Barriers and facilitators to linkage to HIV care after hospital discharge among adults living with advanced HIV disease in Uganda: a COM-B-guided qualitative study.

Abstract

Background: Hospital discharge represents a high-risk transition period for people living with HIV, particularly those with advanced HIV disease. In low-resource settings, substantial gaps persist in linking these individuals to outpatient HIV care following hospitalisation. This study explored barriers and facilitators to post-discharge linkage to care from the perspectives of patients and healthcare workers (HCWs) in Eastern Uganda.

Methods: We conducted a descriptive qualitative study at Mbale Regional Referral Hospital between May and October 2025. Guided by the capability, opportunity, motivation, and behaviour (COM-B) model, we conducted 20 in-depth interviews with adults with advanced HIV disease who had recently been discharged from the medical ward (10 who successfully linked to care and 10 who did not), alongside 10 key informant interviews with HCWs involved in their care. Data were analysed using a thematic framework approach aligned with the COM-B constructs.

Results: Patient-reported barriers included physical weakness (physical capability), limited knowledge of the linkage process (psychological capability), high transport costs and long travel distances (physical opportunity), and stigma or non-disclosure of HIV status (social opportunity). HCWs identified the absence of standardised linkage protocols, post-discharge follow-up mechanisms, and incentive structures as key systemic barriers (physical opportunity). Facilitators reported by patients included initiation or resumption of antiretroviral therapy (ART) before discharge (physical opportunity), support from peer supporters and disclosure to caregivers (social opportunity), and fear of clinical deterioration (reflective motivation). HCWs identified the existing TB-HIV linkage system (reflective motivation) and the presence of ward-based linkage counsellors (physical opportunity) as enabling factors.

Conclusion: People living with advanced HIV disease face multiple, interrelated barriers to linkage with HIV care following hospital discharge, including physical debility, limited knowledge of the linkage process, financial and geographic constraints, and stigma. Conversely, pre-discharge ART initiation, peer support, and disclosure facilitate successful linkage. Strengthening post-discharge care will require standardised linkage protocols, structured follow-up mechanisms, and expanded use of peer supporters within health systems.