Factors influencing the implementation of a guideline for re-engagement in HIV care in primary care settings in Johannesburg, South Africa: A qualitative study

Re-engagement, which involves bringing individuals who have fallen out of HIV care back into treatment, is important in the ongoing care of individuals with HIV, especially in regions with high prevalence and resource limitations. Despite extensive treatment programs, a significant number of people living with HIV in South Africa disengage from care due to different barriers. To address this, the South African Department of Health (DoH) introduced guidelines to support re-engagement. However, while there is a lot of research on factors leading to disengagement, there is a gap in understanding effective strategies for retaining those who re-engage. The objective of this study is to understand the barriers and facilitators influencing the adoption and scalability of strategies for re-engagement in HIV care. Anova Health Institute, in collaboration with the Johannesburg district DoH, launched the Re- engagement Initiative. This initiative aimed to help healthcare providers better understand and implement re-engagement guidelines through capacity-building, clinical decision support tools, mentorship, and data collection. We conducted a qualitative study across nine primary care facilities in Johannesburg to investigate the perspectives of implementing providers. Data collection involved in-depth interviews using semi-structured guides. The Consolidated Framework for Implementation Research (CFIR) was used to analyse factors influencing implementation. Our study identified several factors affecting the implementation of intervention supporting re-engagement guidelines. Leadership was important for driving organizational change, creating the necessary tension for change, and prioritizing the intervention. Knowledge and beliefs about the intervention were also significant; while most providers understood the initiative's objectives and tools, negative attitudes among some hindered adoption. Empathy for client disengagement motivated some providers, while others did not share this understanding. The belief that job aides and re-engagement forms promoted standardized care and improved documentation was a factor in supporting the initiative. Additionally, the alignment of the intervention with existing guidelines, facility plans, and goals influenced its success and sustainability. Our findings offer valuable insights into the opportunities and challenges of implementing intervention to support re- engagement guidelines. They emphasize the need to address negative provider attitudes, foster engaged leadership, and integrate initiatives with broader HIV care program and facil- ity workflows. These insights are important for the adoption and implementation of similar guidelines in similar settings.