Barriers and facilitators to linkage to care and ART initiation in the setting of high ART coverage in Botswana

ABSTRACT

We conducted a qualitative study using focus groups and in-depth interviews to explore barriers to and facilitators of linkage-to-care and antiretroviral treatment (ART) initiation in Botswana. Participants were selected from communities receiving interventions through the Ya Tsie Study. Fifteen healthcare providers and 49 HIV-positive individuals participated. HIV-positive participants identified barriers including stigma, discrimination and overcrowded clinics, and negative staff attitudes; personal factors, such as a lack of acceptance of one’s HIV status, non-disclosure, and gender differences; along with lack of social/family support, and certain religious beliefs. Healthcare providers cited delayed test results, poverty, and transport difficulties as additional barriers. Major facilitators were support from healthcare providers, including home visits, social support, and knowing the benefits of ART. Participants were highly supportive of universal ART as a personal health measure. Our results highlighted a persistent structural health facility barrier: HIV-positive patients expressed strong discontent with HIV care/treatment being delivered differently than routine healthcare, feeling inconvenienced and stigmatized by separately designated locations and days of service. This barrier was particularly problematic for highly mobile persons. Addressing this structural barrier, which persists even in the context of high ART uptake, could bring gains in willingness to initiate ART and improved adherence in Botswana and elsewhere.

KEYWORDS:

• Barriers
• facilitators
• linkage to HIV care
• antiretroviral initiation
• Botswana

Acknowledgements

We are grateful to the Botswana-Harvard School of Public Health AIDS Initiative Partnership (BHP) for giving us the opportunity to lead this qualitative work within the Botswana Combination Prevention Project. We thank Mr Mukokomani for his support and advice. We are grateful to the data collectors. Our gratitude goes to the translators and transcriber team led by Ms Sekoto. We are thankful to Ms Moanakwena who provided editorial services. We extend our acknowledgements to Erik Widenfelt and the BHP IT team who provided technical support, and the grants and finance team (Kevin Opelokgale, Lesika Maruatona, and Dineo Tumagole). We would also like to acknowledge our additional collaborating partners at the Botswana Ministry of Health, the Harvard T.H. Chan School of Public Health, and the United States Centers for Disease Control and Prevention. Finally we are indebted to all participants who provided valuable information; the study would not have been successful without them.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This study was supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention (CDC) under cooperative agreements U01 GH000447 and GH001911. Dr Lockman’s effort was also supported by K24 AI131928. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the funding agencies.