Mobility and structural barriers in rural South Africa contribute to loss to follow up from HIV care

ABSTRACT

Retention in HIV care is crucial to sustaining viral load suppression, and reducing HIV transmission, yet loss to follow-up (LTFU) in South Africa remains substantial. We conducted a mixed methods evaluation in rural South Africa to characterize ART disengagement in neglected rural settings. Using convenience sampling, surveys were completed by 102 PLWH who disengaged from ART (minimum 90 days) and subsequently resumed care. A subset (n = 60) completed individual in-depth interviews. Median duration of ART discontinuation was 9 months (IQR 4-22). Participants had HIV knowledge gaps regarding HIV transmission and increased risk of tuberculosis. The major contributors to LTFU were mobility and structural barriers. PLWH traveled for an urgent family need or employment, and were not able to collect ART while away. Structural barriers included inability to access care, due to lack of financial resources to reach distant clinics. Other factors included dissatisfaction with care, pill fatigue, lack of social support, and stigma. Illness was the major precipitant of returning to care. Mobility and structural barriers impede longitudinal HIV care in rural South Africa, threatening the gains made from expanded ART access. To achieve 90-90-90, future interventions, including emphasis on patient centered care, must address barriers relevant to rural settings.

KEYWORDS:

• antiretroviral therapy
• re-engagement
• rural
• mobility
• structural barriers
• patient centered care

Acknowledgements

The authors wish to thank the staff at Church of Scotland Hospital and Philanjalo NGO for their dedication to the Msinga community.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Availability of data and material

The datasets generated and analyzed during the current study are available in the Mendeley repository. It can be found at this link, https://doi.org/10.17632/rg27cvw69m.1.

Additional information

Funding

The study was funded by the Doris Duke Charitable Foundation Clinical Research Fellowship (AH, #2016178), National Institute of Allergy and Infectious DiseasesNIAID (SS, #K23AI089260), Doris Duke/YCCI (SS, #2015216), Patterson Foundation (#14-001927), Irene Diamond Foundation (#2006078).