Positive interactions with healthcare workers improve HIV care retention in Malawi and Zambia

Most people with unsuppressed HIV in a large population study in Uganda were already diagnosed but not in clinical care, suggesting that re-engaging people with HIV and ensuring that they are receiving antiretroviral treatment could have a substantial impact on HIV transmission.

The findings were presented last week at the Conference on Retroviruses and Opportunistic Infections (CROI 2025) in San Francisco.

A second study presented at the conference showed that men with HIV disengaged from care in Malawi were more likely to return to care if they received a supportive low-cost counselling intervention tailored to address the challenges that men face in taking antiretroviral treatment and remaining in care. A third study, carried out in Zambia, found that an intervention to encourage welcoming and supportive behaviours among care providers significantly improved return to care and retention in care among people who had interrupted treatment.  

Uganda: missing from care, with high viral load

The Ugandan study, carried out by the Rakai Health Sciences research group, investigated what proportion of the population in this rural district had detectable HIV viremia, and how many of these people were already diagnosed but disengaged from care.

The study recruited people aged 15-49 in 34 communities and carried out HIV testing. Everyone who tested positive for HIV received a qualitative viral load test which can detect viral load above 1000 copies/ml. Viral load above this level is associated with a risk of HIV transmission. Participants were asked about their HIV status and any past or current antiretroviral use.

People newly diagnosed with HIV during the study were referred to a clinic for HIV treatment and followed up three months later to confirm that they had started treatment.

Anyone previously diagnosed with HIV was referred to a clinic for treatment. Those who had never started treatment were followed up three months later to confirm that they had started treatment.

The study tested 17,841 people; 3170 tested positive for HIV, 3134 underwent viral load testing and 316 (10%) had viral load above 1000 copies/ml. Just over half of those with detectable viral load (54%) said they were newly diagnosed with HIV, 10% said they had not started treatment, 33% said they were in care and 2.5% were previously in care.

However, after looking for clinical records and carrying out testing for antiretroviral drugs, a different picture emerged. In fact, one in five people who said they were newly diagnosed turned out to be already diagnosed but had not started treatment or had dropped out of care. Altogether, 83% of people with viremia were not in clinical care and three-quarters of this group had never started treatment.

Men, and people over 30 years of age, were more likely to have been misclassified.

A blood test to detect antiretroviral drugs showed that only 4% of those with viremia had any detectable antiretroviral drugs in their bloodstream, all of whom were currently in care.

Half of those who had started treatment dropped out within a year. At the time of the study, the median time since the last clinic visit was 2.8 years.

Malawi: person-centred counselling was sufficient to encourage return to care

A randomised trial carried out in Malawi showed that men with HIV who received person-centred counselling delivered by lay people were just as likely to return to care and stay in care as men who received more complex and costly interventions.

The study, carried out through the Partners in Hope NGO in Malawi, recruited 569 men living with HIV who had been traced from chart reviews at 13 health facilities. Men were eligible for inclusion in the study if they had been diagnosed with HIV but had not initiated antiretroviral treatment or had interrupted treatment.

Participants were randomised to one of three study arms:

• one or two sessions of male-sensitive, person-centred counselling designed to address barriers to care, plus the offer of an escort to the healthcare facility (n=195)
• the same procedures, plus initiation of antiretroviral therapy (ART) at home (n=190)
• a stepped intervention that began with counselling and stepped up to professional mental health support if treatment was not initiated after 14 days (n=184).

The primary outcome of the study was the proportion of participants in each arm who had initiated ART within three months of enrolment and had been out of care for less than 28 days by six months after treatment initiation.

Study participants had a mean age of 39 years and 91% had previously started treatment. Participants had been on treatment for a median of 12 months and out of care for a median of two months at the time of enrolment.

At nine months after enrolment, there was no significant difference in ART engagement between study arms (76% in the counselling arm vs 72% in the home-based ART arm and 85% in the stepped intervention arm).

In-depth interviews with 92 participants found that the elements of interventions most valued by the participants was counselling and positive interactions with healthcare workers. Kind and interactive counselling that offered tailored solutions and compelling messages was more important than dispensing ART at home, the interviews showed.

Zambia: improving healthcare provider-client interactions leads to improved retention in care

Treatment interruptions can be attributable to poor experiences of health care and fears about returning to care after missed appointments. Researchers at the Centre for Infectious Disease Research in Zambia and universities in the United States designed an intervention to promote friendlier, more person-centred attitudes in healthcare staff, using training and coaching, measurement and feedback, and facility-level incentives such as recognition for staff.

To evaluate the effect of the intervention on client return to care after treatment interruption and sustained engagement in care, the researchers conducted a randomised trial involving 24 health facilities between August 2019 and November 2021. During the study period, 128,901 people with HIV were more than 30 days late and were judged to have interrupted treatment. Sixty-four per cent of those who interrupted treatment were female, most (66%) were aged 25-44 and one-third had been on treatment for at least five years.

During the one-year follow-up period, 65% of the control group and 71% of the intervention group returned to care, a risk difference of 5.7%. Among those who returned to care, people in the intervention group were less likely to experience another treatment interruption during the follow-up period (55% vs 44%, risk difference 10.4%). After one year, a total of 73% in the control group and 82% in the intervention group were still in care after returning to care. Overall, 49% of the control group and 58% of the intervention group were in care one year after the study began.