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Background: Notions of ''good'' or ''bad'' patient behaviour affect patient-provider relationships in the domain of HIV care. We know little about the role of these social and moral representations in shaping access throughout the cascade of HIV services. In this study, we sought to explore factors that mediate bad and good patient behaviour, and to examine how these mediation processes could serve to overcome barriers along each stage of the cascade.
Methods: A qualitative study was conducted in six African countries (Uganda, Tanzania, Malawi, Kenya, Zimbabwe and South Africa) through the ALPHA network. We sampled different types of health workers involved in HIV care and patients from each stage of the cascade. Data were collected through in-depth interviews and were analysed inductively, using both open and axial coding. The constant comparison method was used to assess relational themes within and between site-level data.
Results: Providers often labelled certain patients as ''challenging'' or ''difficult'', such as defaulters and late presenters. However, patients were often seen as blameless, with social and contextual factors, such as poverty and stigma, implicated as barriers to ''good'' patient behaviour. Patients were also forgiving to providers failing to maintain high standards of care given health system constraints, such as staff and treatment shortages. Success in mutual understanding resulted in both providers and patients making an effort to accommodate each other, and to find solutions that enhanced access to HIV services along the cascade of care. However, failed mutual understanding resulted in helplessness, apathy and poor attitudinal behaviour among both health providers and patients which hindered patients'' progression through the cascade of care.
Conclusions: In most sites, patients and providers often reached a state of mutual understanding, and formed stronger therapeutic alliances to overcome barriers to access. While the label of ''bad'' patients carry a negative connotation, providers are shifting the blame from individual patients to socio-contextual factors that constrain access and perpetuate poor health-seeking behaviour. Similarly, patients recognise health system constraints faced by providers. Therefore, mutual understanding is a potential mediator of agency in the therapeutic alliance, and may serve to unlock bottlenecks along the cascade of care.

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