Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). However, a recent review of retention data from 33 African patient cohorts concluded that only about 60% remain in medical care for HIV/AIDS after two years. Retention in care is a bigger problem than ART adherence for African patients working toward long-term treatment success. To address the problem of retention, we must understand the reasons for attrition. We propose an exploratory, qualitative study of reasons for attrition from HIV care in sub-Saharan Africa as reported directly by the individuals involved. The study will be based at the Immune Suppression (ISS) Clinic for HIV treatment and care at Mbarara Regional Referral Hospital in rural southwest Uganda. Using an established system of tracking patients, we will locate, enroll and interview representative samples of 75 HIV+ individuals eligible for ART who have enrolled in care but failed to initiate therapy and 75 HIV+ individuals who have become lost to follow- up after beginning ART (Total N=150). Interviews with health professionals and staff at the clinic will also be carried out. The resulting data will be used to characterize reasons for failure to initiate therapy (Aim 1) and loss to follow-up (Aim 2). We will also analytically describe the tracking system in action and use the results to develop strategies for successful tracking (Aim 3). Finally, we will explore tracking as a retention intervention by documenting the number of located individuals who subsequently return to care (Aim 4). Study data consist of interview write-ups, field notes, and a spreadsheet containing data on return to care. Write-ups and field notes will be analyzed using grounded theory category construction methods. The proportion of study participants who return to care will be calculated and expressed as a percentage. This investigation is guided by a theoretical model of adherence developed specifically for sub-Saharan Africa as part of previous NIMH-funded research. The relevance of the model to retention will be assessed and adjustments made as necessary for a better fit. Next steps include operationalizing qualitative """"""""reasons"""""""" categories as variables for future quantitative research and developing ideas for retention interventions suggested by the results.

Public Health Relevance

The purpose of this project is to promote long-term clinical success for sub-Saharan Africans taking antiretroviral therapy for HIV/AIDS by addressing the problem of attrition from HIV care.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Exploratory/Developmental Grants (R21)
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Behavioral and Social Consequences of HIV/AIDS Study Section (BSCH)
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Stirratt, Michael J
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Harvard University
Other Health Professions
Schools of Medicine
United States
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Ware, Norma C; Wyatt, Monique A; Geng, Elvin H et al. (2013) Toward an understanding of disengagement from HIV treatment and care in sub-Saharan Africa: a qualitative study. PLoS Med 10:e1001369; discussion e1001369
Katz, Ingrid T; Ware, Norma C; Gray, Glenda et al. (2010) Scaling up human papillomavirus vaccination: a conceptual framework of vaccine adherence. Sex Health 7:279-86