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Background: The rollout of antiretroviral therapy in sub-Saharan Africa has brought lifesaving treatment to millions of HIV-infected individuals. Treatment is lifelong, however, and to continue to benefit, patients must remain in care. Despite this, systematic investigations of retention have repeatedly documented high rates of loss to follow-up from HIV treatment programs. This paper introduces an explanation for missed clinic visits and subsequent disengagement among patients enrolled in HIV treatment and care programs in Africa., Methods and Findings: Eight-hundred-ninety patients enrolled in HIV treatment programs in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda who had extended absences from care were tracked for qualitative research interviews. Two-hundred-eighty-seven were located, and 91 took part in the study. Interview data were inductively analyzed to identify reasons for missed visits and to assemble them into a broader explanation of how missed visits may develop into disengagement. Findings reveal unintentional and intentional reasons for missing, along with reluctance to return to care following an absence. Disengagement is interpreted as a process through which missed visits and ensuing reluctance to return over time erode patients' subjective sense of connectedness to care., Conclusions: Missed visits are inevitable over a lifelong course of HIV care. Efforts to prevent missed clinic visits combined with moves to minimize barriers to re-entry into care are more likely than either approach alone to keep missed visits from turning into long-term disengagement.

Increasingly, contemporary mental health services research projects aim to combine qualitative and quantitative components. Yet researchers often lack theoretical and practical guidance for undertaking such studies. In September 2006 the authors convened under the auspices of the National Institute of Mental Health at a working conference, "Mixed Methods in Community-Based Mental Health Services Research." This meeting provided the opportunity for participants to share their experiences in conducting mixed-methods research, to critically consider problems they had encountered and their solutions, and to develop guiding principles for others conducting similar research. The authors' discussions, which are described in this article, emphasize that the problems encountered by mixed-methods research teams are rarely simple misunderstandings but often reflect epistemological differences that are overlooked in the study planning phases. Failure to acknowledge these different worldviews may result in significant tensions between members of the study team, use of qualitative methods that are insufficient or inappropriate for a particular research question, or serious conflicts when team members belatedly discover they are interpreting key concepts -- or each other's research techniques -- differently. The authors conclude that ongoing communication is the organizing principle for robust and effective mixed-methods research. Among the recommendations for preventing problems are collaboration between quantitative and qualitative researchers during the study design phase; open acknowledgement of the philosophical approaches brought to the study by various team members; and because not all challenges can be anticipated, a shared willingness to negotiate emerging problems.

Alcohol has a substantial negative impact on the HIV epidemic in sub-Saharan Africa, particularly in Uganda, where heavy alcohol consumption is common. Using a content analytic approach, this qualitative study characterizes changes in alcohol use among 59 HIV-infected Ugandan adults (>18 years old), who reported any alcohol use in the previous year as they entered HIV care. Most participants reported attempting to cease or reduce alcohol intake over the study period. Reasons for decreased use included advice from clinicians, interference with social obligations, threats to financial security, and negative impact on social standing. Participants reported difficulty abstaining from alcohol, with incentives to continue drinking including desire for social inclusion, stress relief, and enjoyment of alcohol. These contrasting incentives created a moral quandary for some participants, who felt 'pulled' between 'good' and 'bad' influences. Results suggest brief interventions addressing self-identified obstacles to change may facilitate long-term reductions in drinking in this population.

We used qualitative data from the Partners PrEP Program (PPP) to address the question: How did Central Ugandan HIV clinics adapt to COVID-19 lockdown restrictions to promote continuous access to HIV care? PPP was a stepped-wedge cluster randomized trial of integrated PrEP and ART delivery for HIV serodifferent couples at Central Ugandan HIV clinics (NCT03586128). Individual interviews with purposefully selected PPP couples (N = 42) and clinicians, coordinators, and counselors providing HIV care (N = 36) were carried out. Sixty-four interviews were completed after lockdown and included questions about accessing and providing ART/PrEP refills during lockdown restrictions. We used an inductive, content-focused approach to analyze these interview data. Barriers to continuous access identified by interviewees included loss of income with increased cost of transport, reduced staff at clinics, and physical distancing at clinics. Interviewees pointed to multi-month refills, visits to clinics "close to home," transport to clinics for providers, and delivery of refills in neighborhoods as factors promoting continuous access to antiretroviral medications. Access barriers appeared somewhat different for ART and PrEP. Fewer resources for community delivery and pre-refill HIV testing requirements were identified as PrEP-specific access challenges. Participants emphasized their success in continuing ART/PrEP adherence during the lockdown, while providers emphasized missed refill visits. These results highlight the contributions of providers and ART/PrEP users to adaptation of HIV services during COVID-19 lockdown restrictions in Uganda. The roles of direct care providers and service users as drivers of adaptation should be recognized in future efforts to conceptualize and investigate health system resiliency. [ABSTRACT FROM AUTHOR]

Pre-exposure prophylaxis (PrEP) is highly effective for HIV prevention, yet PrEP delivery to women in periconception and pregnancy has lagged. We report qualitative research from a study evaluating PrEP use as part of safer conception care for 330 South African women. Fifty-two semi-structured interviews were conducted with 25 study participants to identify influences on PrEP adherence. Influences were: (1) changing proximity to male partners; (2) COVID-19 lockdown; (3) mobile lifestyle; (4) PrEP-related stigma; (5) disclosure of PrEP use; and (6) pregnancy and motherhood. Data also revealed important contextual information shaping adherence influences for women, including: (a) not living with partners, (b) partners as drivers of pregnancy intention, and (c) feeling at high risk for HIV. Disclosure of PrEP use, addressing stigma, strategies for traveling with pills, and counseling on prevention effective adherence are promising components of PrEP-inclusive HIV prevention interventions for South African women who are pregnant or planning pregnancy. [ABSTRACT FROM AUTHOR]

Daily oral pre-exposure prophylaxis (PrEP) can safely and effectively prevent HIV acquisition in HIV-negative individuals. However, uptake of PrEP has been suboptimal in sub-Saharan Africa. The goal of this qualitative study was to identify facilitators of and barriers to PrEP acceptability among target users not taking PrEP. Fifty-nine individuals belonging to Ugandan priority populations participated in a single in-depth interview. Participants perceived themselves as being at high risk for HIV acquisition, and expressed interest in PrEP as an HIV prevention strategy. Two forms of stigma emerged as potential barriers to PrEP use: (1) misidentification as living with HIV; and (2) disclosure of membership in a priority population. Acceptability of PrEP was dampened for this sample of potential PrEP users due to anticipated stigmatization. Mitigating stigma should be a key component of effective PrEP delivery to reach UNAIDS goal of ending the AIDS epidemic by 2030. [ABSTRACT FROM AUTHOR]

The social-ecological model proposes that efforts to modify health behaviors are influenced by constraints and facilitators at multiple levels. We conducted semi-structured interviews with 47 clients in HIV care and 8 HIV clinic staff to explore how such constraints and facilitators (individual, social environment, physical environment, and policies) affect engaging in HIV clinical care in Nakivale Refugee Settlement in Uganda. Thematic analysis revealed that participants were motivated to attend the HIV clinic because of the perceived quality of services and the belief that antiretroviral therapy improves health. Barriers to clinic attendance included distance, cost, unemployment, and climate. Those that disclosed their status had help in overcoming barriers to HIV care. Nondisclosure and stigma disrupted community support in overcoming these obstacles. Interventions to facilitate safe disclosure, mobilize social support, and provide more flexible HIV services may help overcome barriers to HIV care in this setting. [ABSTRACT FROM AUTHOR]

Realization of optimal treatment and prevention benefits in the era of universal antiretroviral therapy (ART) and "U=U" (undetectable = untransmittable) requires high adherence at all stages of HIV disease. This article draws upon qualitative interview data to characterize two types of influences on ART adherence for 100 Ugandans and South Africans initiating ART during early-stage HIV infection. Positive influences are: (a) behavioral strategies supporting adherence; (b) preserving health through adherence; (c) support from others; and (d) motivating effect of adherence monitoring. "De-stabilizing experiences" (mobility, loss, pregnancy) as barriers are posited to impact adherence indirectly through intervening consequences (e.g. exacerbation of poverty). Positive influences overlap substantially with adherence facilitators described for later-stage adherers in previous research. Adherence support strategies and interventions effective for persons initiating ART later in HIV disease are likely also to be helpful to individuals beginning treatment immediately upon confirmation of infection. De-stabilizing experiences merit additional investigation across varying populations. [ABSTRACT FROM AUTHOR]

Little is known about the factors that encourage or discourage refugees to test for HIV, or to access and adhere to HIV care. In non-refugee populations, social support has been shown to influence HIV testing and utilisation of services. The present study enrolled HIV-infected refugees on anti-retroviral therapy (ART) in Uganda, who participated in qualitative interviews on HIV testing, treatment, and adherence. Interviews were analysed for themes about four types of social support: emotional, informational, instrumental, and appraisal support. A total of 61 interviews were analysed. Four roles for these types of social support were identified: (1) informational support encouraged refugees to test for HIV; (2) emotional support helped refugees cope with a diagnosis of HIV; (3) instrumental support facilitated adherence to ART and (4) after diagnosis, HIV-infected refugees provided informational and emotional support to encourage other refugees to test for HIV. These results suggest that social support influences HIV testing and treatment among refugees. Future interventions should capitalise on social support within a refugee settlement to facilitate testing and treatment. [ABSTRACT FROM PUBLISHER]

The Centers for Disease Control and Prevention estimates that one in four sexually active men who have sex with men (MSM) could decrease their HIV risk by using HIV pre-exposure prophylaxis (PrEP). Because many MSM access healthcare from primary care providers (PCPs), these clinicians could play an important role in providing access to PrEP. Semistructured qualitative interviews were conducted with 31 PCPs in Boston, MA, to explore how they approach decisions about prescribing PrEP to MSM and their experiences with PrEP provision. Purposive sampling included 12 PCPs from an urban community health center specializing in the care of lesbian, gay, bisexual, and transgender persons ('LGBT specialists') and 19 PCPs from a general academic medical center ('generalists'). Analyses utilized an inductive approach to identify emergent themes. Both groups of PCPs approached prescribing decisions about PrEP as a process of informed decision-making with patients. Providers would defer to patients' preferences if they were unsure about the appropriateness of PrEP. LGBT specialists and generalists were at vastly different stages of adopting PrEP into practice. For LGBT specialists, PrEP was a disruptive innovation that rapidly became normative in practice. Generalists had limited experience with PrEP; however, they desired succinct decision-support tools to help them achieve proficiency, because they considered preventive medicine to be central to their professional role. As generalists vastly outnumber LGBT specialists in the United States, interventions to support PrEP provision by generalists could accelerate the scale-up of PrEP for MSM nationally, which could in turn decrease HIV incidence for this priority population. [ABSTRACT FROM AUTHOR]

Individuals facing recovery from serious mental illness confront social challenges stemming from discrimination and the structure of our economic safety net. Although research has contributed to significant advances for individuals with the most serious mental illness, questions about the social nature of their world remain largely unasked. How can persons with mental illness move from community isolation to community integration? Building on earlier research, this article uses qualitative data to address developmental challenges as impediments to community integration for young people with serious mental illness. Sixty transcripts from unstructured, in-depth interviews with persons with psychiatric disabilities moving toward social integration were content analyzed to demonstrate possibilities for developmental growth in the context of informal and intentional communities. Data are organized and presented in three conceptual categories drawn from developmental theory: (1) risk taking, (2) reciprocal relationships, and (3) self-determination. Based on the results, the authors suggest that attention to the challenges of developmental growth should complement current evidence-based and best program practices for young adults with mental illness. [ABSTRACT FROM AUTHOR]

Objective: Quality of life, once a priority in caring for people with severe mental illness, has since been eclipsed by other concerns. This article returns attention to quality of life by offering a theory of social integration (as quality of life) for persons disabled by severe mental illness. Methods: Data collection for this qualitative study consisted of 78 individual, unstructured interviews with 56 adults who have been psychiatrically disabled. Field observations and interviews with staff and service users were carried out during eight ethnographic visits to service sites working to promote social integration. Data were analyzed with an inductive strategy based on grounded theory methodology and framed theoretically by the capabilities approach to human development. Goals were to identify personal capacities needed for integration, characterize occasions for capacity development in mental health care, and develop a working theory. Results: Six personal capacities were identified: responsibility, accountability, imagination, empathy, judgment, and advocacy. Occasions were characterized in terms of their defining mechanisms: contradiction, reinterpretation, rehearsal, raising expectations, and confrontation. A working theory was constructed to characterize the process of capacity development for social integration through exposure to increasingly challenging occasions for growth in the context of mental health care. Conclusions: Capacities for social integration can be effectively developed as part of the everyday routines of mental health care. Eventually, the process shifts from development to the exercise of capacities and to participation as full citizens in the social world beyond treatment. [ABSTRACT FROM AUTHOR]

Adherence to anti retroviral therapy promotes viral suppression and extends the lives of individuals with HIV, yet illegal drug users are underrepresented among eligible persons receiving HIV treatment. One explanation for this is the assumption that drug users are less capable than others of adhering to complicated medication regimens. This paper investigates this assumption by making explicit a number of its underlying propositions and examining them in light of data collected from 52 active drug users living in and around Boston, USA, who were taking highly active antiretroviral therapy for HIV (HAART). The propositions are: (1) drug users lead "chaotic" lives; (2) active drug users are always using drugs; (3) being under the influence of drugs precludes taking medications as prescribed; and (4) drug users are intrinsically different from non-users in the lives they lead and the problems they face. Data collection consisted of a series of qualitative interviews with each participant. An analytic approach informed by grounded theory was used to construct thematic content categories from the data. Results revealed stability and control as well as "chaos" in the lives of study participants. Frequency of drug use varied considerably. Using did interfere with adherence, but not in every circumstance or all cases. Not "carrying" medications, competing priorities, and re-defining regimens were the most salient of a number of non-drug-use-related obstacles observed. Documentation of patterns of variation in corresponding data highlights the stereotypical quality of the propositions. Stereotyping risks overemphasis on drug use as a barrier to adherence for active users, and underemphasis on non-drug-use-related obstacles. Adherence capabilities of users, in contrast to inadequacies, are also obscured through stereotyping. As a medium for stigmatization, stereotyping may contribute to unequal treatment for drug users and other populations living with HIV. [ABSTRACT FROM AUTHOR]

Voluntary medical male circumcision (MMC) reduces risk of HIV infection, but uptake remains suboptimal among certain age groups and locations in sub-Saharan Africa. We analysed qualitative data as part of the Linkages Study, a randomized controlled trial to evaluate community-based HIV testing and follow-up as interventions promoting linkage to HIV treatment and prevention in Uganda and South Africa. Fifty-two HIV-negative uncircumcised men participated in the qualitative study. They participated in semistructured individual interviews exploring (a) home HTC experience; (b) responses to test results; (c) efforts to access circumcision services; (d) outcomes of efforts; (e) experiences of follow-up support; and (f) local HIV education and support. Interviews were audio-recorded, translated, transcribed, and summarized into “linkage summaries.” Summaries were analysed inductively to identify the following three thematic experiences shaping men’s circumcision choices: (1) intense relief upon receipt of an unanticipated seronegative diagnosis, (2) the role of peer support in overcoming fear, and (3) anticipation of missed economic productivity. Increased attention to the timing of demand creation activities, to who delivers information about the HIV prevention benefits of MMC, and to the importance of missed income during recovery as a barrier to uptake promises to strengthen and sharpen future MMC demand creation strategies. [ABSTRACT FROM AUTHOR]

Background. Decentralization of care and treatment for HIV infection in Africa makes services available in local health facilities. Decentralization has been associated with improved retention and comparable or superior treatment outcomes, but patient experiences are not well understood. Methods. We conducted a qualitative study of patient experiences in decentralized HIV care in Plateau State, north central Nigeria. Five decentralized care sites in the Plateau State Decentralization Initiative were purposefully selected. Ninety-three patients and 16 providers at these sites participated in individual interviews and focus groups. Data collection activities were audio-recorded and transcribed. Transcripts were inductively content analyzed to derive descriptive categories representing patient experiences of decentralized care. Results. Patient participants in this study experienced the transition to decentralized care as a series of “trade-offs.” Advantages cited included saving time and money on travel to clinic visits, avoiding dangers on the road, and the “family-like atmosphere” found in some decentralized clinics. Disadvantages were loss of access to ancillary services, reduced opportunities for interaction with providers, and increased risk of disclosure. Participants preferred decentralized services overall. Conclusion. Difficulty and cost of travel remain a fundamental barrier to accessing HIV care outside urban centers, suggesting increased availability of community-based services will be enthusiastically received. [ABSTRACT FROM AUTHOR]