With a 19.2% HIV prevalence, South Africa has the largest HIV/AIDS epidemic worldwide. Despite a recent scale-up of public sector HIV resources, including community-based programs to expand HIV care, suboptimal rates of antiretroviral therapy (ART) initiation and adherence persist. As community stakeholders with basic healthcare training, community health workers (CHWs) are uniquely positioned to provide healthcare and insight into potential strategies to improve HIV treatment outcomes. The study goal was to qualitatively explore the self-perceived role of the CHW, unmet CHW needs, and strategies to improve HIV care in rural KwaZulu-Natal, South Africa. Focus groups were conducted in May-August 2014, with 21 CHWs working in Msinga subdistrict. Interviews were audio-recorded, transcribed, and translated from Zulu into English. A hybrid deductive and inductive analytical method borrowed from grounded theory was applied to identify emergent themes. CHWs felt they substantially contributed to HIV care provision but were inadequately supported by the healthcare system. CHWs' recommendations included: (1) sufficiently equipping CHWs to provide education, counseling, social support, routine antiretroviral medication, and basic emergency care, (2) modifying clinical practice to provide less stigmatizing, more patient-centered care, (3) collaborating with traditional healers and church leaders to reduce competition with ART and provide more holistic care, and (4) offsetting socioeconomic barriers to HIV care. In conclusion, CHWs can serve as resources when designing and implementing interventions to improve HIV care. As HIV/AIDS policy and practice evolves in South Africa, it will be important to recognize and formally expand CHWs' roles supporting the healthcare system.

South Africa has the largest global HIV/AIDS epidemic, but barriers along the HIV care continuum prevent patients from initiating and adhering to antiretroviral therapy (ART). To qualitatively explore reasons for poor ART initiation and adherence rates from the unique perspective of community health workers (CHWs), we conducted focus groups during May–August 2014 with 21 CHWs in rural Msinga, KwaZulu-Natal. Interviews were audio-recorded, transcribed, and translated from Zulu into English. Hybrid deductive and inductive analytical methods were applied to identify emergent themes. Multiple psychosocial, socioeconomic, and socio-medical barriers acted at the level of the individual, social network, broader community, and healthcare environment to simultaneously hinder initiation of and adherence to ART. Key themes included insufficient patient education and social support, patient dissatisfaction with healthcare services, socioeconomic factors, and tension between ART and alternative medicine. Fear of lifelong therapy thwarted initiation whereas substance abuse principally impeded adherence. In conclusion, HIV/AIDS management requires patient counselling and support extending beyond initial diagnosis. Treating HIV/AIDS as a chronic rather than acute infectious disease is key to improving ART initiation and long-term adherence. Public health strategies include expanding CHWs' roles to strengthen healthcare services, provide longitudinal patient support, and foster collaboration with alternative medicine providers.