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Support needed to prevent missed clinic visits becoming long-term disengagement from care
Roger Pebody, 2013-01-28 07:50:00
Missed clinic visits may be unintentional or intentional, with complex reasons that change over time, according to qualitative research conducted with people with HIV in three African countries and published in PLOS Medicine. While the initial, practical reasons for non-attendance may pass, people are frequently reluctant to return to the clinic, owing to feeling shame about their absence and in anticipation of negative responses from care providers.
Over a lifetime of antiretroviral treatment, some absences are inevitable, the authors say. Efforts to prevent missed clinic visits are required, but so is work to minimise barriers to people coming back into care.
A systematic review has previously found that in sub-Saharan Africa around 30% of people who are not yet on antiretroviral (ARV) treatment are retained in care. On average, between 60 to 70% of patients remain on ARVs for two years after starting treatment.
Research has identified a number of factors which contribute to missed clinic visits – stigma, fear of disclosure, difficulties travelling to clinic, dissatisfaction with care, improved health, feeling discouraged and wanting to ‘give up’ and a desire to return to a ‘normal life’.
But, according to Norma Ware of Harvard Medical School, most studies simply report lists of the reasons that patients give, stopping short of deeper analysis. She therefore designed a large, qualitative study in order to explore these issues further.
Participants were recruited through three large clinics providing comprehensive HIV and AIDS care in Jos, Nigeria; Mbarara, Uganda; and Dar es Salaam, Tanzania.
In each setting, trained staff or volunteers known as ‘clinical trackers’ attempt to make contact with people who have stopped attending, either by phone or by home visits, in order to facilitate re-engagement with care.
Once standard clinical tracking procedures were complete, patients were asked if they were willing to be contacted by the researchers. Interviews, of an average duration of one hour, were conducted in the local language, exploring experiences of care at the clinic and the circumstances of missed appointments. (One limitation of the study is that the experiences of individuals who wished to avoid all HIV-related activities or who were impossible to contact are under-represented.)
Ninety-one individuals were recruited in this way. Their average age was 36, a little over half were female and three-quarters were employed. Their average journey time to clinic was 45 minutes (maximum three hours).
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