Strategies to improve retention in care among people living with HIV at health facilities in Manaus, Brazil: insight from health care providers

Abstract

BACKGROUND: Retention in HIV care is a key component of the continuum of care and is essential for achieving the UNAIDS 95-95-95 targets. In Manaus, Northern Brazil, despite advances in HIV treatment and prevention, loss to follow-up among PLHIV remains a significant barrier to viral suppression and epidemic control. The present research explored health care providers' perspectives on strategies to improve retention in care among people living with HIV (PLHIV) at referral health facilities in Manaus. METHODS: A qualitative cross-sectional study was conducted between November 2023 and October 2025 in six public health facilities in Manaus. Semi-structured, in-depth interviews were performed with 56 health care providers, including physicians, nurses, social workers, psychologists, pharmacists, and HIV/AIDS program state managers. Data were analyzed using thematic framework analysis with MAXQDA software. RESULTS: Six major themes emerged from the analysis: (1) monitoring and follow-up of PLHIV, (2) challenges related to loss to follow-up, (3) impact of loss to follow-up on UNAIDS 95-95-95 goals, (4) barriers to retention, (5) strategies to optimize retention, and (6) state-level initiatives to improve retention. Providers identified poverty, food insecurity, unemployment, stigma, discrimination, transportation barriers, substance use, and health system constraints such as workforce shortages, long waiting times, and lack of privacy as key drivers of disengagement. Proposed strategies included strengthening multidisciplinary teams, promoting continuous professional training, implementing patient-centered and stigma-free care, enhancing active patient tracing, expanding digital communication tools, decentralizing services, and ensuring adequate financial and human resources. CONCLUSIONS: Retention in HIV care in Manaus is shaped by complex social and systemic factors. Integrated, multisectoral strategies addressing socioeconomic vulnerabilities and service-level barriers are essential to improve long-term engagement in care and advance progress toward the UNAIDS 95-95-95 targets.