Study setting.

The study was conducted in nine primary care facilities in Johannesburg. Johannesburg is the economic epicentre of South Africa and has a population of 6 million. It is home to approximately 677,500 people living with HIV, with an adult HIV prevalence of 16.4% [20]. The initiative was implemented in 3 of the city’s 7 sub-districts. The facilities had an average monthly total remaining on ART ranging between 750 and 32 000 (DHIS,2023). Implementation sites were purposively selected based on the health facilities’ expressed interest, while ensuring a mix of both large and small healthcare facilities distributed across the three sub-districts. The implementation started with meetings to engage leadership at facility, then moved on to training the appropriate staff members.

Characteristics of individuals involved in intervention delivery.

Knowledge and beliefs about the initiative. Most providers demonstrated good understanding of re-engagement in general and the initiative tools and job aides in particular. Additionally, most healthcare providers had strong personal beliefs on the importance of re-engaging clients into care. Participants recognized and empathized with the reasons for client disengagement, acknowledging the complexity of this issue, often involving interconnected barriers. Healthcare providers, especially retention counsellors, were sympathetic, highlighting that clients typically do not plan to disengage from care; instead, various life demands and circumstances, like providing for their families and managing other unrelated health issues, make it challenging for them to stay engaged.

There are patients that are lost to follow due to not having a steady income, the ability to meet basic needs (food and transport money to come to the facility). Retention Counsellor

Furthermore, all cadres of healthcare providers recognised that unplanned travel and the lack of flexibility of clinic services sometimes made it impossible to attend appointments. The geographical distance to healthcare facilities, coupled with daily work commitments, was highlighted as an additional challenge that some clients go through:

And also, the clinic doesn’t operate on weekends because they are at work during the week, some will say that they would have come if the clinic was open on weekends, they have reasons. And they will come to the clinic, and we will make them wait last in the queue because they have disengaged, and they end up getting bored and leaving the clinic without getting the assistance that they need.

Retention Counsellor

This understanding of the complexities of client disengagement motivated some healthcare providers to commit to implementing the initiative.

However, some participants noted negative attitudes among other providers, expressing concerns about confrontational behaviours when clients missed their appointments which discouraged clients and affected re-engagement:

There are those who never got fair treatment, I mean by the clinicians or any of the staff, some might feel like they are being judged.

Data Clerk

There were healthcare providers who had negative attitudes towards re-engagement and believed it negatively impacts HIV care provision overall. Some felt that it disrupted services, as stated by this clinician:

…my workload is still going up … it means now I have these 5 patients that I was not expecting and those that were scheduled for today, and those are the patients that complain.

Clinician

Additionally, some clinicians showed a patronizing and blaming attitude towards clients, at times describing clients as "dishonest and uncommitted". There were instances where participants felt that clients did not give the same level of importance to their health as healthcare providers do. Some participants expressed the perspective that clients displayed a lack of commitment, suggesting that clients might be intentionally late or inattentive to their appointments, which was seen as a form of disregard for their own well-being.

They [patients] don’t take it as important as the health providers. Because remember when someone wants to be late, they will be late which is being ignorant on their part.

Clinician

Moreover, some clinicians expressed discomfort with prioritization of re-engaging clients, as it disadvantaged those who adhered to their appointment schedules. As one clinician lamented,

But the thing is, the priority that the system says we must give them is the thing that makes me angry because these people decided to stop medication, now they’re coming back. They have liked to be seen first before those people who are here on the due date for their medication. That’s the thing that makes me angry. They said if they’re here, you must welcome them back with open hands. No, that is fine. But they must not be in front of those people who have been on treatment and not missing their medication.

Clinician

Although the re-engagement forms were created to assist clinicians with developing a management plan, record keeping and standardising care, they also had the unintended consequence of clinicians using the forms to threaten clients experiencing challenges. For these clients, clinicians hoped that the documentation served as a wakeup call to address their adherence issues. This sentiment suggests a confrontational attitude in the interactions between clinicians and clients.

But now I have the tool that I use to defend myself and the medication to say if you have missed 14 days, I must write you down and give the names to the superiors. Then you know why they do this. Ah, okay. I’ll never do it again. I’ll never do it again. And then again after that, you remove it. Yes. And paste it in their file clip it on the file and then say you, I’m in trouble.

Clinician

Self-efficacy. Clinicians and data clerks indicated confidence in their ability to use the job aides and tools. This was an important factor facilitating delivery of the initiative with fidelity.

Characteristics of the intervention.

Perceived impact of initiative. Some clinicians acknowledged the usefulness of the job aides and re-engagement forms in promoting standardized care, reducing variation among providers, and enhancing quality of care through proper documentation. Additionally, they believed that the job aides helped to make the correct care choices and improve overall healthcare delivery. The job aides were described by some participants as providing healthcare teams with a defined methodology to identify and implement clinical decisions.

As I have said that SOP-9 [re-engagement initiative] acts as a guideline in terms of how to go about approaching and assisting the patient and also you go in-depth with the patient because it gives you a margin on what information you can ask from the patient. You get to [discuss] other challenges that you did not see before you use the SOP-9 [re-engagement initiative].

Clinician.

Relative advantage. The majority of healthcare providers perceived the re-engagement initiative as advantageous compared to existing processes. They noted its structured approach to assessing clinical conditions and the time elapsed since a missed appointment, as well as its ability to tailor follow-up management, including faster access to MMD and less-intensive DSD models, essential for achieving the last "95" in the "95-95-95" goals. The job aides empowered healthcare providers to target their clients’ specific challenges, providing a clear direction for improving service quality. Recognizing the initiative’s value and its potential benefits motivated them to put it into practice. These providers believed that the tools enhanced the quality of care they could offer to clients, aligning with broader national goals for re-engagement and retention in care. As one clinician shared:

…for me it’s helpful and I do not see it as any addition to work. I think it impacts positively on the facility and my work because for me it makes me happy to see that people do come back and they remember that we are here to serve them.

Clinician

While acknowledging certain advantages of the job aides, some clinicians perceived the re-engagement forms to be a disadvantage, not providing as much benefit compared to traditional working methods. They stated that the initiative, especially the re-engagement forms added minimal value and increased their workload, extending waiting times due to redundant recording of information, thus negatively impacting quality of care.

…it adds more work, the form itself- it’s a problem because I spend more time with a patient that is being re-engaged. Although it does make everyone be managed in the same way, it also adds another aspect of workload. And we are saying we want people not to spend more time at the clinic but also with this paperwork we are making them stay longer-

Clinician.

Inner setting.

Leadership engagement, tension for change, and relative priority. Engagement of the facility manager or another high-level representative was ensured before initiating the project. However, it was reported that scheduling time for leadership teams to meet, collaborate effectively, and communicate decisions with the facility staff posed logistical challenges. It was observed that managers were not actively involved in re-engagement services, creating an environment that was not conducive to the adoption and implementation of the initiative. While there was a sense that most facility leadership were generally supportive, they tended to take a hands-off approach, leaving clinicians responsible for implementation. This approach had a negative impact on the tension for change (the degree to which stakeholders perceive the current situation as intolerable or needing change) and the prioritization of the initiative for instance, some healthcare providers expressed uncertainty about how services would align with existing systems, as they felt that the new requirements contradicted the previous operational methods. Greater alignment could have been achieved if leadership had taken a more proactive role in driving the process.

The facilities that adopted the model and recorded positive outcomes were characterised by highly engaged leadership, highlighting the impact of engaged leadership in successful implementation.

Compatibility. The initiative’s compatibility was a complex issue, serving as both a facilitator and a barrier to implementation. It was discussed as aligning re-engagement efforts with various factors, including client needs, clinic goals, and existing workflows. One of the key facilitators identified, especially emphasized by non-clinical providers, was the potential for addressing treatment literacy. They highlighted that comprehensive counselling as part of the initiative had the potential to enhance clients’ understanding of treatment, ultimately leading to improved outcomes that aligned with the goals of the facility.

However, another group of participants raised concerns about the impact of the additional documentation (especially the re-engagement forms) on the client experience, including longer waiting times. The additional documentation requirements which were said not to be integrated into existing processes, coupled with a shortage of healthcare providers and high volume of clients, led to an increased workload and complication in client flow. Participants reported that the process of completing forms required considerable time and effort, which resulted in extended waiting times. Moreover, the documentation process was reported as a duplication, highlighting a lack of integration. According to one clinician:

It’s a burden because if you have six patients that you normally see a day and they take about 18 minutes, with this form of engagement it can take an hour-

No, initially I started, I tried to, but I realised the distraction which came with it and how I was losing time at that particular time, and I stopped to say that this is just a repetition of the guidelines.

Clinician

Participants emphasized the importance of maximizing existing tools and resources. They discouraged the introduction of additional forms for completion and instead advocated for the efficient utilization of the tools already at their disposal, despite these not being designed to support or document re-engagement processes. Additionally, some clinicians recommended that forms should be handled by other healthcare providers, such as data clerks, to distribute the workload and enhance efficiency. This approach would allow clinicians to prioritize direct client care. However, this suggestion overlooks the responsibility of clinicians in record completion, as well it the role of structured records in guiding clinical management.

…have someone who is responsible for gathering or collecting for follow up purposes, whether it’s the retention officer or someone else because all these files end up with one person–the data capturer… find how the data capturer can help so that you can capture all the right information.

Clinician

Readiness for implementation—Available resources and access to knowledge.

Training for the implementation. All selected facilities were provided with training by clinician mentors who received train-the-trainer training. Reactions to training were mixed. Some healthcare providers wanted more information to manage and respond to client needs. They emphasized the need for ongoing training because the HIV environment constantly evolves, necessitating continuous updates to stay current.

More training but not so much training but in-service training. I am not saying that we forget what we have been taught but we just need re-emphasis on things like things keep changing. We just to be kept up to date with everything.

Retention Counsellor

In addition, the providers mentioned that there was limited training coverage in some instances. Most of the clinicians and data clerks receiving training, however some of the retention counsellors did not.

Resource availability. Staff shortages were also raised as a challenge to successful implementation. Participants described themselves as being overworked by the introduction of new initiatives.