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

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MacPherson, Peter ; MacPherson, Eleanor E ; Mwale, Daniel ; Squire, Stephen Bertel ; Makombe, Simon D ; Corbett, Elizabeth L ; Lalloo, David G ; Desmond, Nicola (2012)
  • Publisher: International AIDS Society
  • Journal: Journal of the International AIDS Society, volume 15, issue 2 (eissn: 1758-2652)
  • Related identifiers: pmc: PMC3535694, doi: 10.7448/IAS.15.2.18020
  • Subject: HIV testing and counselling | antiretroviral therapy | linkage to care | qualitative studies | wc_503 | wc_503_2 | wb_330 | Research Paper | sub-Saharan Africa | wc_503_7

Introduction: Linkage 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.\ud \ud Methods: Semi-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.\ud \ud Results: Progression 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.\ud \ud Conclusions: Key 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.