Understanding Drivers of Loss to Follow‐Up in HIV Care in Oromia Regional State, Ethiopia: A Qualitative Grounded Theory

Background: Despite significant advancements in antiretroviral therapy (ART), loss to follow-up (LTFU) remains a critical challenge in HIV care, particularly in low-resource settings like Ethiopia. LTFU contributes to increased morbidity and mortality rates, heightened transmission risks, and treatment failure. While individual and clinical factors have been widely studied, structural drivers of LTFU are less understood. Hence, this study aimed to understand the structural factors driving LTFU in HIV care. Methods: A qualitative study using grounded theory was conducted. Data were collected through Key Informant Interviews (KIIs) with program staff, Focus Group Discussions (FGDs) with social support groups, and group interviews with program coordinators and regional directors. Thematic analysis was performed using ATLAS. ti. Software version 7.5.18, and findings were reported following the Standards for Reporting Qualitative Research (SRQR). Results: Four key themes emerged from the analysis: (1) programmatic and service challenges, including drug supply interruptions, inadequate service integration, and human resource shortages; (2) weak transfer, linkage, and tracing systems, marked by gaps in referral networks and untraceable client identifiers; (3) cultural and socio-behavioral factors, such as stigma, discrimination, and reliance on faith-based healing practices. Participant quotations highlighted the pervasive impact of stigma and weak referral systems on patient disengagement from HIV care; and (4) integration gaps in social change and stakeholder engagement, including weak counseling services and limited collaboration with non-governmental organizations and community organizations. Conclusion: The findings underscore the critical role of structural factors in shaping retention in HIV care in Oromia. Addressing these barriers may benefit from a multi-faceted approach, including strengthening health systems, improving referral and tracing mechanisms, reducing stigma, and enhancing stakeholder engagement. These insights provide a foundation for targeted interventions to reduce LTFU and improve HIV care outcomes in the region.