A Qualitative Study of Barriers to Enrollment into Free HIV Care: Perspectives of Never-in-Care HIV-Positive Patients and Providers in Rakai, Uganda

Abstract

Background. Early entry into HIV care is low in Sub-Saharan Africa. In Rakai, about a third (31.5%) of HIV-positive clients who knew their serostatus did not enroll into free care services. This qualitative study explored barriers to entry into care from HIV-positive clients who had never enrolled in care and HIV care providers. Methods. We conducted 48 in-depth interviews among HIV-infected individuals aged 15–49 years, who had not entered care within six months of result receipt and referral for free care. Key-informant interviews were conducted with 12 providers. Interviews were audio-recorded and transcripts subjected to thematic content analysis based on the health belief model. Results. Barriers to using HIV care included fear of stigma and HIV disclosure, women's lack of support from male partners, demanding work schedules, and high transport costs. Programmatic barriers included fear of antiretroviral drug side effects, long waiting and travel times, and inadequate staff respect for patients. Denial of HIV status, belief in spiritual healing, and absence of AIDS symptoms were also barriers. Conclusion. Targeted interventions to combat stigma, strengthen couple counseling and health education programs, address gender inequalities, and implement patient-friendly and flexible clinic service hours are needed to address barriers to HIV care.

Linkage to HIV care before and after the introduction of provider-initiated testing and counselling in six Rwandan health facilities

“…As hypothesized, when coming to the OPD for a different reason than to be tested for HIV, some patients might be less ready to enrol into HIV care; this may be especially the case for patients without clear symptoms of HIV. Low perceived susceptibility to HIV has been linked to treatment avoidance (Nakigozi et al, 2013;Varni, Miller, McCuin, & Solomon, 2012). This hypothesis is supported by the finding that out-patients in this study who enrolled into pre-ART care had lower absolute CD4 counts than VCT patients both before and after the introduction of PITC.…”

“…Difficulty in accepting their test result and fear of being seen at the HF were main barriers towards enrolment in pre-ART care mentioned by patients in this study and also resulted in them repeating HIV testing. Other studies have reported that denial of HIV status and fear of HIV stigma can result in non-engagement in care and decreased quality of life (Beer, Fagan, Valverde, & Bertolli, 2009;Kamen et al, 2012;Nakigozi et al, 2013;Weaver et al, 2004).…”

“…The prevalence is higher in urban (7.1%) than rural areas (2.3%) (NISR, 2012). ART is available in 93% of hospitals and 29% of health centres (HCs) (NISR, 2008).…”

“…The prevalence is higher in urban (7.1%) than rural areas (2.3%) (NISR, 2012). ART is available in 93% of hospitals and 29% of health centres (HCs) (NISR, 2008). In 2005, the Demographic and Health survey of Rwanda reported that around 80% of adults had not been tested for HIV (NISR, 2006).…”

“…ART is available in 93% of hospitals and 29% of health centres (HCs) (NISR, 2008). In 2005, the Demographic and Health survey of Rwanda reported that around 80% of adults had not been tested for HIV (NISR, 2006). The Ministry of Health therefore recommended introducing PITC in all its health facilities (HFs) in 2008.…”