Barriers and Facilitators to Successful Intensive Adherence Counseling in Rural Northern Uganda: An Exploratory Interview with HIV-Positive Clients Using the COM-B Framework

Abstract

Intensive adherence counseling (IAC) was introduced as a strategy to enhance adherence to antiretroviral therapy (ART) among HIV clients with non-suppressed viral loads. There has been sub-optimal viral load suppression among HIV clients in Uganda enrolled in IAC. However, there is a scarcity of literature on the barriers and facilitators of successful IAC. We aim to explore the barriers and facilitators to successful IAC among HIV-positive clients seeking care in public health facilities in rural northern Uganda. Patients and Methods:This was an exploratory qualitative study conducted among 15 purposively sampled HIV-positive clients enrolled in IAC in public health facilities offering ART services in northern Uganda. We conducted in-depth interviews using semistructured interview guides based on the capability, opportunity, motivation, and behavior (COM-B) framework for behaviour change. Data were analyzed using the deductive thematic approach of Braun and Clarke following the COM-B framework. Results: The majority of the participants were females (60%), married (53%), and attained primary education (47%). Barriers to successful IAC were Capability -alcoholism and promiscuity, Opportunity -stigma and discrimination, delayed viral load result, shortage of food, and heavy workload; and Motivation -deteriorating health and lack of incentives. Facilitators to successful IAC were Capability -good knowledge of ART, good memory, and reminder alerts; Opportunity -availability of ART, social support, availability of ART, prolonged ART refill, and good counseling; and Motivation -desire to live longer and healthy and the desire to fulfill dreams and goals. Conclusion: Successful implementation of IAC needs to consider the context of the person in care thus the need to strengthen individualized IAC sessions. HIV care providers can adopt the COM-B framework to perform individualized IACs and use the information to strengthen the counseling sessions.

Factors Influencing the Status of Adherence to Second Clinic Visit Among Clients Newly Diagnosed with HIV in Northern Uganda: A Mixed-Methods Study

“…Quality of counseling was yet another important factor influencing adherence to second clinic visit that came up during our survey and in-depth interview. Although this finding is contrary to that reported by a study in Kenya, 26 which did not find any benefits of counselling to adherence to clinic visit among HIV clients, our finding is consistent with a study among HIV clients in Uganda 27 which found that quality counselling improves HIV linkages and management in care. The disparity between findings could be attributed to the use of lay counsellors in the Kenyan study, who may be less skilled in counselling.…”

Effectiveness of intensive adherence counselling in achieving an undetectable viral load among people on antiretroviral therapy with low‐level viraemia in Uganda

“…For instance, a Ugandan study found that only 23% of paediatric patients with HIV achieved viral suppression after IAC [46]; another Ugandan study evaluated the outcomes of IAC in improving viral suppression and found that 48.2% of participants with HIV achieved viral suppression following IAC [47]; and in Zimbabwe, 31.2% of participants with HIV who underwent a repeat VL after IAC achieved VL suppression [48]. This low success rate of IAC could be due to various challenges affecting the implementation of IAC, including clients missing IAC sessions, shortage of food, stigma and discrimination, delayed VL results, a lack of incentives, and heavy workloads, among others [46,49]. In our study, people living with HIV were given an incentive in the form of a transport refund every time they came to the health facility for IAC, which led to all participants in the intervention arm reporting for all their IAC sessions.…”