Social barriers in accessing care by clients who returned to HIV care after transient loss to follow-up

Abstract

Background People living with HIV (PLHIV) constantly need to address social issues such as the cost of accessing care, stigma, and lack of social support which impacts on their level of adherence to clinic visits or antiretroviral treatment leading to adverse health outcomes. This study examined the social barriers in accessing care by clients who returned to care after transient loss to follow-up. Methods This study was a cross-sectional survey of PLHIV from 99 US CDC PEPFAR-supported HIV clinics located in 10 of Nigeria’s 36 states and Federal Capital Territory, who were momentarily lost to follow-up but returned to care after tracking. Demographic and social factors at bivariate and multivariate level were analyzed to determine the predictors of difficulty in accessing HIV clinics. Results Of the 7483 clients tracked, 1386 (18.5%) were confirmed to be in care, 2846 (38.2%) were lost to follow-up (LTFU), 562 (7.5%) returned to care, 843 (11.2%) discontinued care, 827 (11.1%) transferred out to other facilities for care, 514 (6.8%) had died while 505 (6.7%) could not be reached by phone or located at their addresses. 438 out of the 562 (78%) returnee PLHIV gave consent and participated in the study. 216 out of the 438 (50%) clients who returned to care were transiently lost to follow-up because they had difficulty accessing their HIV clinic. Also, 126/438 (29%) of returnee PLHIV were previously lost to follow-up. Difficult access to a HIV clinic was significantly influenced by prior LTFU (OR 2.5 [95% CI 1.3–4.8], p = 0.008), history of being stigmatized (OR 2.1 [95% CI 1.1–3.8], p = 0.02), lack of social or financial support (OR 2.8 [95% CI 1.3–6.0], p = 0.01) and perceived in-adequate healthcare workers support (OR 3.8 [95% CI 1.2–11.2], p = 0.02). Age (p = 0.218) and gender (p = 0.771) were not significant determinants of difficult access to an HIV clinic. Conclusion Stigma, lack of support and prior loss to follow-up event are essential factors affecting retention in care. Social constructs such as home-based visits, community-based care services, transportation subsidies, and robust strong social systems should be built into HIV service delivery models to improve retention in care of people on HIV treatment. The authors advocate for further studies on how differentiated care models impact on retention of patients in care.

Prevalence and reasons of loss to follow-up in HIV clinics: a systematic review of current evidence

“…Patients who start ART within seven days after HIV diagnosis were more likely to be at risk for LTFU. In general, same-day patients were at higher risk for LTFU, but the mortality rate was slightly lower in this group [24,49]. According to the results, the number of baseline CD4+ cells did not play a role in LTFU; however, it seems that higher CD4+ cells during treatment was effective in reducing the risk of LTFU [43,50,76].…”

“…Different studies have reported social and economic issues, such as poverty, lack of social support, and community level stigma as important factors in not receiv-ing proper HIV care [61]. Another important factor is the long distance to a medical facility; one of the major problems for patients living far from medical centers is transportation [24,60,77]. In most of the studies reviewed, there was no difference between genders.…”

“…In these studies, the reasons for HIV patients' loss to follow-up have been evaluated. Since most of these factors should be taken from patients' reports, the lack of cooperation of patients in explaining the reasons for termination of treatment has been one of the most important limitations mentioned in these articles [24]. Also, the lack of complete documentation of information about main indicators of patients' health status was one of the most important limitations mentioned in the references [69].…”

“…Debates still exist surrounding the possible causes of LTFU among PLHIV. Social, psychological, economic, and political deficiencies are some of the proposed causes of LTFU in HIV service providing centers [24][25][26]. Nevertheless, the need to identify and review these reasons still exists.…”

Final HIV status outcome for HIV-exposed infants at 18 months of age in nine states and the Federal Capital Territory, Nigeria

“…This should be interpreted with caution, as our study is not population-based and did not include pregnant women who did not enroll in, or have access to the services and support received in PMTCT programs in the nine included states or across the entire country. Several factors occurring throughout the PMTCT cascade including at the interpersonal, community, healthcare facility and policy/governance levels contribute to low access to maternal ART in Nigeria and other African countries [ 34 – 40 ]. We expect that as lifelong treatment coverage improves in Nigeria, more women living with HIV would have early access, remain adherent and on ART throughout their first and subsequent pregnancies.…”