My family sold a cow to pay for my Traditional doctor and now there’s no money to travel to the HIV clinic: barriers to antiretroviral adherence among rural-Indigenous peoples living with HIV in the Comarca Ngäbe-Buglé, Panamá

Abstract

AbstractIntroductionThe Comarca Ngäbe-Buglé (CNB) is an administratively autonomous Indigenous region in Western Panama that is home to over 200,000 individuals of Ngäbe and Buglé ethnicities. The CNB is the most impoverished region in Panama and is relatively isolated from outside influences, with limited roads, electricity, and internet connection. Around 1.5% of all rapid HIV tests are positive, compared to a national prevalence of 0.9%; in CNB, diagnosis tends to be late where 56.3% of individuals had an initial CD4 count of <350 cells/mm3. In this region, antiretroviral treatment (ART) dropout is five times higher than the national average; there is high early mortality due to opportunistic infections. This study aims to describe some of the barriers associated with ART adherence and retention in HIV care among PLHIV the CNB. A better understanding of factors that obstruct adherence could lead to more effective HIV care and prevention in CNB.MethodsWe conducted 21 semi-structured interviews with PLHIV who reside across all three regions of the CNB and who have attended an ART clinic at least once. The interviews took place between November 2018 and December 2019.DiscussionPsychological health and social support and discrimination acted as both individual-level facilitators and barriers to adherence and retention. Notably, structural barriers included difficult access to ART care due to travel costs, ART shortages, and uncooperative Western/Traditional medical systems. Recommended interventions used in other Low- and Middle-Income settings include increasing peer and family-level support and community knowledge and understanding of HIV infection. Additionally, we suggest structural interventions, including decreasing cost and distance of travel to the ART clinic through decentralization of services and multi-month dispensing, decreasing food scarcity, and increasing collaboration between Western and Traditional providers.