Understanding reasons for treatment interruption amongst patients on antiretroviral therapy--a qualitative study at the Lighthouse Clinic, Lilongwe, Malawi

Abstract

Background: In recent years, scaling up of antiretroviral therapy (ART) in resource-limited settings moved impressively towards universal access. Along with these achievements, public health HIV programs are facing a number of challenges including the support of patients on lifelong therapy and the prevention of temporary/permanent loss of patients in care. Understanding reasons for treatment interruption (TI) can inform strategies for improving drug adherence and retention in care.

Objective: To evaluate key characteristics of patients resuming ART after TI at the Lighthouse Clinic in Lilongwe, Malawi, and to identify their reasons for interrupting ART.

Design: This study uses a mixed methods design to evaluate patients resuming ART after TI. We analysed an assessment form for patients with TI using pre-defined categories and a comments field to identify frequently stated reasons for TI. Additionally, we conducted 26 in-depth interviews to deepen our understanding of common reasons for TI. In-depth interviews also included the patients' knowledge about ART and presence of social support systems. Qualitative data analysis was based on a thematic framework approach.

Results: A total of 347 patients (58.2% female, average age 35.1±11.3 years) with TI were identified. Despite the presence of social support and sufficient knowledge of possible consequences of TI, all patients experienced situations that resulted in TI. Analysis of in-depth interviews led to new and distinct categories for TI. The most common reason for TI was travel (54.5%, n=80/147), which further differentiated into work- or family-related travel. Patients also stated transport costs and health-care-provider-related reasons, which included perceived/enacted discrimination by health care workers. Other drivers of TI were treatment fatigue/forgetfulness, the patients' health status, adverse drug effects, pregnancy/delivery, religious belief or perceived/enacted stigma.

Conclusions: To adequately address patients' needs on a lifelong therapy, adherence-counselling sessions require provision of problem-solving strategies for common barriers to continuous care.

Keywords: Malawi; adherence; antiretroviral therapy; retention in care; treatment interruption.

Fig. 1

Study population. Eligibility criteria were ≥15 years, documented treatment interruption of ≥21 days (between January 2008 and November 2009), resumption of ART. In total, patient characteristics of 347 patients were analysed, 147 B2C forms were entered into an MSAccess database and 26 in-depth interviews were conducted for descriptive analysis and to gain a further understanding of reasons for treatment interruption. ART: Antiretroviral therapy; B2C: Back-to-Care; EDS: Electronic data system; LTFU: Lost-to-Follow up

Fig. 2

Reasons for treatment interruption. Relative frequency of reasons for treatment interruption as stated by patients in the B2C form n=147; multiple reasons per patient possible. Additional categories exceeding the scope of the pre-defined categories were derived from the comment field and are marked with a star: *. B2C: Back-to-Care.