Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

Abstract

Background: Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies.

Methods: We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains.

Results: We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time.

Conclusion: This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.

Fig 1. PRISMA flow diagram.

^a Sampled studies include those characterized as (1) conducted in Africa, and ‘thick’, or (2) ‘thin’ and belonging to specific population group of interest: A ‘thick’ study was defined according to the depth of analysis which included the following features: 1) the extent to which the authors transformed/analysed their findings, 2) insight into perspectives was demonstrated, 3) richness and complexity had been portrayed, and 4) there was theoretical or conceptual development. “Thin” studies were all other studies not classified as ‘thick’. Specific population of interest studies included those classified as thin but that evaluated perspectives which were of special interest for the review, including; provider perspectives, MSM populations, sex-worker populations; PWID populations; youth being transferred to new facilities; or conducted among refugee populations. ^bData saturation was reached.

Fig 2. Theoretical model of influences on engagement and adherence to ART.