Table 2 Facilitators and challenges to normalization of HTS

 Health care workers’ understanding of policy to test all patients.

“I think provider-initiated counselling and testing says that any patient that comes, I offer them HIV [testing] whether they came with headache or having whatever…” (H-010-02, nurse)

“It’s usually each and everybody, we do not say you will see this one thin. You will see this one big, but still they might have HIV. So we offer each and everybody” (S-003-01, nurse).

Targeted testing

“By their clinical pictures, physical things…another one maybe by the signs/symptoms that they are mentioning …especially when they have STIs, I encourage them to go.” (E-002-02, nurse)

Well from our wing it’s mostly initiated based on symptom, so 99% of patients who come in will have features of something that could possibly be immunodeficiency then we’d like to test you for HIV”. (H-010-04, doctor)

Lay counsellors relied on clinicians to refer patients

“If I’m going to leave my room and go promote when my line gets longer here, it means I’m still busy there and I am wasting time. And if only health promoters would promote it every day and other sister-professional nurses would promote it.” (E-002-01, counsellor)

 Lay counsellors understood HTS as their duty and were committed to providing it.

“I know how to do my work [HIV counselling and testing]. Patients sometimes don’t want counselling, but I tell them that I have to do everything accordingly…” (N-001-0, counsellor)

Clinicians (doctors & nurses) felt that HTS was not their work.

“I think doctors & nurses’ involvement would be a good thing but due to the workload we are not able to do it personally. We have a lot of patients who are waiting for us and we do have counsellors who are employed to do the HIV testing…” (E-003-02, nurse)

“We don’t keep patients who have come to test to ourselves because we have work to do. The counsellors are there for testing and if we take the patients they will have nothing to do”. (E-003-02)

 Division of roles

“As I told you, we do assess patients and then we offer [HTS], if the patient agrees we send them to the counsellors, and they test and counsel them.” (S-001-01, nurse)

Clinicians not providing HTS even when lay counsellors are nor around

“We knock off at 2 and you find that people come to the clinic to test knowing that the clinic closes at 4 pm. When they get here they are told that the counsellors have left…” (N-003-01, counsellor))

Low compensation of counsellors for the work.

“Thing is we counsellors in the hospital we are called “volunteers”, so you can’t cover a volunteer. We are doing this because … I love what I am doing but I won’t stay in this profession for long, I am still looking for greener pastures”. (H-001-01, counsellor)

Limited HTS workspace

“We always have test kits. Every Monday the nurse orders test kits for us. We have everything except the working space.” (N-001-01, counsellor)

We don’t have enough working spaces. We only have 1 room to test the patients and there is always a queue that side”. (E-002-02, nurse)

Long queues and huge work load

Remember you can get 5 or 10 patients at a time, isn’t it? Now there’s 1 counsellor, they can only see 1 patient at a time, then the patients get irritated” (H-010-02, doctor)

 Emphasis on need to test all patients to prevent stigma and discrimination

10-1: It is easier to get people to agree when they see that everyone is going, it is not just me who’s being picked saying no you must come and also this picking…obviously it’s stigmatizing so the person will wonder, why me, (Hospital doctor).

HTS lower priority compared to patient’s reason for visiting clinic

“You keep thinking that now if this patient goes there he’s going to spend 15 minutes then maybe I’ll also send him to X-ray that’s another 15-30…then you say no no….this one [HIV testing] can wait.” (H-010-02, doctor)