history of HIV test (due increased awareness), repeated test before initiate ART	Disclosed HIV status, agree to take both ART and holy water, aware pros and cons of timely ART initiation, improved awareness about HIV/ART	Availability of treatment supporters, understand lifelong commitment for ART	Patient-friendly clinical environment, good patient-clinic staffs relationship Availability of free ART	Stay healthy and live for others, encouraged due to good treatment outcomes
Possible intervention	Counsel and educated about the advantage of early ART initiation (further complications; help to prevent transmission to others; prevents disfiguring and reduce stigma and decrease MTCT; increase quality of life and productivity); about the immunity and viruses interaction; testing procedure; treat/address patient’s’ priority first, the special emphasis for male, CSW and students	Assisted by case managers/adherence supports/peer supporters to counsel, join HIV associations, Individualized care (give time); Use mass media to create awareness about the test and treat policy	open discussion with healthcare workers and patients encourage disclosure and treatment supporter	Access for health insurance system, encourage patients to take treatment in their locality	Policy interventions such as appointment spacing for stable patients, continued awareness creation, patient transfer out to other health facilities to their locality