ARV Defaulters Tugela Ferry

Background: Antiretroviral therapy (ART) is critical to improving health outcomes for people living with HIV (PLWH). Retention in care is critical to achieving and sustaining viral load suppression, and reducing HIV transmission, yet lost to follow-up (LTFU) in South Africa is high. We sought to understand reasons for disengagement in neglected rural settings. Methods: We performed a mixed methods evaluation in rural KwaZulu-Natal among a convenience sample of PLWH taking ART who were LTFU subsequently resuming HIV care. Questions assessed HIV knowledge, stigma, barriers to health care, and reasons for both disengaging and returning to care. Results: Among 102 participants, the median age was 36 (IQR 28-44), 47% were male and 57% had completed secondary school. Participants had previously discontinued their ART for a median of 9 months (IQR 4-22 months). Participants had a high degree of HIV knowledge. Mobility was a major contributor to LTFU. Other factors included HIV stigma, dissatisfaction with the current clinic model, and lack of social support. Illness often precipitated return to care. Conclusions: Cracks in the cascade of care threaten the gains made by expanding access to ART. Patient motivation to continue ART was high, but mobility and structural barriers contributed to disengagement from HIV care in rural South Africa. Future interventions must address factors relevant to rural areas to optimize HIV care in resource limited settings.

背景：抗逆转录病毒治疗（Antiretroviral therapy, ART）对改善人类免疫缺陷病毒（HIV）感染者（people living with HIV, PLWH）的健康结局至关重要。维持诊疗随访是实现并持续维持病毒载量抑制、降低HIV传播的关键环节，但南非的失访（lost to follow-up, LTFU）率居高不下。本研究旨在探究被忽视的农村地区中患者脱离HIV诊疗的原因。
方法：本研究在夸祖鲁-纳塔尔省（KwaZulu-Natal）农村地区开展混合方法评估，研究对象为便利抽样选取的、曾失访后重新恢复HIV诊疗的接受ART治疗的PLWH。调研问卷涵盖HIV知识、病耻感、医疗保健障碍，以及脱离诊疗和重返诊疗的相关原因。
结果：本研究共纳入102名参与者，年龄中位数为36岁（四分位距28~44岁），其中47%为男性，57%完成了中等教育。参与者此前中断ART治疗的时长中位数为9个月（四分位距4~22个月）。参与者对HIV知识的掌握程度较高。流动性是导致失访的主要因素，其他相关因素还包括HIV病耻感、对当前诊疗模式的不满以及社会支持匮乏。罹患疾病往往是促使患者重返诊疗的诱因。
结论：HIV诊疗服务链中的漏洞威胁着扩大ART可及性所取得的成果。患者坚持ART治疗的动机较强，但流动性与结构性障碍导致南非农村地区的HIV感染者脱离诊疗服务。未来的干预措施需针对性解决农村地区的相关问题，以在资源有限的环境中优化HIV诊疗服务。