Factors contributing to non-initiation of ART amongst eligible pre-ART patients in rural clinics in Swaziland

AIM The purpose of this study was to explore and describe factors that contribute to the non-initiation of Antiretroviral Therapy (ART) amongst Pre-Antiretroviral Therapy eligible patients and to make recommendations for health care workers to enhance early initiation of pre-ART-eligible patients for primary health care facilities in Swaziland. METHOD A qualitative design was applied in rural primary health care (PHC) facilities in the Hhohho region of Swaziland. The target population for this study included nurses who have successfully completed the National Nurse Led Antiretroviral Therapy Initiation in Swaziland (NARTIS) training, and who actively initiated ART to eligible patients in rural PHC facilities. Data was collected through semi-structured interviews and field notes. Purposive, convenient sampling was applied. Eleven respondents were interviewed for the study, and data was collected until data saturation was reached. Data from transcripts and field notes was analysed and categorised with thematic analysis through Tesch’s open coding process. RESULTS The study identified the following three predominant themes: 1) systematic enablers of prompt ART initiation, 2) barriers to prompt ART initiation, 3) sources of support. Categories included public health care (PHC) factors, community level factors, the interdependence of the health care system, patient centred barriers, individual patient agency, and NARTIS nurse support. CONCLUSION The recommendations for health care workers that emerged from the study included continued HIV treatment scale-up and decentralisation to grass roots levels, aggressive treatment prioritisation among pre-ART patients, building the capacity of the local health care system and continued research initiatives. It is hoped that recommendations emerging from the findings of this study will have positive implications for programming and practice regarding the initiation of ART for eligible pre-ART patients in Swaziland.Health StudiesM. PH

Enrollment in HIV Care Two Years after HIV Diagnosis in the Kingdom of Swaziland: An Evaluation of a National Program of New Linkage Procedures

To improve early enrollment in HIV care, the Swaziland Ministry of Health implemented new linkage procedures for persons HIV diagnosed during the Soka Uncobe male circumcision campaign (SOKA, 2011–2012) and the Swaziland HIV Incidence Measurement Survey (SHIMS, 2011). Abstraction of clinical records and telephone interviews of a retrospective cohort of HIV-diagnosed SOKA and SHIMS clients were conducted in 2013–2014 to evaluate compliance with new linkage procedures and enrollment in HIV care at 92 facilities throughout Swaziland. Of 1,105 clients evaluated, within 3, 12, and 24 months of diagnosis, an estimated 14.0%, 24.3%, and 37.0% enrolled in HIV care, respectively, after adjusting for lost to follow-up and non-response. Kaplan-Meier functions indicated lower enrollment probability among clients 14–24 (P = 0.0001) and 25–29 (P = 0.001) years of age compared with clients > 35 years of age. At 69 facilities to which clients were referred for HIV care, compliance with new linkage procedures was low: referral forms were located for less than half (46.8%) of the clients, and few (9.6%) were recorded in the appointment register or called either before (0.3%) or after (4.9%) their appointment. Of over one thousand clients newly HIV diagnosed in Swaziland in 2011 and 2012, few received linkage services in accordance with national procedures and most had not enrolled in HIV care two years after their diagnosis. Our findings are a call to action to improve linkage services and early enrollment in HIV care in Swaziland

Cumulative verified enrollment in HIV care, by type of health facility, SHIMS male clients only.

<p>Log-rank test for differences in functions = 18.47; <i>P</i> < 0.0001.</p

Clisssent and referral facility characteristics, by study-gender group.

<p>Clisssent and referral facility characteristics, by study-gender group.</p

Interviewed client self-reported linkage services, by study-gender group^a.

<p>Interviewed client self-reported linkage services, by study-gender group<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0150086#t003fn001" target="_blank">^a</a>.</p

Interviewed client self-reported and verified enrollment in HIV care, and reasons for enrolling at an alternate facility or not enrolling in HIV care at all, by study-gender group.

<p>Interviewed client self-reported and verified enrollment in HIV care, and reasons for enrolling at an alternate facility or not enrolling in HIV care at all, by study-gender group.</p

Distribution of newly HIV diagnosed SHIMS and SOKA clients referred to health facilities in the four regions of Swaziland.

<p>Distribution of newly HIV diagnosed SHIMS and SOKA clients referred to health facilities in the four regions of Swaziland.</p

Cumulative verified enrollment in HIV care, by region of facility.

<p>Log-rank test for differences in functions = 0.73; <i>P</i> = 0.87.</p

Cumulative verified enrollment in HIV care, by type of health facility, SHIMS female clients only.

<p>Log-rank test for differences in functions = 6.09; <i>P</i> = 0.014.</p

Cumulative verified enrollment in HIV clinics located in rural and peri-urban areas, by road condition serving the clinic, SHIMS clients only.

<p>Log-rank test for differences in functions = 8.01; <i>P</i> = 0.005.</p