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.