Navigating the HIV continuum of care from treatment to retention strategies in Carnot, Central African Republic: a sequential explanatory mixed-methods study.

BACKGROUND: HIV remains a major public health challenge globally, including in the Central African Republic (CAR). Despite progress in awareness, prevention and access to antiretroviral therapy (ART), notably with dolutegravir (DTG), significant challenges persist. This study aimed to describe clinical status, virological failure (VF), ART resistance and reasons for disengagement among people living with HIV at Médecins Sans Frontières-supported sites in CAR.

METHODS: A sequential explanatory mixed-methods study was conducted in Carnot district, comprising: (1) a retrospective cohort analysis (2011-2022); (2) a cross-sectional study estimating VF and resistance profiles in patients on ART ≥6 months; and (3) a qualitative component exploring factors influencing engagement and disengagement in HIV care from patients, healthcare workers and key informants. The cross-sectional component included clinical exams, CD4 counts, viral load (VL) and resistance testing for patients with VL ≥500 copies/mL. VF was defined as VL ≥1000 copies/mL. Qualitative data were collected through semistructured interviews and analysed using content analysis.

RESULTS: Since 2011, over 5400 adults living with HIV have been managed in Carnot. By 2022, 46.5% remained in care, 35.5% were lost to follow-up and 11.3% had died; median follow-up was 32.7 months dropping to 16.6 months among those who died. After Test & Treat, over 80% initiated ART at diagnosis, but differentiated service delivery did not improve long-term retention. By 2022, 96% received DTG-based regimens; 88% achieved VL 1000 copies/mL, but only 32% were fully suppressed. Qualitative data identified insecurity, distance, food insecurity, stigma and health system barriers as key drivers of attrition and poor adherence.

CONCLUSION: Sustained ART delivery and high DTG uptake were achievable in this fragile context, yet retention and full viral suppression remain limited. Attrition and suboptimal adherence driven by insecurity and health system barriers underscore the need for context-adapted, patient-centred and community-responsive HIV care models.

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