Multi-level Determinants of Starting ART Late: Aim 2

Background: Although HIV care and treatment programs are scaling up in sub-Saharan Africa, more than 50% of patients who need ART are not receiving it and significant mortality from AIDS persists. One major challenge in this region is high rates of late ART initiation (i.e., in the advanced stages of HIV disease) which results in high rates of mortality soon after ART initiation. The clinic-level factors that contribute to late ART initiation are unclear.

Objective: As the second of a 3-phase NIH-sponsored project, this study aims to identify clinic-level enablers and barriers to timely ART initiation.

Methods: A cross-sectional qualitative study will be conducted at 4 purposively selected HIV care and treatment clinics in Ethiopia. Data will be collected using 4 methods:

• Data abstraction
• Key informant interviews with clinic personnel
• Observation of post-test counseling sessions at the voluntary counseling and testing (VCT) clinic
• Observation of provider-patient interactions in the care and treatment clinic Descriptive statistics will be produced from the data abstraction. Content analysis of key informant interviews will be conducted. Descriptive summaries will be produced from observations. All analyses will focus on identifying within- and across-clinic themes, and include triangulation across data collection methods to identify clinic-level enablers and barriers to timely ART initiation.

Expected use of results: Identifying modifiable clinic-level enablers and barriers to timely ART initiation will facilitate implementation of interventions, programs and policies to reduce late ART initiation. Additionally, results will inform the third phase of the NIH-project referenced above.

The inclusion and exclusion criteria for the clinics and the various study participants are given below:

• Data abstraction

Inclusion criteria

N/A - all study sites included. Exclusion criteria: N/A - all study sites included. .

• Key informant interviews

Inclusion criteria

• ≥18 years of age;
• paid or voluntary employee in the 4 study sites for ≥6 months;
• and give verbal informed consent.

Exclusion criteria

• <18 years of age;
• employed at the 4 study sites <6 months;
• and/or not willing to give verbal consent.
• Observation of post-test counseling sessions in the VCT clinic

Inclusion criteria

• Providers: ≥18 years of age; paid or voluntary employee in the 4 study sites for ≥6 months; responsible for HIV post-test counseling in VCT or PICT in the adult outpatient clinic; and give verbal informed consent
• Patients: ≥18 years of age; unaware of HIV status, and give verbal informed consent.

Exclusion criteria

• Providers: <18 years of age; employed <6 months; and/or not willing to give verbal consent.
• Patients: <18 years of age; and/or not willing to give verbal consent.
• Observation of provider-patient interactions in the care and treatment clinic

Inclusion criteria

• Providers: ≥18 years of age; paid or voluntary employee in the care and treatment clinic of 4 study sites for ≥6 months; and give verbal consent.
• Patients: ≥18 years of age; not yet on ART (regardless of eligibility), receiving counseling or another service from one of the observed providers, and give verbal informed consent.

Exclusion criteria

• Providers: <18 years of age; employed <6 months; and/or not willing to give verbal consent.
• Patients: <18 years of age; and/or not willing to give verbal consent.