Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries

Abstract

Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.

A Qualitative Assessment of Provider and Client Experiences With 3- and 6-Month Dispensing Intervals of Antiretroviral Therapy in Malawi

“…This finding aligns with many other studies that identify health-seeking costs-long wait times, expensive transport, and lost wages-as major barriers to successful ART adherence. 3,[17][18][19] Additionally, several clients in the 6-month arm noted that reduced clinic visits improved their ability to keep their HIV status private to the community and contributed to feelings of normalcy because they were spending less time seeking health services. Benefits of decreased clinic visits also extended to the health system level.…”

“…A growing body of research has identified a number of health systems and service delivery barriers to antiretroviral therapy (ART) adherence and retention in care among people living with HIV, 1,2 particularly in high-prevalence low-and middle-income countries. 3 Common challenges to delivering ART in resourcelimited settings include overburdened clinical staff and facility congestion, resulting in constrained abilities to offer quality care. 4,5 Although ART is provided free-ofcharge in many low-and middle-income countries, the need for lifelong medication imposes burdens on clients, including the time and cost of frequent refill visits.…”

“…4,5 Although ART is provided free-ofcharge in many low-and middle-income countries, the need for lifelong medication imposes burdens on clients, including the time and cost of frequent refill visits. 3,6 Malawi has been heavily impacted by the HIV epidemic with a current prevalence of 9.4% and 740,000 adults currently on ART. 7 Routine HIV care for clients who are stable is delivered using an integrated model in which all services (i.e., clinical evaluation and dispensing of ART and any other medications) occur in a single visit at a single location.…”

“…Differentiated models of care (DMOC) may improve clients' adherence to ART and engagement in care by relieving their time-and costrelated barriers and may improve the capacity of health facilities and providers to care for clients who have been newly diagnosed or who require more support. 1,3 Examples of ART DMOCs that have been implemented in sub-Saharan Africa include community-based ART groups, adherence clubs, fast-track refills, mobile clinics, and multimonth dispensing (MMD). [8][9][10] The MMD model increases the quantity of ART received at one time and subsequently reduces the frequency of client facility visits.…”

Progression of HIV Disease Among Patients on ART in Ethiopia: Application of Longitudinal Count Models

“…Although most of the patients included in our study started with lower CD4 + cell counts (<200 cells/mm 3 ), there were patients who had higher baseline CD4 + cell counts (971 cells/mm 3 ). Despite the continuous effort to initiate early, some patients still presented with lower CD4 + cell counts, which might be due to patients' lack of willingness to get tested (13,14) or difficulties to provide treatments to all patients in lower-income countries including Ethiopia. Hence, we believe that our result could be generalizable.…”