Factors associated with interfacility transfer and follow up of adult HIV positive clients in South Western Uganda

doi:10.21203/rs.3.rs-5004387/v1

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Research Article

Factors associated with interfacility transfer and follow up of adult HIV positive clients in South Western Uganda

https://doi.org/10.21203/rs.3.rs-5004387/v1

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Introduction

Human immunodeficiency virus (HIV) is still a significant public health problem with a prevalence of 37.7 million worldwide. In Uganda, awareness of HIV status among adults is at 80.9%, 96.1% of People living with HIV are on ART treatment and 92.2% having viral load suppression as of 2021. Proper linkage, follow up and retention in care are key to successful treatment of people living with HIV. Guidelines for Inter-facility transfer of HIV clients stipulate officially documented transfer of clients to ease access to ART and client follow up. These guidelines though existent, translation into practice is unclear with evidence of self-transfers and registration of transferred clients as ‘ART naïve’ in the new facilities. We therefore sought to assess the prevalence of transferred clients, factors associated with the transfer and follow up of transferred HIV clients in Kabale District in South Western Uganda.

Methods

A concurrent mixed methods study design was employed. Quantitative data was collected among 183 consecutively sampled adult HIV positive clients who had transferred into the selected facilities using a semi-structured questionnaire. Data was analyzed using SPSS 16. A total of 4 counsellors and 2 expert clients that were purposively selected and subjected to in-depth interviews regarding challenges in transferring of clients. The data obtained was thematically analyzed.

Results

A total 183 transferred in clients were interviewed, 69.9% were documented transfers and 30.1% were self-transfers. Psychosocial factors were significantly associated with being officially transferred (Chi square value 5.471, df- 1, p value − 0.02) while majority of the clients who self-transferred had structural factors as reasons for transfer. Only 32.8% of the transferred clients had been followed up after transfer contributing to a follow up rate of only 17.9%. Mis-identification of the self-transferred clients and poor interfacility communication emerged as the major challenges to follow up.

Conclusion

The high prevalence of self-transferred clients and lack of follow up create a great challenge in linkage and retention into care of people living with HIV. Therefore rigorous mechanisms for official transfers and follow up of clients at all levels are necessary to improve client retention in care.

self-transfer

official transfer

HIV clients

client follow up

transfer in

client tracing

The global HIV prevalence as of 2021 is 38.4 million with the majority living in low and middle income countries [1]. 53% (20.6 million people) as of 2021 were living with HIV in Eastern and Southern Africa where Uganda is found[2]

Huge strides have been taken in achieving the 2020 UNAIDS 95-95-95 strategy to end AIDS, much so that of the people living with HIV in 2021, 85% knew their status, 75% were accessing treatment and 68% were virally suppressed globally. Uganda has similarly been successful in achieving the targets of the 95-95-95 strategy with awareness of HIV status at 80.9%, 96.1% of People living with HIV on ART treatment and 92.2% having viral load suppression as of 2021[3]

Studies have shown that factors that influence successful retention in care are structural advantages, support after disclosure, ability to receive care outside their community but there is a visible research gap in systems leaks that occur in the process of transferring clients from one facility to another, which contributes to loss to follow up and gaps in reporting retention rate of HIV clients. [4]

Researchers predict that ‘silent transfers’ compared to mortality due to HIV contribute greatly to loss to follow up as the sending facilities as well as the receiving facilities maybe unaware of these transfers. Furthermore decentralization of ART services with only paper based report forms and poorly supported electronic patient data bases increase the difficulty in the interfacility follow up of transferred clients, this in turn poses a great risk for loss patients in care[5].

Inter facility linkages in Uganda stipulate that a client when diagnosed with HIV should to be referred to a health facility of their choice and this client should be followed up by a VHT or linkage facilitator to verify that the client has been successfully transferred into their new facility [6].

Inter facility transfer of HIV clients requires rigorous monitoring with the use of referral form from the primary HIV care setting to the secondary or new care setting. Clients frequently appear at care settings with official referral notes from their primary setting while a good majority are undocumented or self-transfers or silent transfers.

. Several reasons have contributed to incomplete or deficient transfer of HIV clients such as poor linkage between health facilities, poor record keeping, inadequate funding for patient follow up and home visits as well as those who miss appointment date, limited staff, poor staff supervision, lack of space for patient counselling. Most patients transfer because of stigma, distance to health facility and chronic disease such as hypertension [7].

Studies have shown multiple gaps in tracing of transferred HIV clients with a number of transfers being undocumented which has led to challenges in care such as discontinuation in ART, misreporting of clients which eventually affects the clinical outcomes of transferred HIV clients [8].

A study done in East African countries reported a total prevalence of transferred HIV clients as 14% where only 4% were official transfers and 10% were unofficial [9]. A study done in Zambia further reports that out of 178 clients transferred into the HIV care facility, only 46 (25.8%) had official documents from the original care facility [10]. This further creates difficulty in determining actual prevalence of transferred HIV clients.

There is a noted difference between the number of HIV clients transferred from one care setting and those who actually report to the new care setting and are enrolled as ‘transfer in’ clients. A study done in India reported that a total 158 (5.24%) HIV clients were transferred from the primary care setting, 123 (77.8%) reached the designated centers while 15 (9.5%) did not reach the new settings [9]. A successful transfer rate of 85% was also reported in South Africa, though out of 659 transferred patients who had been reached and interviewed in the study 46 reported to have reported to a different clinic from that one designated by the primary care setting [11].

Improper identification of clients also creates difficulty in the determining of actual prevalence of transferred patients. A study done in Uganda reported that among the 350 clients reported as lost to follow up (LTFU), 178 (51%) were successfully verified through chart review at the new-facility as transferred in clients. 110 patients (61.8%) were registered under new ART-IDs and 97 (54.5%) received a new HIV test [10]. Many patients use new identifiers at new facilities, indicative of inefficiencies in enrollment and tracing of clients.

A study done in the USA reported that some of the HIV clients receive care from multiple clinics (8%). This creates difficulties in locating the actual numbers of transferred patients in each of the clinics where these patients are permanently receiving care thus further causing misreporting. This movement from one facility to another encourages the likelihood of missing drug doses and therefore affecting viral suppression of the clients [12].

In view of the above-described difficulties and paucity of information in South Western Uganda, determining the prevalence of transferring HIV clients is of great importance in the provision of continuity of care to People Living with HIV in South Western Uganda.

Studies have been done in developed countries to trace and ascertain numbers of transferred clients and if they actually arrived in the new areas of care, as well the factors that are associated with their transfer (Hickey, Omollo et al., 2016). However there is paucity of information for South Western Uganda about the prevalence of transferred patients, factors associated with transfer of HIV clients and tracing system.

Study setting and design

A concurrent mixed methods study design was employed for this study. The quantitative method was used to determine the prevalence and factors associated with transfer of HIV clients and the qualitative aspect was used to explore the follow up and monitoring systems of transferred HIV clients as a mean to understand the facility and caregiver based knowledge and challenges in successful transfer of HIV positive clients from one facility to another in the selected health facilities (Rugarama Hospital, Kamukira health center IV and Kamuganguzi health center III) in Kabale district.

Kabale district is found in South Western Uganda, borders Rwanda in the East and the South. Health centres in this district serve HIV positive clients as far as the border of Rwanda and some clients from the neighboring districts like Kisoro and Kanungu. Reports have shown very high prevalence of HIV (6.6%) in Kabale district with many of the victims from the Uganda – Rwandan border, Lake Bunyonyi and Kabale town. As of 2020 the number of HIV positive clients was more than 8,920 [13].Due to this prevalence the likelihood for having many interfacility transfers to accommodate the clients’ needs is great.

Study population

For the quantitative study

The study was conducted among adult HIV positive clients who had transferred into the selected health facilities of Rugarama hospital, Kamukira health center IV and Kamuganguzi health center III in Kabale district.

For the qualitative study

This part of the study was conducted among two participants from each facility, they were aged between 22–37 and had been 18 months and 10 years of experience. Four counsellors and two expert clients (people who have declared their HIV positive status publicly and are willing to use their experiences to inspire others into testing for HIV, accessing treatment, disclosure and retention in care at the health facility) who interact with clients and are instrumental in enabling clients make informed decisions especially at times of choosing transfer from one facility to another at each of the selected health facilities of Rugarama hospital, Kamukira health center IV and Kamuganguzi health center III in Kabale district.

Sample size and Sampling technique

For the quantitative study

Due to the expected number of clients transferred into the health centres monthly being small, we consecutively recruited all transferred in participants that were available irrespective of the year in which they transferred into the facility. The range for years since transfer was 1–10 years.

Out of a total of 384 expected participants as estimated using Kish and Leslie formula for quantitative sample size estimation, we were able to interview 183 participants[14].

For qualitative

A total of four counselors and two expert clients were purposively selected from the selected health facilities were, consented and subjected to structured in-depth interviews. Counsellors and expert clients that had worked at the ART clinic for period of more than 12 months with with experience of the challenges faced by HIV positive clients in their care and especially in the area of transferring from one care giving centre to another .

Data collection tools

Quantitative data was collected using researcher administered questionnaires with both close ended and open-ended question. The questions included demographic characteristics for the clients, date for transfer, whether they were transferred with a referral document or they self-transferred (clients who accessed care in a facility without a referral form their previous facility), reasons for transfer and whether they were followed up after transfer. The questions in the questionnaire were developed following review of literature of interfacility transfer of HIV positive clients [9, 15] [10, 16]. The questionnaires provide had both an English and a Rukiga (the local language in Kabale) version to suit the understanding of individual clients.

Qualitative data was collected using a semi structured interview guide with probing questions at each level of question. This guide was created following review of literature. The guide contained questions on identification of clients transferred with documents and self- transferred clients, interfacility transfer processes, and client reasons for transfer and challenges in transfer of clients. The interviews were conducted at selected offices spaces within the health facility by a research assistant proficient in English and in conducting in-depth interviews. The interview lasted on average 45 minutes for each participant. Interviews were audio recorded. Data collection was done for a period of one month from 1st May 2022 to 1st April 2022.

The questionnaire was validated through a pretest that was conducted at Kakoba health Centre III in Mbarara district that serve HIV positive clients as the selected health facilities. A total of five transferred in HIV clients were interviewed with the questionnaire and records person and one health worker were interviewed using the interview guide. The ambiguities found in the questionnaire were eliminated and the revisions were made to create a valid questionnaire.

To maintain confidentiality of the clients’ information, a total of three research assistants (one from each facility who worked with the clients) were trained in understanding of the research, interpretation of the questionnaire and consenting of the clients. A fourth research assistant was trained in understanding of the research concept and qualitative data collection using the interview guide.

The research assistant recruited the transferred clients from the ART clinic on the designated days for receiving of ART. The research assistant clearly explained the purpose of the study to the client, consented and enrolled the client for the study.

.3.9 Data management and analysis

In the field at the end of each data collection day the tools were reviewed for completeness by the research team. For the tools that were incomplete the team leader discussed with the research assistants to fill the missing fields. The data from the questionnaires was entered in duplicate into excel where it was be coded and then entered into SPSS 16.0 where it was cleaned and analyzed.

Quantitative data was represented using proportions. Associations were tested using Pearson’s chi square test and level of significance was represented by P values.

Recorded in-depth interviews were transcribed, responses that had the same message we coded then same way with a color by three of the research team members. The team members then categorized the coded responses to meaningful categories as they emerged from the responses and the developed themes from the categories.

This section shows the responses from participants, their proportions, and results for tests of association (chi square and P values).

Descriptive statistics for study participants

The population was normally distributed, with a mean age of 40.41, age range of 54, minimum age of 18 and maximum age of 72 years. See Fig. 1.

From the study, there were more participants among transferred in HIV clients in the age category 36–65 years. Most of the clients (69.9%) had official transfer documents from their previous health facility while 30.1% had self-transferred. There were more female transferred in clients (71%) as compared to the males (29%). Of the HIV clients that transferred in, most were at primary level of education 50.8% (93) and among these, most were farmers 47.5% (87) as shown in Table 1.

Table 1

**showing the number of participants and the percentages of the various independent variables** N = 183
Variable	n (%)
Age category 18–35 36–65 > 55	73(39.9) 91(49.7) 19(10.4)
Transferred With a document Self-transfer	128(69.9) 55(30.1)
Gender Male female	53(29.0) 130(71.0)
Level of education Primary Secondary Tertiary No formal education	93(50.8) 46(25.1) 11(6.0) 33(18.0)
Occupation Farmer Not employed Teacher Motor cyclists others	87(47.5) 46(25.1) 7(3.8) 2(1.1) 41(22.4)
Marital status Married Single Divorced Widow Widower	100(60.1) 20(10.9) 32(17.5) 19(10.4) 2(1.1)

Factors associated with transferring in of HIV clients.

Among the HIV clients transferred into the Facilities, the predominant age group was in the category of 36–65. Additionally within this group, 51.6% (66) were transferred in with documents while 45.5%( 25) were self-transfers. More females compared to males (75% (96) were transferred with documents. There was no statistical significance between distance, occupation, marital issues, age category, gender and transfer of HIV clients. However long distance was a contributing factor to transfer among the HIV clients that transferred in with documents as shown in Table 2.

Table 2

table showing factors associated with transfer of HIV clients
Variable	Transferred in patients		P value
	Transferred with documents, n (%)	Self-transferred, n (%)
Age category 18–35 36–65 >55	51(39.8) 66(51.6) 11(8.6)	22(40.0) 25(45.5) 8(14.5)	0.466
Gender Male Female	32(25.0) 96(75.0)	21(38.2) 34(61.8)	0.075
Marital Status Married Single Divorced Widow Widower	78(60.9) 12(9.4) 23(18.0) 13(10.2) 2(1.6)	32(58.2) 8(14.5) 9(16.4) 6(10.9) 0(0.0)	0.654
Occupation Farmer Not employed Teacher Motor cyclists Others	61(47.7) 29(22.7) 4(3.1) 2(1.1) 32(25.0)	26(47.3) 17(30.9) 3(5.5) 0(0.0) 9(16.4)	0.366
Distance from previous health facility 0 < 10km 10-20km > 20km	7(5.5) 27(21.1) 27(21.1) 67(52.3)	3(5.5) 14(25.5) 11(20.0) 27(49.1)	0.936
Health facility Rugarama Kamuganguzi Kamukira	38(29.7) 42(32.8) 48(37.5)	9(16.4) 32(58.2) 14(25.5)	0.006
Level of education Primary Secondary Tertiary No formal education	62(48.4) 32(25.0) 7(5.5) 27(21.1)	31(56.4) 14(25.5) 4(7.3) 6(10.9)	0.367

Participant’s reasons for transferring to other health facilities.

The factors/ reasons as to why clients transferred from their previous facilities were grouped into 3; Structural factors which included; lack of transport, long distance to the health facility and poor terrain. Psychosocial factors which included; relocation due to job loses, marriage, divorce, family recommendation, stigma and loss of care takers. Clinic based factors included; long waiting hours, high population of clients and rude health workers. Psychosocial factors were significantly associated with being officially transferred (Chi square value 5.471, df- 1, p value − 0.02 ) as shown in Table 3.

Table 3

Factors associated with transfer of the participants
	Transferred		Total	P-Value
Factors	Transferred with a document n (%)	Self-transferred n (%)
Structural Factors	48(37.5)	29 (52.7)	77 (42.1)	0.56
Psychosocial Factors	74 (57.8)	21 (38.2)	95 (51.9)	0.02
Clinic-based Issues	6 (4.7)	5 (9.1)	11 (6.0)	0.16
Total	128 (69.9)	55(30.1)	183(100)

Follow up of transferred HIV clients.

Only 32.8% (60) of the transferred clients received a phone call from their previous care giving facilities as a means of follow up giving a follow up rate of only 17%. More HIV clients that transferred in with documents (40.6%) were called by a health worker from their previous care giving facility to ascertain if they had reached their new facility compared to the ones that were self-transferred. There was a statistically significant association between being transferred with documents and being follow up (Chi square value 11.87, df -1 and P-value 0.001) as shown in Table 4.

Table 4

Showing Transferred clients who were followed up by their previous facility.
	Transferred		Total
	Transferred with a document n (%)	Self-transferred n (%)
Was called	52(40.6)	8 (14.6)	60 (32.8)
Was not called	76 (59.4)	47(85.5)	123 (67.2)
Total	128 (69.9)	55(30.1)	183(100)

QUALITATIVE RESULTS

This section shows responses from health workers handling HIV positive clients in the selected Health Centers.

Demographic characteristics of participants

The participants were all female, 2 participants from each facility, their age rage was from 22 to 37 years and the range for experience working in the ART clinic was 18 months to 10 years.

Themes that emerged from the responses of participants.

Responses from the participants were categorized into 3 main themes: Identification of clients with official transfer documents, Description of the procedure for transferring and follow up of HIV clients and challenges faced by health workers in transferring of HIV positive client from one care giving centre to another.

Identification of clients with official transfer documents,

Participants cited that most of the clients usually come with transfer in letters that indicate the date of ART initiation, the range of their adherence to the medicine, their CD4 baseline and their most current viral load. They also indicate the reason for transfer and some the contact of the previous health facility as indicated in the quotations below:

“Yes… and some of them indicate the telephone numbers of the health facility that they are from while others don’t ” IDI06 Counsellor

“When they are transferring in they come with some documents that they got from their previous facilities and that is when we know that they are transfers in and want to access our services … the document shows the date when you began your medication, the CD4 counts, your location and contacts of the previous facility” IDI05 Expert Client

“They usually come with a letter that shows the facility where they were accessing their services from so we put that letter in their file for easy identification. We also put a code of TI on their files and documentations so when you are going through their files and you find TI it means that this person did not start their services from here.” IDI 02 Counsellor

Participants also cited that some clients who appear without transfer letters and find it difficult to return to the previous care centres for the letters are treated as visitors to the centres so they can get drug refills

“It is usually difficult for clients to go back to their previous facility to get the transfer letter so sometimes they come as visitors and we give them refills as visitors but most times they come with the transfer letters ” IDI 04 Counsellor

Handling of clients who transfer without documents

Participants mentioned the multiple ways in which clients who come without transfer documents are handled. They cited that the participants who appear with their drug containers and know when they were first enrolled on ART, are given new files and enrolled into the centre. Others without any of this evidence are complex and are referred to the regional referral hospital for enrolment as seen in the quotations below;

“If a patient comes without their documents we first ask them if they have any of the telephones numbers of the health workers that used to handle her at her former facility but if we fail, we ask the patient because some of these patients know the year when they began their medication so we open for them a new file according to that year and most of them usually come with their tins of medicine..” IDI01_Expert client

“Those without tins are a challenge to us and sometimes we send them to the regional referral so that they handle.” IDI01_Expert client

Participants also cited that they at times call the previous facilities to verify the existence of the client in the former care giving facility. It was also noted that the clients without information from previous facility were admitted into care as new patients (‘ART naïve’ patients) in the receiving facility.

“Those that come without documents usually tell us the facility where they usually collect their medicine from so we have a directorate that has phone numbers of facilities; we call them and know when this patient began their treatment and all the other information that is on the transfer letters. Then we work on the patient as a transfer in” IDI06 Counsellor

“For those that fail to tell you which facility they come from…..for such people we don’t have anything to do for them so we just examine their viral load, help them open up a file which is usually the same as that of the new patients.” IDI06 Counsellor

“…if they can’t manage to go back and get the letter but have a phone number of a health worker at the previous facility, we call them and they make the transfer letter and take a picture of that letter and send it to us so we download it and file it” IDI04 Counsellor

“We have a card that has all phone numbers of all facilities in this district so when the patient tell us the facility they are from, we call and get in contact with them. We ask this patient detail so when we call we verify with the facility and if they tell us that they don’t know this patient so we see how to handle them either record them as a new client because you’re not sure whether they are actually a transfer in” IDI05 Expert Client

“Of course it is really difficult for us to handle with such issues so we make them start a fresh, test the a fresh the CD4 and it is from this that you will know what kind of medication to give the patient” IDI05 Expert Client

Procedure for transferring and follow up of HIV clients

The participants cited that the procedure of transferring out patients includes giving clients who want to transfer out transfer letters that indicate all the client details and the facility contact and also refilling their drugs before they leave and sometimes the health workers advise clients that are constantly complaining of long distance and lack of transport to transfer to nearer health facilities. Clients that are transferring out are asked to leave their phone contacts behind for follow up and the transfer letters also indicate that the health facilities the clients transfer to should notify the previous health facility that the clients have reached as indicated in the quotations below:

“If someone comes to us and tells us that they want to change facility to another because they got a new job, we give them a transfer letter that contains all the information that is about them, the medicine they have been taking, their viral load and the reasons to as why they are transferring and the facility that they want to go to then we also indicate our telephone number. In the mean time we give them medicine to be taking as they are transferring to another facility, after transfer out we have put their files in a separate place.” IDI02_Counselor

Participants also cited that follow up of the transferred clients is done by calling the care centre where they transferred the client or going to the centre and verify if the client reached in cases where the centre is nearby as quoted below;

“Yes… we do follow ups because the transfer letter we give them indicates that they should notify us once they have received our patient so they call us and inform us that they have received our client” IDI02_Counselor

“If it is a nearby place we go there and follow up but if it is not accessible there is nothing that we can do honestly or sometimes we call the client because we have their phone number and we follow up and know if they are taking their treatment” IDI02_Counselor

“Before the patient leaves, we try and get a telephone number from them and when he goes you call them and ask whether they went to the facility. We have counsellors, peers and the ART focal person so this people play a big role in the follow up” IDI03_Counsellor

One of the participants cited that follow up of clients from the centre which has transferred is uncommon, they just await phone calls from the receiving health centre.

“It is not common but usually the facilities where we have transferred them call us to inform us that they have received the patient. But I have not really seen the health workers following up transfer outs, they did not take it as something that is important” IDI01_Expert client

Challenges in transferring of HIV positive clients from one facility to another

Participants cited that transfer in of clients without documents is a challenge as some of them lie that they are ART naive. Some of those that transfer in with documents have a wrong medication documented which is also a major challenge as indicated in the quotations below:

“Some of them once they realize that they don’t have any documents, they lie to the health workers that they have never been on medication and have even never tested to know their status, others once they see the people that know them at the facility, they get shy and ask for referral” IDI01_Expert client

“Sometimes you find that the other facility is writing a wrong medicine from the one that they have been taking so sometimes you find that you are giving the patient a wrong medication but they challenge you and tell you that you have given them different medicine from what they usually take” IDI01_Expert client

“Sometimes we get defaulters and initiating them into our medical routine becomes difficult and they find challenges and this becomes more difficult for patients that have stigma so it becomes hard to supress them. We also face challenges of people who give us false information like changing names so that they can’t be known” IDI05 Expert Client

“Some of them come without phones and after that visit they don’t come for another and they get lost so you can’t get in contact with them anymore so some people come and you find that even the names they used for their transfer in are actually not their real names, you even look for them where they stay and you don’t find them” IDI06_Counsoller

Participants also reported difficulties follow up of clients who transfer out as their phone numbers become unavailable. Another challenge is that some clients delay to the reach facilities they are transferring to and others become defaulters as indicated in the quotations below:

“We usually find challenges referring patients to far places because we usually find challenges with follow ups because the number of the patient becomes unavailable and the facility also doesn’t call us so we stay there without any information” IDI02_Counselor

“Some clients give us wrong details like about their age and name for example sometime we got clients that didn’t have any documents so we decided to test them newly so we started them on the first line when they were actually on the second line already so they reacted to that because they had lied to us which was not good” IDI03 Counsellor

“Some patients are mobile, you give them a transfer letter and after like six months they come back with another transfer letter and you again include them in the files and after some months they again go, another thing is that there are some patients that transfer themselves, they go without telling you so you look for the patient and they get lost. Another challenge is that some clients give you a wrong telephone number and when you want to follow them, the numbers don’t pass through” IDI04 Counsellor

PREVALENCE OF TRANSFERRED IN HIV CLIENTS

Our study indicated that the general prevalence of transferred in HIV clients was 7.67%. This is lower than what has been reported in another study done in East Africa which reported that the total prevalence of transferred HIV clients as 14% (Geng, Odeny et al. 2016). The low prevalence can be attributed to some of the HIV clients who should be in the transferred in category being reported as ART naïve because of lack of transfer documentation and clients’ falsification of their information as mentioned by the ART clinic workers compared to the studies done in areas where support for electronic client data bases enable follow up of clients.

Multiple systems of drug refills with longer return dates up 6 months have reduced accessibility to the clients. The likely hood of having mobile clients who keep visiting different centers as told by the clinic workers also greatly impacted the true prevalence of transferred clients.

The prevalence of HIV positive clients with official transfers (69.9%) was high in our study compared to other studies which reported a low prevalence of official transfers as 4% and 25.8% respectively [9, 10]This can be attributed to the encouraged practice of implementation of the new guidelines for transferring client. Also the creation of community based drug distribution centers which has contributed to the elimination of one of the most important factors associated with transfer (distance to health centre and lack of transport).

The prevalence for self-transfers or unofficial transfers (30.1%) was high in our study compared to other studies. Multiple factors contribute to this prevalence including structural issues like lack of transport to the previous health facility, terrain as some clients reported that they have to climb hills or go around swamps to reach the health facility.

Factors associated with transfer of HIV positive clients

In our study, the number of transferred HIV clients was more among age category 36–65 years, with those transferring with documents being higher than those that self-transferred. This was different from other studies including one that reported being younger (less than or equal to 25) as a risk factor for transfer out of patients [10].

Furthermore, our study found that the number of transfers was generally higher among females than males with more females being transferred with documents as compared to males. Similar findings have been reported in another study which indicated that being a woman was associated with attending multiple clinics [12]. Transfer was also associated with failure to have specialized services such as contraceptives and comorbidity clinics at the initial caregiving center [15].

In our study, more married clients were reported as transfers. This is most likely because some relocated to stay with their partners and female clients relocated after marriage to stay with their husbands. This tendency of transferred clients being most likely to be married has been alluded to by another study which showed that clients who were not living with their partners were 4.53 time more likely not to reach the allocated ART centre after getting a transfer [17].

Our study also found that more of the transfers were farmers compared to other occupation groups. This is in line with what another study has previously reported that transfer of adults can be dependent on their occupation and availability of job opportunities which majorly affected people with mobile jobs. A client would opt to go to a nearer health facility because they don’t have transport money [15]

In our study, most clients transferred due to long distance from their homes to their previous facility. Clients whose distance was greater than 20kmwere mostly likely to transfer to another facility because they had no money for transport. Our finding agrees with a previous study that reported that poverty was one the factors that influenced patient transfer. A client would opt to go to a nearby health facility because they didn’t have transport money [15].

Our study found a significant association between health facility and transfer of HIV clients which is similar to other studies which indicated that some the factors associated with transfer of HIV clients are the good reputation of the facility, this was described in terms of care services provided, client-care giver relationship, absence of translation services for the clients that cannot speak English and location of the facility were listed as very important contributors to transfer of patients[15].

Follow up of transferred clients

Though the process of transferring of clients was known by the ART clinic workers, we observed a low number of clients being followed up. Some challenges that emerged as reasons for the low follow up were that some clients could not be traced, unavailable client phone numbers, falsified client biographic data, mobile clients who keep moving from one clinic to another and finally health workers not finding importance in calling the receiving health centre or client to verify if they have arrived at their new center. Studies have reported that part of the lost to follow up clients are self-transfers in other care facilities and with phone calls as a means to follow up re-engagement and retention into care was achieved [18]. The attitude of not finding importance in calling transferred clients creates a more profound gap in the efforts of follow up and eventually retaining of patients into care.

Counsellors mentioned that they sometimes personally follow up the clients if the transfer facility is nearby but when the transfer facility is far nothing is done about that client. This was similar to another study where an outreach coordinator for follow up of clients lost to care was found effective in tracing clients, re- engagement and retention[19]. This however to be effective requires an available funding structure which is a common possibility for developed countries but may not be in the reach for health facilities in rural settings in low income countries.

The ART clinic workers also reported that they would call the transferring facility immediately when a transferred in client arrived so as to get baseline information about the client but it was not common to call the receiving health facility or client whenever they transferred them out of their facility. This is a gap in care as studies have shown that immediate tracing including accurate recording of phone contact of clients in a health tracking system as well as and regular contacting of the lost to follow up and transferred clients greatly increases the probability of return into care [20, 21].

Though the study showed an increased number of clients officially transferring to other centres, there is still a high number of clients self-transferring due to structural factors like lack of transport. It is of great importance to put effort in systems like community-based drug distribution which help reduce costs of reaching the centres. Tracing and follow up was generally low with mainly the receiving facility calling the transferring facility for clients that had documents. Creation and implementation of more rigorous and innovative ways of registering and following up of transferred clients should be paramount for the improvement in the quality of care for these clients.

Recommendations:

Rigorous monitoring and tracing systems at all levels of care are necessary for retaining transferred clients into care.

Establishing active outreach coordination teams that can follow up transferred clients.

Continuous monitoring of the records and numbers of the clients in each centre can also provide alerts for clients who could have self-transferred to other clinics.

Limitations and delimitations to the study

Having small number of participants was a limitation as many of the clients subscribe to village drug distribution points and community based drugs collection groups. This was mitigated by including all the participants who meet the inclusion criteria at all the selected health centers.

Conflict of Interest

All authors declare no conflict of interest

Author contribution:

Conceptualization and Proposal Writing: Syson Karungi, Shibah Babeho, Rachel Luwaga

Data collection: Syson Karungi, Shibah Babeho, Rachel Luwaga

Formal analysis:Syson Karungi, Shibah Babeho, Rachel Luwaga

Mentorship: Rachel Luwaga

Writing – original draft: Syson Karungi, Shibah Babeho, Rachel Luwaga

Writing – review & editing: Syson Karungi, Shibah Babeho, Eve Katushabe, Gladys Nakidde, Timothy Nduhukire, Jane Kabami, Rachel Luwaga

Acknowledgement

The authors thank the District Health Officer for Kabale District and the health workers of respective health facilities; namely Rugarama Hospital, Kamukira health center IV and Kamuganguzi health center III for their support.

Additionally the authors are grateful to all the participants who took part in this study.

We also acknowledge the HEPI TUITAH Principal Investigator, Professor Celestino Obua for the great effort in expanding research horizons at undergraduate level in all the Universities in this Partnership.

We acknowledge the CO Principal Investigators; Kabami J, Maling S, Rukundo G, Wakida E and Komachech, E for the job well done in executing the tasks for the programs in each of the Universities to completion

Funding Disclosure

Research reported in this publication was supported by the Fogarty International Center (U.S. Department of State’s Office of the U.S. Global AIDS Coordinator and Health Diplomacy [S/GAC] and the President’s Emergency Plan for AIDS Relief [PEPFAR]) of the National Institutes of Health in the form of a grant (R25TW011210). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

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No competing interests reported.

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Editorial decision: Revision requested
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Factors associated with interfacility transfer and follow up of adult HIV positive clients in South Western Uganda

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Abstract

Introduction

Methods

Results

Conclusion

Figures

INTRODUCTION

METHODS

Study setting and design

Study population

For the quantitative study

For the qualitative study

Sample size and Sampling technique

For qualitative

Data collection tools

RESULTS

Descriptive statistics for study participants

QUALITATIVE RESULTS

Demographic characteristics of participants

Handling of clients who transfer without documents

Procedure for transferring and follow up of HIV clients

Challenges in transferring of HIV positive clients from one facility to another

DISCUSSION

PREVALENCE OF TRANSFERRED IN HIV CLIENTS

Factors associated with transfer of HIV positive clients

Follow up of transferred clients

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1