2.2 LITERATURE REVIEWAdoption of treatment for all strategy has ignited new hope to the HIV infected patient and the health care workers because the approach is seen as the drive toward reducing the disease burden in Sub-Saharan Africa (MaxART, 2018). Moreover, the UNAIDS strategy 2016-2021 key element is to provide antiretroviral therapy to all persons infected with HIV (UNAIDS, 2016). To ensure that more individuals know their HIV status, community-based models, including home-based HIV testing most of the sub-Saharan African countries are implementing vary. Available evidence supports that home-based testing is feasible and highly acceptable as an intervention that yields better results (Barnabas et al., 2014; Dalal et al., 2013).Additionally, starting the patient treatment on the same day after home-based testing has led to a reduction of the gap between testing and treatment. These new interventions have led to an increase in the number of persons receiving ART care (Skovdal et al., 2016) and consequently, evoking new treatment disengagement and linkage challenges (Labhardt, 2018; Rosen, 2015). The patients will obtain the full benefit of ART if they adhere to treatment. Treatment adherence is determined by several factors which are attributes of individual behaviour, beliefs and perceptions of health care systems (Joglekar, 2011). It is evident through literature that HIV and AIDS pandemic has evolved over the years, but since the introduction of the ART, the quality of life of people living with HIV and AIDS and the lifespan have improved tremendously (Samji et al., 2013, Losina et al., 2009). ART benefits infected individuals by reducing the chances of getting opportunistic infections rather than curing the disease. Wasti et al., (2011) argues that for the patients to receive full benefits of the treatment, they have to adhere to treatment to ensure that the ART functions effectively. Moreover, with the increase in the number of infected people being initiated on treatment, non-linkage and disengagement to care poses a new challenge (Geng et al., 2010).Several studies have been done to examine the possible reasons why patients may fail to link to health care after home-based HIV testing and eventually disengage in the care cascade (Maria et al., 2016; Safira, et al., 2018; Renju, et al., 2017; Hendrickson et al., 2018). For example, (Naik et al., 2017) conducted a qualitative study using the in-depth interview to understand clients’ reasons for time delay or non-linkage to care within home-based testing intervention in South Africa. They found that linkage to care was influenced by how an individual interacts with the others and the health care systems. Factors such as belief in the results, coping ability and social support limited the ability of the individual client to link to health care. However, this does not conclude that these are the only reasons because in another study in South Africa only 67% of the participants linked to care 6 months after home-based testing despite the offer for a treat regardless of CD4 (Kranzer et al., 2010). Therefore, this implies that other reasons might influence an individual to link to care.Other common reasons from identified from literature included stigma and discrimination, pill burden, ART-related side effect, feeling healthy, mobility and social and economic factors have been linked with non-linkage or disengagement to care (Shabalala et al. 2018). Shabalala et al. conducted a qualitative study using semi-structured face to face interview involving 9 clients and 1 treatment supporter in Swaziland where clients identified as lost to follow-up in the programme database who had initiated ART under the intervention arm of MaxART study were purposely selected from 2 facilities. The study described mobility as the first step to the many reasons that affect retention. It was also clear that lack of employment, care delivery, Lack of social support and anticipated stigma contributed to patient disengagement to care. The researchers concluded that the clients’ reasons for stopping ART are complex involving a chain of events rather than a single occurrence (Shabalala et al., 2018). While this study explored individuals initiated treatment at the facility, it does not give us insight on individuals who were started treatment at the community, thus a need to explore reasons from individuals who initiated treatment during community-based testing. In Zambia Mwamba et al. (2018) conducted a qualitative study in four provinces involving 69 participants purposively selected from 12 facilities. The data were collected using in-depth interviews and 24 focus group discussions with 158 lay and professional healthcare workers. The findings of the study shown that inadequate infrastructure to protect privacy, distance to the health facility, chronic understaffing, drug rationing and inflexibility in visit schedule influenced patient behaviour to engage or disengage to care. However, in this study patients preferred ART over alternative treatment such as traditional medicine, unlike other previous studies (Lubega, 2010; Malungu, 2007) hence indicating that reasons may vary from one setting to another.Individuals infected with HIV have been highly stigmatised since because the disease is viewed by the society as behaviourally acquired (Martinez et al., 2012). This fact was also aptly demonstrated by the study conducted by (Mphil et al., 2008) a qualitative study in 2 districts of Copperbelt province of Zambia. They collected the data through focused groups and individual in-depth interview. Patients from 5 health facilities (3 urban and 2 rural) were recruited. They also interviewed 12 health professionals with experience in ART (3 doctors, 2 clinical officers, 3 nurses, 1 programme coordinator for home-based care programme and 3 pharmacists). The finding has shown that stigma and discrimination played a vital role in an individual’s decision to engage or disengage to care. Although these findings agree with other previous studies (Jabulani, 2017; Nachega et al., 2006), we need to explore reasons disengagement among individuals who are offered same-day ART during Home-based testing.Studies have shown high acceptance on home-based testing intervention in sub-Saharan Africa, with the majority of those tested 79% being new diagnoses (Sabapathey et al., 2012). Although interventions like counselling and referrals of those diagnosed HIV positive being done, still the number of individuals linked to care after home-based counselling remains low. A quantitative study conducted in South Africa using a prospective cohort analysis of linkage to care within three months. Showed that only 76% (95% Cl: 71.6-80.4%) linked to care after home-based counselling (Naik et al., 2015). Therefore, it is prudent to explore the reasons why individuals do not link to care after knowing their HIV status following home-based testing.
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