title: Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi.
abstract: BACKGROUND
  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.
  
  
  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.
  
  
  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.
  
  
  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.
authors: Clinical Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK. p.macpherson@liverpool.ac.uk
authors: Peter
authors: P
authors: MacPherson
authors: Eleanor E
authors: EE
authors: MacPherson
authors: Daniel
authors: D
authors: Mwale
authors: Stephen
authors: S
authors: Bertel Squire
authors: Simon D
authors: SD
authors: Makombe
authors: Elizabeth L
authors: EL
authors: Corbett
authors: David G
authors: DG
authors: Lalloo
authors: Nicola
authors: N
authors: Desmond
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003625:Data Collection; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D012944:Social Support; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents
keywords: HIV testing and counselling; antiretroviral therapy; linkage to care; qualitative studies; sub-Saharan Africa