Understanding reasons for discontinued antiretroviral treatment among clients in test and treat: a qualitative study in Swaziland

Abstract

IntroductionRetention on antiretroviral therapy (ART) is critical for the successful adoption of the test and treat policy by sub‐Saharan African countries, and for realizing the United Nations programme on HIV and AIDS target of 90‐90‐90. This qualitative study explores HIV positive clients’ reasons for discontinuing ART under the Max ART test and treat implementation study in Swaziland.MethodsClients identified as lost to follow‐up (LTFU) in the programme database, who had initiated ART under the intervention arm of the Max ART study, were purposively selected from two facilities. LTFU was defined as stopping ART refill for three months or longer from the date of last appointment, and not being classified as transferred out or deceased. Semi‐structured face‐to‐face interviews were conducted with nine clients and one treatment supporter between July and August 2017. All interviews were conducted in the local language, audio‐recorded, summarized or transcribed and translated to English for thematic analysis.ResultsRespondents described mobility as the first step in a chain of events that affected retention in care. It was entwined with precarious employment, care delivery, interactions with health workers, lack of social support, anticipated stigma and ART‐related side‐effects, including the exacerbation of hunger. The chains of events involved several intersecting reasons that occurred one after the other as a series of contiguous and linked events that led to clients’ eventual discontinuation of ART. The individual accounts of step‐by‐step decision‐making revealed the influence of multi‐layered contexts and the importance of critical life‐events.ConclusionsClients’ reasons for abandoning ART are a complex, inextricably interwoven chain of events rather than a single occurrence. Mobility is often the first step in the process and commonly results from precarious economic and social circumstances. Currently the health system poorly caters to the reality of people's mobile lives. Interventions should seek to increase healthcare workers’ understanding of the chain of events leading up to discontinuation on ART and the social dilemmas that clients face.

Daily struggle to take antiretrovirals: a qualitative study in Papuans living with HIV and their healthcare providers

“…As in other studies, fear of disclosure of HIV status and the stigma associated with disclosure was an important barrier to accept this care closer to home. 32 This was not only found to be a barrier to get supply with ART, but also to discuss concerns and get information on the disease and treatment. 31 33 Contrary to a previous study, 34 patients valued the competence of HCPs highly.…”

Migration and first-year maternal mortality among HIV-positive postpartum women: A population-based longitudinal study in rural South Africa

“…One possible explanation for this finding is that HIV-positive women who externally migrated away from the study area, mainly seeking economic and educational opportunities in larger cities, might have had difficulty accessing care in a new environment. A recent mixed-method study in Swaziland reported that PLWH who were lost to follow-up from HIV care described mobility as the first factor that affected their falling out of the care [38]. It is also possible that HIV-positive women might have self-selected into migration, as seen among HIV-positive individuals in Malawi [19].…”

One step ahead: timing and sexual networks in population mobility and HIV prevention and care

“…We must consider time as well as space when conceptualizing and examining how migration might affect HIV prevention and care, including Universal Test and Treat (UTT) interventions. Forms of population mobility, especially in sub‐Saharan Africa, are complex and often characterized by multiple rounds of travel, seasonal migration or movement events in time . Circular migration, where migrants leave home to work (or for other reasons) but frequently return home before leaving again, is also common, especially in South Africa .…”