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Abstract
Objectives This article considers the potential of ‘theories of practice’ for studying and understanding varied (dis)engagement with HIV care and treatment services and begins to unpack the assemblage of elements and practices that shape the nature and duration of individuals’ interactions with HIV services.
Methods We obtained data from a multicountry qualitative study that explores the use of HIV care and treatment services, with a focus on examining the social organisation of engagement with care as a practice and as manifested in the lives of people living with HIV in sub-Saharan Africa. The dataset comprised of 356 interviews with participants from six countries.
Results We noted fluctuating interactions with HIV services in all countries. In line with theories of practice, we found that such varied engagement can be explained by (1) the availability, absence and connections between requisite ‘materialities’ (eg, health infrastructure, medicines), ‘competencies’ (eg, knowing how to live with HIV) and ‘meanings’ (eg, trust in HIV services, stigma, normalisation of HIV) and (2) a host of other life practices, such as working or parenting. These dynamics either facilitated or inhibited engagement with HIV services and were intrinsically linked to the discursive, cultural, political and economic fabric of the participating countries.
Conclusion Practice theory provides HIV researchers and practitioners with a useful vocabulary and analytical tools to understand and steer people’s differentiated HIV service (dis)engagement. Our application of practice theory to engagement in HIV care, as experienced by HIV service users and providers in six sub-Saharan African countries, highlights the need for a practice-based approach in the delivery of differentiated and patient-centred HIV services.
- Social Theory
- Patient Engagement
- HIV
- Health Services Research
- Highly Active Antiretroviral Therapy
- Africa
This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/
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Footnotes
Handling editor Jackie A Cassell
Contributors All authors contributed to the development of The Bottlenecks Study protocol under the leadership of AW and OB. CN, JW, MM, WD, KO supervised the data collection by trained research assistants and prepared detailed site reports. MS conducted the analysis and prepared the first draft of this manuscript. OB, AW, JR, JS, SP, SB, MM made significant contributions to the manuscript and revised it for intellectual content. All authors have read and commented on the manuscript. All authors have approved the final manuscript and act as guarantors of the paper.
Funding The bottlenecks study was funded by the Bill & Melinda Gates Foundation (OPP1082114). This paper was also made possible with the support of The Wellcome Trust (085477/Z/08/Z) and the National Institutes of Health (NIH) through the IeDEA project. AW is funded by a Population Health Scientist award, jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement and is also part of the EDCTP2 programme supported by the European Union.Research (undertaken in Kisesa and) reported in this publication was supported by the National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institute on Drug Abuse, National Cancer Institute and the National Institute of Mental Health, in accordance with the regulatory requirements of the NIH under award number U01AI069911 East Africa IeDEA Consortium. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Competing interests None declared.
Ethics approval Ethical approval was granted by the London School of Hygiene and Tropical Medicine and the relevant ethics boards at each of the study settings. These were the following: Malawi National Health Sciences Research Committee no. 15/5/1427 (Karonga); Medical Research Coordination Committee MR/53/100/370 (Kisesa); Uganda National Council for Science and technology (UNCST)- HS1857 (Kyamulibwa) and Office of the president ADM154/212/01 (Rakai); Kenya Medical Research Institute (KEMRI) Scientific and Ethics Review Unit (SERU) KEMRI/SERU/CGHR/018/3115 (Kisumu); Medical Research Council of Zimbabwe MRCZ/A/1990 (Manicaland) and University of KwaZulu Natal (UKZN) UKZN/BE338/15 (uMkhanyakude). Informed and written consent was obtained from all participants.
Provenance and peer review Commissioned; externally peer reviewed.
Data sharing statement The data corpus sits with the ALPHA Network at the LSHTM. The ALPHA Network and its members will continue to publish from the data. Access to the data may be provided on request from AW (Alison.Wringe@lshtm.ac.uk).