Table A1.

Additional illustrative quotations.

Themes	Illustrative quotations
Learning by doing—facility context	When we went to those facilities, what we had in mind changed because each facility is unique (PrIYA FGD 5, participant 4). Judging by our clinic flow currently and how it's working, I think sitting down and discussing how best we can also make it work for PrEP. So we will have to redesign some of the things because we go back and see is this working, is this working…. So how can we best accommodate them [PrEP clients] into the clinic that is already in existence (POWER Johanessburg, IDI 3).
Learning by doing—dispensing	Initially when we started, we would write the prescription, and then we let them go and pick the medication from the pharmacy. But being a facility that was seeing so many patients and [because] that pharmacy was the pharmacy where we also had people living with HIV [getting ARVs]…most of the time the queues would be long. And when you sent the young woman for PrEP there, they would, like, take more time. … The second [issue] is that the staff … in the pharmacy felt like by them dispensing PrEP, we were adding them more work, and they were not really comfortable to dispense the PrEP. And so we decided that we'd let the nurse or the clinician prescribe the medication and also dispense the medication….[W]e would keep the drugs in the pharmacy, but in the morning when we open the clinic, we would take enough for that day (POWER, Kisumu IDI 17).
Learning by doing—counseling on risk assessment	The feedback we were getting was that people were quite resistant to being told they were at risk. And that is something I can totally relate to. I would hate it if I went somewhere and someone told me I was at risk based on my behavior. Like, “Excuse you?”…. But I think that we spent a lot of time thinking about how to change that narrative…. And so I think we learned a lot about how to talk about risk (POWER, Johannesburg IDI 10).
Concerns with PrEP encouraging promiscuity	Because PrEP is associated with issues of sexuality, there is always this concern about how we are promoting promiscuity. “Are we encouraging people to have sex?” (POWER, Kisumu IDI 13). And to many people, they are thinking if you are making this PrEP available and so effective in preventing HIV, you are saying to these women to be promiscuous. … But we try by all means to advise or show them that … we are not saying people should be reckless because they are on PrEP (POWER, Johannesburg IDI 11).
Concerns with PrEP encouraging promiscuity negatively impacting service provision	[W]e find some clinics where have . staff who believe strictly that some things are meant to be done when people are adults or when people are in marriage and should [not] be done at some other time—so for this kind of staff, they will not be open to giving the young women whatever they need. If they see a young woman coming maybe for family planning, they will be like “Why are you here? You are supposed to be in school. You are supposed to doing something else.” And that discourages young women from interacting with them (POWER, Kisumu IDI 17). …[L]ike I have seen whereby a nurse…a female nurse, now feels like she is the mother to this girl and she is seeing this girl is now promiscuous, she becomes so annoying, shouts at her and when such a thing happens you find that the girl is scared and tends to stop opening up anymore (PrIYA, FGD 2 participant 5).
Conflicting personal and professional values and beliefs	To some of us health workers we tend to believe that sex should begin at a given age such that when we encounter maybe an adolescent who is 15 years of age in need of PrEP, we start doubting whether it is true or not, we tend to [project] our own beliefs on that client. So it is high time we need to change our attitude so that we get to know that some of the adolescents, actually they have early sexual activity, their sexual activeness starts very early (PrIYA, FGD 6 participant 2). Some staff have values, you know, “Maybe I'm not supposed to offer family planning because I'm a Catholic. Catholics are against this” (POWER, Kisumu IDI 8).
Fostering motivation: focusing on the longer term	I even say to them [providers], ‘You remember we are trying to curb the spread of HIV, and people you are seeing for ART, you know, the number would be less if we now had this prevention option of PrEP. So we are working toward the same goal (POWER, IDI Johannesburg 11).
Fostering motivation: professional expectations	I started going [to trainings] with the policies, so I could be like, ‘This is a policy. It's just not widely disseminated yet.’ … [Providers] often say they want to see the research, but that's not quite what they mean. They want to see the legitimacy. … This is approved by government. This is something that we're now providing that's been legitimately approved, like it's been regulated by SAPRAA [Southern African Pharmaceutical Regulatory Affairs Association]. …. There have been studies that shown us this, and it's been regulated and approved by government and regulatory bodies around the world (POWER, Johannesburg IDI 10). …. [I]t comes down to things like personal motivation…. I think there are other staff motivational issues that can be put into place even if you can't influence the actual salary change. So that even if they provide this additional service that they may feel is onerous and is taking up our time and is an additional responsibility for which I'm not paid, then it's looking at “what are you here for?” You're here to provide a service. Now what is that service? That service could range from PrEP, to contraception, to ARV treatment, to putting plaster of Paris on broken bones, to whatever else. So helping them appreciate what they are doing and then helping them recognize they're appreciated for what they are doing. So that they also feel that they are important and that what they are doing is contributing the overall goals of the country, of the region, in achieving better health (POWER, Kisumu IDI 13).
Fostering motivation through seeing value to the community	People would argue, “Why give the medication? That one is promotion for promiscuity.” But it reached certain levels where people were seeing the importance [of PrEP] because the clients themselves were coming for it… And when we saw them coming, we got to know, “Oh! So this thing is very important to the people.” It is not important to the providers themselves. Those who consume it are now coming more and more, and they were really in good numbers. So that is the time we realized this is very important. …. [W]hen we were in training, we were also worried…. “What will people perceive about the PrEP?” But we came to realize that people are in need of it fully (POWER, Kisumu IDI 9). I'm sure at some point for them [HCW], they felt quite helpless as a helping professional. You know, you're trying to bring about a positive change in this person and to decrease the amount of risk that they are faced with. But there's really not that much that you can do. But PrEP sort of gave them another gateway, you know, to help these patients to take PrEP (POWER Johnaessburg, IDI 6).
Fostering motivation through continuing medical education	At initial stages people were a bit skeptical [about providing PrEP] and I think it was mainly with relation to what …they thought, that this would lead to more maybe promiscuity and you know the reserved cultures that maybe the hospital is [in], the catchment area, so they thought maybe it would lead to promiscuity. But again after the sensitization and the CMEs, they discovered that that is not the case, yeah so they gained a better reception after they got the information, yeah (PrIYA, FGD 8, participant 1).
Fostering motivation through highlighting professional values	[E]ven if it is an adolescent and the rest of the age groups we should treat them as clients so we should not impose our values on the patients and then as health care workers we should think that this is a preventing measure so what if you don't give this patient the preventive measure then now the client turns to be positive so it is better to prevent than to treat yes (PrIYA, FGD 6, participant 1). …[I]t is up on us as the health workers who are at those various stations [FP/MCH clinics] because the reason as to why we are here is to give quality service to our clients and all of us want to help in reduction of HIV prevalence in our country isn't it? So it is up on us to change our attitude and maybe not to wait for support supervision [laughter] because you know we always know the right thing that we should be doing there yeah… So it is upon us to embrace the new intervention that has come and give good services to our clients (PrIYA FGD 06, participant 2). My advice to them [reluctant HCW]is that they should just call a spade a spade and because they are tasked with the duty of giving service to mankind, they should just talk about PrEP, talk about sex and talk about everything, not hiding any information from the young women so that they see the light and follow the light (PrIYA, FGD 1, participant 4).
Fostering motivation through emphasizing social realities and professional role	The thing I'm seeing is that sometimes it's difficult for them to negotiate condom use. It's also difficult for them to say “no” to sex because sometimes they are forced into it. So I thought it [PrEP] was a really good idea (POWER, Johannesburg IDI 05). The thing that had the nurses embrace [PrEP] is just because we were dealing with the same group of people, because there is no way a girl can come for family planning and you are offering PrEP at the same time and not talk to her about PrEP. That was not fair because this girl has come to see me, so a girl has come to seek family planning and also she wants to test for pregnancy …. So it is just unfair that I will go, provide her with the [family planning] methods and not talk to her [about PrEP]. ….if someone is coming for contraception, it means that they are sexually active. She does not want to get pregnant, but what about HIV? So it puts you in a situation where you really need to talk to her about the need for her to be protected against HIV, and protecting yourself against HIV, that is giving PrEP (POWER, Kisumu IDI 01). My [initial] concern was that it [giving PrEP to AGYW] was like we were promoting promiscuity, like we were giving them a room. But later I realized that it [risk behavior] is still there, despite the fact that we are denying them [PrEP] … They will not stop [change their risk behavior] because you think they should be stopping (POWER, Kisumu IDI 5). It's mostly, the decision of a partner more than their decision, to use it [condoms] or not to use it. Because, if the male partner doesn't feel like using it, that means that the condom won't be used even though sex is gonna be happening….So it was quite a nice thing to hear about, and then I strongly felt that it's a good thing for them to have power on their hands as well so that they can their own informed decisions…and be in charge of their sexuality or sexual life as well (POWER, Cape Town IDI 3).
Fostering motivation through empathy	Because if you have people that pull in a different direction, that makes things difficult for you. But once people [are] of one in mind, and one in, “this needs to be done”, then it can be done. Most of them [HCW in our studies] are living in the townships…. So they knew also the risks in the townships. For me coming in to the township, and my findings as in, so many girls testing positive and so many girls [are] coming for contraceptives, and so many stories we hear. That was for me a driving force. So it was really, we can actually save someone here, that was the thing, we can actually save someone. ….So the reality for me was also evident, I could see that this can make a difference into someone's life (POWER, Cape Town IDI 10). What I know about PrEP now has really changed my—is it attitude. The way I viewed PrEP before is not the way I view it now, because now I understand we don't want our young people to get infected because they are the future generation. HIV has been like “God, so what do we do?” So if something can be done to protect this young generation, to me it is a plus. … I am happy, and now I can be more involved because now I understand what it is all about, and I cannot be judgmental. You know, before I was like, “You are giving [PrEP to] which people?” But now [I feel] it can even help your own child (POWER, Kisumu IDI 04). … I have family members who are HIV positive, that also has an influence of me, making things easy for myself to actually deliver PrEP because, my goal is to have an HIV-free generation…. I always tell stories that are happening because I am part of the community. I've been in the township; I know exactly what is happening there. …I always reference from what's happening in the township, and then uhm I think also they can relate to that, and uhm, it kind of flows. …And nobody wants to have HIV so, people want anything that is going to prevent them from getting HIV. And for now we have PrEP and it works (POWER Cape Town IDI 6).