title: Multi-level factors affecting entry into and engagement in the HIV continuum of care in Iringa, Tanzania.
abstract: Progression through the HIV continuum of care, from HIV testing to lifelong retention in antiretroviral therapy (ART) care and treatment programs, is critical to the success of HIV treatment and prevention efforts. However, significant losses occur at each stage of the continuum and little is known about contextual factors contributing to disengagement at these stages. This study sought to explore multi-level barriers and facilitators influencing entry into and engagement in the continuum of care in Iringa, Tanzania. We used a mixed-methods study design including facility-based assessments and interviews with providers and clients of HIV testing and treatment services; interviews, focus group discussions and observations with community-based providers and clients of HIV care and support services; and longitudinal interviews with men and women living with HIV to understand their trajectories in care. Data were analyzed using narrative analysis to identify key themes across levels and stages in the continuum of care. Participants identified multiple compounding barriers to progression through the continuum of care at the individual, facility, community and structural levels. Key barriers included the reluctance to engage in HIV services while healthy, rigid clinic policies, disrespectful treatment from service providers, stock-outs of supplies, stigma and discrimination, alternate healing systems, distance to health facilities and poverty. Social support from family, friends or support groups, home-based care providers, income generating opportunities and community mobilization activities facilitated engagement throughout the HIV continuum. Findings highlight the complex, multi-dimensional dynamics that individuals experience throughout the continuum of care and underscore the importance of a holistic and multi-level perspective to understand this process. Addressing barriers at each level is important to promoting increased engagement throughout the continuum.
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Erica H
authors.initials: EH
authors.lastname: Layer
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Caitlin E
authors.initials: CE
authors.lastname: Kennedy
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: S. Wilson
authors.initials: SW
authors.lastname: Beckham
authors.affiliation: Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
authors.forename: Jessie K
authors.initials: JK
authors.lastname: Mbwambo
authors.affiliation: Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
authors.forename: Samuel
authors.initials: S
authors.lastname: Likindikoki
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Wendy W
authors.initials: WW
authors.lastname: Davis
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Deanna L
authors.initials: DL
authors.lastname: Kerrigan
authors.affiliation: Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Heena
authors.initials: H
authors.lastname: Brahmbhatt
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003266:Continuity of Patient Care; D005260:Female; D006678:HIV / Q000302:isolation & purification; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D010342:Patient Acceptance of Health Care; D057545:Social Stigma; D012944:Social Support; D013636:Tanzania / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents