Abstract:
Objective—
Engagement in care is key to successful HIV treatment in resource-limited settings;
yet little is known about the magnitude and determinants of reengagement among patients out of
care. We assessed patient-reported reasons for not returning to clinic, identified latent variables
underlying these reasons, and examined their influence on subsequent care reengagement.
Design—
We used data from the East Africa International Epidemiologic Databases to Evaluate
AIDS to identify a cohort of patients disengaged from care (>3 months late for last appointment,
reporting no HIV care in preceding 3 months) (
n
= 430) who were interviewed about reasons why
they stopped care. Among the 399 patients for whom follow-up data were available, 104 returned
to clinic within a median observation time of 273 days (interquartile range: 165–325).Methods—
We conducted exploratory and confirmatory factor analyses (EFA, CFA) to identify
latent variables underlying patient-reported reasons, then used these factors as predictors of time to
clinic return in adjusted Cox regression models.
Results—
EFA and CFA findings suggested a six-factor structure that lent coherence to the range
of barriers and motivations underlying care disengagement, including poverty, transport costs, and
interference with work responsibilities; health system ‘failures,’ including poor treatment by
providers; fearing disclosure of HIV status; feeling healthy; and treatment fatigue/seeking spiritual
alternatives to medicine. Factors related to poverty and poor treatment predicted higher rate of
return to clinic, whereas the treatment fatigue factor was suggestive of a reduced rate of return.
Conclusion—
Certain barriers to reengagement appear easier to overcome than factors such as
treatment fatigue. Further research will be needed to identify the easiest, least expensive
interventions to reengage patients lost to HIV care systems. Interpersonal interventions may
continue to play an important role in addressing psychological barriers to retention
