Table 4 Summary of quotes from the emerged themes

Health care provider related factors

“For the parent to be able to disclose, we first talk to the child. We then counsel the parents on how they can talk to the child”. N01

“We need to understand who is supposed to disclose to the child; is it the healthcare provider or the parent/guardian?”Y01

“Being healthcare providers, we are not supposed to disclose to the child. We should empower the parent/guardian so that she/he can disclose to the child.” L01

“I often explain to the parent/guardian about the benefits of early disclosure. If she/he allows me to disclose to the child, I do it on the spot as long as the child has reached the required age.” T01

Health system related factors

“Each month we conduct a paediatric club in our clinic which enables us to identify children who are fully disclosed and those who are not.”L01

We often use picture books to explain slowly to the child about the policemen (CD4 cells) in her/his body and their fight against the bad person (HIV virus). We tell the child, unless you take your medication, all the policemen in your body will be destroyed and you will become sick.” A01

“We only have two picture books at the clinic. Sometimes I have to wait for my colleague to finish using the book before I proceed attending another child.” C02

“When the child comes to the clinic, we ask if he/she is aware of her/his HIV status; if not we ask the parents/guardians to talk to the child.”Z02

Training and guideline related factors

“We are not skilled enough to disclose to children as we are for adults. Some of us have not received any training on paediatric HIV disclosure. This makes it difficult counselling parents/guardians about paediatric disclosure.” L01

“In a one day paediatric HIV training we were encouraged to always ask what the child knows about HIV.” Y01

Had we been adequately trained, we could have been be able to cope with challenges that we face when dealing with parents/guardians of these children. We need more skills on how to deal with these parents/guardians during the disclosure process. T01

“It could be good if we received frequent training to update our knowledge on HIV issues concerning children.” C02

Parent/guardian related factors inducted

“Parents/guardians are often reluctant to disclose, they claim that the child is too young to be told about his/her HIV diagnosis. …Parents fear that the child might tell others in the streets…Others fear being hated by the child.” T01

“Mothers find it difficult to disclose to their children because they feel guilty after having transmitted HIV infection to the child.” C01

“Some parents find it easier lying about the diagnosis when confronted by their HIV infected children. A child may be told that he/she takes daily medication to treat conditions like TB or heart disease.” D02