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Table 1 Emerging themes from the study findings, interviews with HCPs and patients

From: The comorbidity of HIV, hypertension and diabetes: a qualitative study exploring the challenges faced by healthcare providers and patients in selected urban and rural health facilities where the ICDM model is implemented in South Africa

Theme Sub-Theme Illustrative quote
Under-resourced facilities - Lack of staff
- Slow delivery of services
- Medication not delivered on time
- Poor information provided to patients on chronic disease prevention and management
- Lack of HIV and chronic disease support programmes
“Sometimes the facility itself would be packed meaning that you don’t have enough time to spend with one patient; you have to rush the queue … another thing is that sometimes we have problems with shortage of drugs especially chronic medication like for hypertension and diabetes”, professional nurse, EC.
“At the clinic, they didn’t give us enough information about how to live correctly with this condition”, P8 EC.
“There is no such programme here that helps people with comorbidities to manage … maybe it’s still coming but not yet”, P2 GP.
Lack of training and guidance on chronic care delivery - No provision of training for HCPs on HIV and chronic disease treatment and care
- HCPs unavailable to attend training on integrated chronic care
“To be honest with you, nurses don’t always have the time for refresher courses because most of the time hospitals are short-staffed”, professional nurse, EC.
Lack of standardisation in adopting the guidelines for chronic care integration   “HIV falls under the chronic part … so the nurse in chronic will see that client in totality, so she won’t get from chronic to another place [a different department]” professional nurse, EC.
“Somehow chronic care is not yet too much integrated into the government sector because I remember asking another patient why she had another date for another treatment … you find one condition [i.e. HIV] is handled by the other [referring to one nurse/clinician] and one [other condition i.e. hypertension] also handled by the other [a different clinician/nurse]”, Dr, EC.
“I get my hypertensive medication and ARVs from two different nurses … I am travelling in between different institutions now because I was transferred to Bara because of my hypertension. And it got controlled, so a month ago, when I went for a check-up, it was down. So, I was transferred back to Bheki Mlangeni for my Anti-Natal Care (ANC) and hypertension. And then, for my ARVs, I go to Chiawelo clinic … I would love to go to one facility for everything”, P12 GP.
Non-disclosure - Non-disclosure of HIV status
- Stigma
- Treatment default
“It’s disclosure when a patient has not disclosed it becomes difficult for them to cope with two conditions … for example, I am here and I test positive, I have stress, my hypertension becomes uncontrolled whether I am taking treatment or not; the fact that I am stressing is not helping … so disclosure is a problem and it also affects adherence”, professional nurse, GP.
“I haven’t told my husband about my illness … there are already problems in our marriage; it will torment us even more”, P7 EC.
“There is this cousin sister of mine staying at Jabulani Township; I went there to tell her about what I had found out and she said ooh! as though shocked but then we spoke, she advised me that you are like this, you need to take the treatment. Furthermore, she said I must buy myself food and eat. But then after, I heard that she went around speaking about me behind my back. That hurt me very badly but I told myself, oh well it’s okay; it doesn’t matter … You know what makes a person afraid is that when you tell someone,then, that very someone goes outside and talk about you, it’s how they say it and they laugh”, P2 GP.
Polypharmacy - Difficulty with taking more than one treatment
- Pill burden
“They feel like they can be off the medication; they decide which one is more dangerous between HIV and hypertension. Oh! It’s HIV … So they only want to take the treatment for HIV and not the other treatment”, professional nurse, GP.
“When you start combining another condition, they become discouraged … I mean I was starting to comply with this one and now you are coming with this other one … when you start introducing something else and adding more pills, they feel like argh! I have lost the battle so why do I have to …, registered nurse, GP.
“Well, it is difficult … you should always look at the time; at a certain time, you must take the pills … For example, I must take pills for BP then at night, I must take pills for HIV every day at 20:00. So, it’s that thing that the time must always be on mind and guard that I don’t drink pills late or early”, P4 GP.
Poor knowledge of treatments - Names of treatment taken
- Understanding of chronic medication
“90% of patients do not know their treatment … The hypertensive and DM patients … they don’t know their treatment … its now easier with ARVs because there is regimen one and regimen two so we found an easier way of asking them by saying if they take one tablet at night or two, that is, in the morning and evening … which is the difference between regimen one and two, Dr. EC.
“They don’t understand the term chronic; they think that after they have taken treatment for a month and then they come for a check-up … you will tell them that they are fine and stable then they stop taking medication”, professional nurse, GP.
“I don’t know their name; I just drink pills”, P9 EC.
Relocation of patients - Moving from clinic to clinic “Most of our patients are taking medication where they are not staying; the people we are serving are not from this area. Most of them … they are from another community”, professional nurse, GP.
Socio-economic issues - Access to health care
- Long travel distance to the hospital
Some patients will tell you that I don’t have food at home and don’t even have money to go fetch that treatment at the hospital so mostly it’s social factors”, Dr. EC.
“The clinic is far; worse, there are no forms of transportation here. We are in rural areas. It is not a walkable distance and I have a leg problem”, P10 EC.