“It’s not easy, but we need to support them so they don’t get tired on the way”: provider perspectives on delivering HIV services for people returning to HIV care in Cape Town, South Africa

Abstract

BACKGROUND: People living with HIV who interrupt treatment often face challenges when re-engaging in care and remain at risk for future interruptions. Understanding the provider perspective on the healthcare context in which re-engagement occurs is essential for designing effective and scalable support interventions. We aimed to characterize the implementation context for re-engaging in HIV care in Cape Town, South Africa, with a view to inform the design of future interventions in this setting. METHODS: We conducted semi-structured in-depth interviews with nurses (n = 5), counsellors (n = 3) and administrative clerks (n = 3) at two public-sector health facilities. Data collection and thematic analysis were guided by the inner setting of the Consolidated Framework for Implementation Research (CFIR), including structural characteristics, organizational culture, relational dynamics, and communication. RESULTS: We identified compounding and interconnected challenges within the CFIR inner setting. Limited staffing and fragmented clinic organization contributed to delays and frustration for both clients of HIV services and providers, reinforcing negative client-provider interactions. Despite valuing person-centred care, providers struggled to uphold these principles amid high workloads and systemic pressures relating to physical, information system, and human resource infrastructure limitations. Additionally, a cross-cutting theme was the challenge of inter-facility transfers, driven by geographic mobility and stigmatizing clinic interactions. Difficulties in linking client information across clinics intersected with the structural and relational barriers, adding another layer of complexity to providing supportive care for people returning to HIV services. CONCLUSIONS: Providers in this context were empathetic but layered inner setting barriers made it challenging to provide person-centred care. Addressing these challenges requires interventions that not only accommodate the changing life circumstances of people living with HIV but crucially facility- and system-level changes to support the providers and their working environments, which together will foster strong reciprocal client-provider relationships. Future interventions must prioritize strengthening staffing and workload capacity, physical infrastructure, and information systems alongside simplified, responsive service delivery models to ease the path back into care for people living with HIV and their providers.