Hospitalized with HIV in Zambia: individual and system factors driving the high burden of admissions and post-discharge mortality in the era of HIV epidemic control.

Background: Despite progress towards HIV epidemic control, people living with HIV (PLHIV) in Zambia continue to face high mortality during and especially after hospitalization, with suboptimal post-discharge care leading to poor outcomes. We conducted a qualitative study to better understand factors influencing post-discharge engagement in care for HIV and associated comorbidities.

Methods: We conducted in-depth interviews with 16 recently discharged PLHIV, seven caregivers, and two doctors; and three focus group discussions with inpatient doctors (n = 8) and lay counsellors (n = 16) at two tertiary hospitals in Lusaka, guided by the social-ecological model. Data were audio-recorded, transcribed verbatim, managed with Atlas.ti 9, and thematically analyzed.

Results: Individual and household-level barriers to post-discharge care for PLHIV included HIV status denial and stigma, limited disclosure, and limited social and emotional support. Health-related barriers included concomitant treatments for TB, HIV comorbidities, and behavioral health issues like depression and alcohol abuse. Health system barriers included limited confidentiality during admission and poor communication between healthcare providers and between facilities aftercare transitions following discharge. Social-economic factors included economic shocks of hospitalization and post-discharge recovery, which compounded pre-existing poverty and high transportation and food costs. Conversely, disclosure of HIV status, better social support, a financially stable household, and hospital follow-up appointment reminders facilitated better post-discharge care.

Conclusion: After hospital discharge with HIV, system and individual challenges exacerbate pre-existing interpersonal, health, environmental, and system-related factors to cause poor outcomes. Holistic community-based interventions to facilitate these patients' re-engagement in care after discharge could help HIV programs reach the last mile in epidemic control.