Understanding reasons for treatment interruption amongst patients on antiretroviral therapy – A qualitative study at the Lighthouse Clinic, Lilongwe, Malawi

Background In recent years, scaling up of antiretroviral therapy (ART) in resource-limited settings moved impressively towards universal access. Along with these achievements, public health HIV programs are facing a number of challenges including the support of patients on lifelong therapy and the prevention of temporary/permanent loss of patients in care. Understanding reasons for treatment interruption (TI) can inform strategies for improving drug adherence and retention in care. Objective To evaluate key characteristics of patients resuming ART after TI at the Lighthouse Clinic in Lilongwe, Malawi, and to identify their reasons for interrupting ART. Design This study uses a mixed methods design to evaluate patients resuming ART after TI. We analysed an assessment form for patients with TI using pre-defined categories and a comments field to identify frequently stated reasons for TI. Additionally, we conducted 26 in-depth interviews to deepen our understanding of common reasons for TI. In-depth interviews also included the patients' knowledge about ART and presence of social support systems. Qualitative data analysis was based on a thematic framework approach. Results A total of 347 patients (58.2% female, average age 35.1±11.3 years) with TI were identified. Despite the presence of social support and sufficient knowledge of possible consequences of TI, all patients experienced situations that resulted in TI. Analysis of in-depth interviews led to new and distinct categories for TI. The most common reason for TI was travel (54.5%, n=80/147), which further differentiated into work- or family-related travel. Patients also stated transport costs and health-care-provider-related reasons, which included perceived/enacted discrimination by health care workers. Other drivers of TI were treatment fatigue/forgetfulness, the patients' health status, adverse drug effects, pregnancy/delivery, religious belief or perceived/enacted stigma. Conclusions To adequately address patients' needs on a lifelong therapy, adherence-counselling sessions require provision of problem-solving strategies for common barriers to continuous care.