HIV Care Continuum in Jimma, Southwest Ethiopia: A Multiphase Mixed Methods Study

Author: Hailay Abrha Gesesew

Gesesew, Hailay Abrha, 2019 HIV Care Continuum in Jimma, Southwest Ethiopia: A Multiphase Mixed Methods Study, Flinders University, College of Medicine and Public Health

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Introduction: The HIV care continuum framework aims to provide a linked continuum of care through diagnosis, effective treatment and patient monitoring. Significant progress has been achieved in the antiretroviral therapy (ART) era, but several challenges have also hampered its ultimate success. These include: late HIV care presentation (LP), discontinuation from pre-ART and ART, poor adherence to ART and immunological failure. The aims of this thesis were four-fold, to: (i) review the available evidence on ART discontinuation in Ethiopia, (ii) examine the whole continuum of HIV care, (iii) explore the facilitators, barriers and solutions of HIV care and treatment (HCT), and (iv) develop consensus-based solutions for improving access to and utilization of HCT in Southwest Ethiopia.

Methods: The thesis employed a mixed-methods study in four phases: (i) systematic review and meta-analysis of ART discontinuation in Ethiopia, (ii) retrospective cohort study in Southwest Ethiopia of predictors of LP, ART discontinuation, HIV related immunologic failure and mortality, (iii) qualitative study to explore the facilitators, barriers and solutions for HIV care from the perspectives of HIV patients, care providers, community advocates and program managers from Southwest Ethiopia, and (iv) consensus-development study using a Nominal Group Technique (NGT), involving service providers, researchers, governmental and non–governmental HIV program managers, to identify possible solutions (identified from the qualitative study) for improving access to HCT. Ethics approvals were obtained from Flinders University of South Australia and Jimma University of Southwest Ethiopia.


(i) The systematic review and meta-analysis identified risk factors for discontinuation as: rurality, poor literacy, alcohol consumption, tobacco smoking, mental illness and functional incapacity.

(ii) The 12-year retrospective cohort study (n=5299 patients with HIV) found the following. LP (in 65% of participants) led to poor outcomes and was associated with risk factors such as being younger, female, Tb/HIV co-infected and no history of HIV testing among adults but not in children. Discontinuation rate from ART care was 22.3% and the problem increased with time. Predictors of ART discontinuation comprised being female, having an immunological failure, having Tb/HIV co-infection, and no previous history of HIV testing. Immunologic failure was seen in 20% of participants and its magnitude increased with time. Similarly, predictors of immunologic failure included being: female, late presenters for HIV care, and CD4 <200 cells/mm3. The cumulative incidence of HIV mortality was 6.2%, and CD4 count <200 cells/µL, WHO clinical stage 3 or 4, having immunologic failure, bedridden functional status, and no history of HIV testing. Using the above continuum of care as surrogate measures, the performance of Southwest Ethiopia to the UNAIDS 90-90-90 targets was 35-66-65.

(iii) The qualitative study included semi-structured interviews with 35 participants (10 HIV patients, nine HIV care providers, 11 community advocates and five HIV program managers/policy makers). Facilitators for HIV care were found to be new programs, knowledge and trust in ART and support. Emerging barriers were fear of being seen by others, availability, role of tradition, free ART as expensive, poor knowledge and trust in ART care system and fragmented health care system. The suggested solutions included strengthening existing programs, implementing new programs (self-HIV testing, house-to-house HIV testing, community ART distribution, and teach, test, link and trace model), decentralizing and integrating services (ART in health post, ART in private clinics), and filling gaps in legislation (in issues related with disclosure and traditional healing practices).

(iv) The consensus method included 18 experts, who identified the following possible solutions: filling gaps in legislation, self-HIV testing and teach-test-link-trace model.

Conclusions: This thesis shows that poor HIV care outcomes were prevalent in Southwest Ethiopia, and the UNAIDS performance was very low compared to the global target. The HCT programs were affected by patient-, HIV care provider-, community- and policy-level barriers. The involvement of multidisciplinary teams is recommended to act on the complex issue, and call for the implementation of the suggested solutions from these studies. However, a large-scale study would be required before implementing the solutions from the experts.

Keywords: HIV care continuum, late presentation for HIV care, discontinuation, lost to follow up, retention, attrition, immunologic failure, mortality, UNAIDS 90-90-90, meta-analysis, cohort, qualitative study, nominal group technique, mixed method

Subject: Medicine thesis

Thesis type: Doctor of Philosophy
Completed: 2019
School: College of Medicine and Public Health
Supervisor: Associate Professor Lillian Mwanri