Toward an understanding of disengagement from HIV treatment and care in sub-Saharan Africa: a qualitative study.
BACKGROUND
The rollout of antiretroviral therapy in sub-Saharan Africa has brought lifesaving treatment to millions of HIV-infected individuals. Treatment is lifelong, however, and to continue to benefit, patients must remain in care. Despite this, systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programs. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programs in Africa.


RESULTS
Eight-hundred-ninety patients enrolled in HIV treatment programs in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda who had extended absences from care were tracked for qualitative research interviews. Two-hundred-eighty-seven were located, and 91 took part in the study. Interview data were inductively analyzed to identify reasons for missed visits and to assemble them into a broader explanation of how missed visits may develop into disengagement. Findings reveal unintentional and intentional reasons for missing, along with reluctance to return to care following an absence. Disengagement is interpreted as a process through which missed visits and ensuing reluctance to return over time erode patients' subjective sense of connectedness to care.


CONCLUSIONS
Missed visits are inevitable over a lifelong course of HIV care. Efforts to prevent missed clinic visits combined with moves to minimize barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement.
Harvard Medical School, Boston, Massachusetts, USA. norma_ware@hms.harvard.edu
Norma C
NC
Ware
Monique A
MA
Wyatt
Elvin H
EH
Geng
Sylvia F
SF
Kaaya
Oche O
OO
Agbaji
Winnie R
WR
Muyindike
Guerino
G
Chalamilla
Patricia A
PA
Agaba
D017954:Africa South of the Sahara; D000553:Ambulatory Care; D023241:Antiretroviral Therapy, Highly Active; D032882:Comprehension; D003695:Delivery of Health Care; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D008297:Male; D017063:Outcome Assessment, Health Care; D010349:Patient Compliance; D036301:Qualitative Research