Table 1 Summary of main themes, subject themes, and supporting evidence

Constantly starting over

Frequent rotation and turn-over of staff working in the HIV/AIDS response

Lack of handover

“Start over and begin again.”

“Reinvent the wheel”, “we never learn.”

Effects of instability rippling from central level throughout the health pyramid

Changes at central level leading to changes in regional health directors

Effects on people living with HIV/AIDS

Outward emigration of health personnel, including HIV/AIDS specialists and care providers

“The farther you go from Bissau… you don’t have this political instability problem.”

“The butterfly effect, it starts from the top and when flapping the wings it drags all that [down].”

Vulnerable populations becoming more vulnerable

Breakdown of the Guinean family

Extreme vulnerability of girls and women to HIV infection

Social and economic conditions favouring spread of HIV

“Any political crisis… means that those who are vulnerable become much more vulnerable.”

“At this period it was quite obvious that who provides for the family was the young girls.”

Coping mechanisms

Community-led response to HIV/AIDS was early and has filled gaps

Decentralized approaches

Technical staff who keep working despite challenges

“That was how [the NGO] practically emerged as a pioneer in filling the gaps left by the Ministry in the national response.”

“If you want to promote changes in Guinea-Bissau, the best level to invest on is at local level where you can force changes at upstream level.”