Barriers to HIV care in Uganda and implications for universal test-and-treat: a qualitative study

ABSTRACT

Achieving universal HIV test-and-treat will require targeted interventions for those with worse outcomes, including advanced HIV. We conducted qualitative, semi-structured interviews with healthcare workers (HCWs) and people living with HIV (PLWH) at 5 HIV clinics in Kampala, Uganda, to understand barriers to care. PLWH enrolled started/restarted on HIV treatment ≤3 months prior. PLWH were grouped as 1) “ART-experienced” or those restarted therapy after ≥12 months off, 2) ART naïve CD4 count <100 cells/uL “late presenters” or 3) ART naïve CD4 count >350 cells/uL “early presenters”. In-depth interviews were conducted in Luganda, translated, and transcribed verbatim. Between May and August 2017, 58 PLWH and 20 HCWs were interviewed. High stigma and low social support emerged as themes among all as barriers to care. Alcohol abuse was a barrier for men. Fear of domestic violence and abandonment were barriers for women, limiting disclosure of their HIV status to their male partners. Clinic factors such as rapport with staff, distance, efficiency, and privacy impacted care. Future interventions to decrease delayed ART initiation should target stigma and social support. Assisted disclosure, contact tracing, and alcohol abuse treatment should be implemented. Strengthening client support, reducing wait times, and increasing privacy assurances would improve care-seeking behaviors.

KEYWORDS:

• HIV
• late presentation
• Africa
• health systems
• barriers to care

Acknowledgments

We thank the administration of KCCA and for the individual clinic staff for their time and the time of their colleagues for interviews. We thank Freddie Kibengo and Cynthia Ahimbisibwe for connecting us with contacts at the KCCA clinics and their advice for the project. We thank the Fogarty International Program for their funding and for their Qualitative Methods Course, especially Kate Murray who provided the resources and support to do this project. Thank you to Drs. David Boulware and Radha Rajasingham for their assistance in designing this work. We thank Charles Osingada for his reviewing the work. This research was supported by the Fogarty International Center (R01NS086312, R25TW009345), the National Institute of Allergy and Infectious Diseases (T32AI055433), and the National Institute of Mental Health (K23MH121220). REDCap was supported by the National Institutes of Health's National Center for Advancing Translational Sciences (UL1TR002494).

Disclosure statement

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

Additional information

Funding

This work was supported by Division of Intramural Research, National Institute of Allergy and Infectious Diseases: [Grant Number T32AI055433]; Fogarty International Center: [Grant Number R01NS086312, R25TW009345]; National Center for Advancing Translational Sciences: [Grant Number UL1TR002494]; National Institute of Mental Health: [Grant Number K23MH121220].