BACKGROUND: Ethiopia has prioritized the transition of people doing well on antiretroviral therapy (ART) into an appointment spacing model (ASM) with twice-yearly health facility (HF) clinical visits at which 6 months of ART are dispensed. It is one of the first countries in sub-Saharan Africa to take biannual multi-month scripting and delivery (6-MMD) to scale. We conducted a qualitative study to explore why some eligible individuals choose not to enroll in ASM.
METHODS: We convened 12 focus group discussions (FGDs) at three HFs in Ethiopia's Oromia region. The 93 participants were all ASM-eligible and had been on ART for '¥ 1 year; participants in 6 FGDs had chosen to enroll in ASM and participants in the other 6 FGDs had chosen not to enroll in ASM. We conducted inductive and deductive thematic analyses.
RESULTS: Participants' median age was 41 years (IQR 12) and 89% had been on ART > 5 years. Those in ASM were very satisfied. Three key themes emerged when those not in ASM explained their rationales: concerns about medication storage; dissatisfaction with decreased visit frequency; and misunderstandings about ASM. Non-enrolled participants feared that they could not store 6 months of ART safely, securely, and privately, e.g., that the ART would be vulnerable to heat-induced spoilage, access by children, and/or discovery by others leading to forced HIV status disclosure and stigmatization. They also preferred more frequent HF visits which enabled social bonding with providers and other patients, the reassurance of frequent check-ups, and ongoing counseling and adherence support. Concern about synchronizing ART pick-ups with those of an HIV+ partner or child also deterred ASM enrollment. Finally, many non-enrolled participants misunderstood ASM, thinking that they would be limited to twice-yearly HF visits, that they would receive different ART than in the conventional model, and/or that the ART dispensed would expire prior to their next visit.
CONCLUSIONS: Not all intended ASM benefits were viewed as patient-centered, and ASM is unlikely to be the preferred model for everyone. However, some resistance to ASM may be mitigated by optimizing ART packaging, enhancing pre-enrollment orientation, strengthening community engagement, and/or providing the option of supplemental community-based support services.