Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi

Abstract

IntroductionLinkage from HIV testing and counselling (HTC) to initiation of antiretroviral therapy (ART) is suboptimal in many national programmes in sub-Saharan Africa, leading to delayed initiation of ART and increased risk of death. Reasons for failure of linkage are poorly understood.MethodsSemi-structured qualitative interviews were undertaken with health providers and HIV-positive primary care patients as part of a prospective cohort study at primary health centres in Blantyre, Malawi. Patients successful and unsuccessful in linking to ART were included.ResultsProgression through the HIV care pathway was strongly influenced by socio-cultural norms, particularly around the perceived need to regain respect lost during a period of visibly declining health. Capacity to call upon the support of networks of families, friends and employers was a key determinant of successful progression. Over-busy clinics, non-functioning laboratories and unsuitable tools used for ART eligibility assessment (WHO clinical staging system and centralized CD4 count measurement) were important health systems determinants of drop-out.ConclusionsKey interventions that could rapidly improve linkage include guarantee of same-day, same-clinic ART eligibility assessments; utilization of the support offered by peer-groups and community health workers; and integration of HTC and ART programmes.

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“…Late ART initiation may also reflect the challenges encountered in timely treatment initiation including regular follow-up of pre-ART patients and health system delays. Reasons for delays in ART initiation among adults include distance and cost, prolonged adherence preparation and patients’ unwillingness to initiate treatment [20-22], but factors specific to youth have not been characterized.…”

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“…77,82,85,91,92 Disclosure to friends and family enables patients to access the psychosocial and material support crucial for initiating and staying on treatment. 78,85,88,91,92 …”

“…74,75,77,81,88,93 Other studies have found negative provider attitudes and lack of confidentiality to be barriers to initiation. 77,78,88,91 …”