Continuum of care and health service engagement among people living with HIV in Carnot, CAR
Study design
A multi-methods study: Retrospective study, cross-sectional analysis to estimate the prevalence of virological failures and qualitative study
Context and objectives
In Carnot, Central African Republic, MSF collaborates with the Ministry of Health at the District Hospital (DH), providing comprehensive care for chronic diseases, including integrated HIV services. Since 2016, HIV differentiated treatment models (DTMs) have been introduced, including multi-monthly dispensing of antiretroviral therapy, Community ART Groups (CAGs), and decentralized care. A multi-methods study was conducted to describe and understand the continuum of care of patients in the cohort, including retention indicators, treatment adherence, perceptions of DTMs and reasons for late presentation to care.
Additionally, it aimed to estimate the prevalence of virological failure and associated drug resistance. The quantitative facets of the research have been concluded and interpreted in conjunction with the qualitative component, which aimed to delineate factors influencing engagement and disengagement among individuals living with HIV.
Our role
Coordination
Partners
- Ministry of health, RCA
Methods
Programmatic data of the HIV cohort in Carnot between 2011 and 2022 was analysed retrospectively. A cross-sectional survey was conducted on a random sample of active patients who underwent a clinical examination, CD4, viral load (VL) and ARV resistance tests to estimate the proportion of virological failures and resistance profiles. Lastly, semi-structured interviews were conducted with key informants, health care workers, active patients, and patients late for their appointments (< 6 months).
Results
In 2023, the cohort included 4,745 patients on treatment, with 35.5% (N=1,684) lost-to-follow-up. The probability of retention in care decreased over time and adherence to care (% of late appointment to the health centre) was lower than 80%. Among the 341 patients surveyed, 96% of them were on a treatment based on dolutegravir (DTG), and 12% (N=40, 95%CI 8-16) had virological failure. Among those, nearly one third (29.6%) presented drug resistances to the class of molecules currently used and 2.4% presented resistance to DTG, indicating that lack of adherence was likely the cause of virological failure. DTMs were not optimally implemented, and perceptions were mixed. Reasons for late presentations to appointments included access and service-related barriers, stigmatisation and socio-economic vulnerability, however, patients facing these barriers were often excluded from accessing DTM.
Conclusion
Despite DTMs, patients’ retention in care remains low. Strategies for better implementation and equitable access for patients are urgently needed.
