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. 2026 Feb 4;21(2):e0337637. doi: 10.1371/journal.pone.0337637

Determinants of return to HIV treatment after interruption on ART among HIV positive clients in Katakwi District, Uganda

William Okello 1,*, Saadick Mugerwa Ssentongo 1, Bonniface Oryokot 1, Baker Bakashaba 1, Ronald Opito 1,2, Bosco Opio 3, Christine Acio 3
Editor: Ibrahim Jahun4
PMCID: PMC12872005  PMID: 41637412

Abstract

Background

Returning to treatment following interruptions is crucial for achieving optimal HIV care outcomes. In Uganda, despite a 20% treatment interruption rate, only 58% of clients successfully resume treatment. Evidence on determinants of returning to treatment remains limited. This study aimed to identify determinants of return to HIV treatment after interruption in Katakwi District, Uganda.

Methods

We conducted a cross-sectional study at three high-volume antiretroviral therapy (ART) clinics in Katakwi District. Data were collected using face-to-face interviews from study adult participants and analyzed using Poisson generalized estimating equations (GEE) with robust standard errors to identify factors independently associated with a return to care.

Results

The rate of return to care was 63.9%. Clients without an occupation were less likely to return (aRR = 0.80, 95% CI: 0.73–0.88, p < 0.001). Surprisingly, those living within 5 km of a facility were also less likely to return compared to those 5–10 km away (aRR = 0.78, 95% CI: 0.63–0.95, p = 0.019). Positive community beliefs about treatment adherence significantly increased the likelihood of returning (aRR = 1.18, 95% CI: 1.06–1.33, p = 0.003), as did belonging to a community support group (aRR = 1.16, 95% CI: 1.01–1.39, p = 0.04).

Conclusion

Return to HIV care was associated with occupation, distance to the facility, community beliefs, and belonging to a community support group. Interventions to improve re-engagement should include targeted economic support for unemployed clients, community-based anti-stigma campaigns, flexible clinic hours, and improved rural access through mobile clinics. Continuous client education at both the facility and community levels is essential.

Introduction

Return to treatment refers to clients’ initiative to reinitiate care after a gap of 28 days or more from the last expected clinical contact or drug pick up [1]. Globally, despite the availability of safe ART, only 28.2 million out of the 37.7 million people living with HIV (PLHIV) are currently accessing antiretroviral therapy (ART), a situation resulting from poor retention in care stemming from a sub-optimal return to treatment [1–3]. Global estimates of return to treatment rates remain low, varying from 32.7% in America, 12.1% in Europe, and around 39.4% in Africa [4]. In sub-Saharan Africa, which has an estimated 16 million people living with HIV, only 12 million are currently in treatment, despite tremendous scale-up activities to increase access to ART [5–7].

In Uganda, 80.9% of adults living with HIV were aware of their HIV status, and of these, 96.1% were on ART [8]. Although the country has made commendable strides in increasing ART coverage, treatment interruption rates are as high as 12%, well above the acceptable threshold of 2%. In response, Uganda has implemented various interventions to improve return to treatment, including using physical locator forms, phone calls, and physical tracing of clients who interrupt treatment. Despite these efforts, retention rates are still suboptimal at 81%, far below the Joint United Nations Program on HIV/AIDS (UNAIDS) target of 95%, and also return to treatment (RTT) of only 58%, short of the 95% UNAIDS target [9,10].

Katakwi district has one of the highest numbers of clients in care (5,600) in the Teso Sub-region, second only to Soroti City. It registered a high treatment Interruption rate of 4% with a low RTT rate of only 67% compared to the rest of the districts in the region in January-March 2024 [11]. The dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on return to treatment predictors to guide HIV programs to better support patient engagement [12,13].

Several studies have identified various reasons why people interrupt their HIV treatment, including individual factors such as fear, unstable income, forgetting to take medication, and negative attitudes towards healthcare workers, stigma, lack of social support, poor community support systems, and unsupportive clinic structures, as well as other associated factors that may contribute to a return to care [2,10,14–17]. Interruption in treatment results in clinical deterioration, viral resistance, persistent viremia, ongoing HIV transmission, poor health outcomes, high mortality, and loss of economic opportunities. Up to 30% of hospital HIV-related admissions occur amongst people who interrupt treatment [10,12,18–20]. This study aimed to examine determinants of return to HIV treatment after interruption in Katakwi District, Uganda. The findings will inform the development of strategies to re-engage lost patients, ensure treatment adherence, achieve viral load suppression for improved health outcomes.

Materials and methods

Study design

This was a cross-sectional study. Data were collected using a structured questionnaire by 31st July 2024. The findings were reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [21].

Study population

The Study population consisted of PLHIV aged 18 years and above with a history of treatment interruption who either returned to care or had not yet successfully returned to care. Participants were recruited from three ART sites in Katakwi District, purposively selected for having the highest client volumes in the district.

Study setting

The study was conducted at three high-volume ART clinics in Katakwi District: Katakwi General Hospital, Magoro Health Center III, and Ngariam Health Center III, which together serve 73% of the total PLHIV in the district. Katakwi District had a total of 5,600 PLHIV as of January-March 2022 and is located approximately 350 km northeast of Kampala. The district has a total population of 234,705 according to the 2024 Uganda National Housing and Population study [22]. The district is characterized by a semi-arid climate, with cattle-keeping and subsistence farming as the major economic activities. The district borders Karamoja to the east, and insecurity caused by cattle rustlers may hinder return to care [23].

Inclusion and exclusion criteria

We included all PLHIV 18 years and above receiving care from the three high-volume sites, who had experienced treatment interruption between October 2023 and June 2024. We excluded clients with a history of psychiatric illness impairing their ability to provide informed consent, those who did not consent to the study, incarcerated individuals, those too ill or admitted, and those residing outside the Katakwi District.

Sample size estimation

A sample size of 355 was calculated using the Kish-Leslie formula (1965) [24] for a cross-sectional study in a single population with an estimated return to treatment following interruption at 70% from a previous study [25], a type 1 error of 5%, a 95% confidence level (Z = 1.96), and a 10% non-response rate. The sample size was then distributed proportionally among three selected facilities based on their PLHIV caseload in care as of the January-March 2024: 229 from Katakwi General Hospital, 65 from Magoro Health Center III, and 61 from Ngariam Health Center III.

Sampling procedures

Participants with a history of treatment interruption were identified through the Open Electronic Medical Record System (EMRS) at the three sites. The identified participants were cross-checked with their paper-based charts in real time to ensure data accuracy and minimize misclassifications due to missing or incorrect data entries. A sampling frame was created from this list, and participants were selected using consecutive sampling. All eligible clients with appointments during the study period were interviewed; those with later appointments were called back for an interview. Clients who had interrupted treatment but not returned were followed up and interviewed.

Study variables

The Primary Outcome was Return to treatment, defined as reinitiating treatment after a gap in care of more than 28 days [26].

Interruption in treatment (IIT), defined as no clinical contact for 28 days or more after the last expected clinical contact or drug pick up [22].

Lost to Follow Up (LTFU) was defined as no clinical contact for at least 90 days after the last expected clinical visit [27].

The Independent Variables included socio-demographic characteristics (age, Sex, educational level, occupation, and marital status), clinical factors (duration on ART, Mode of care, Line of treatment (first, second, and third line), Distance to clinic, HIV status Disclosure, community factors (belonging to community support groups, and beliefs in the community against ITT and community networks) and Institutional factors (Clinic Operating Hours, adequacy of Privacy, having received Phone/Short Message Service (SMS) reminders, experience of Drug Stock Out, and adequacy of Health workers.

Data collection.

Data on clients who had missed appointments was first collected by trained research assistants from the Open EMRS system and triangulated with paper-based charts and registers to ensure accuracy and completeness, and to avoid misclassification. From this extracted data, individuals with a history of treatment interruption (both those who had returned to care and those who had not yet returned to care) were identified. We then further collected data from these identified individuals through face-to-face interviews administered by structured questionnaires. The interview lasted between 10–20 minutes using a questionnaire based on the existing literature and translated into the local language (Ateso).

Data analysis.

The data were entered into Microsoft Excel, where it was cross-checked and validated for correctness and completeness. After checking for missing data and unsound entries, the data were exported to STATA version 17 (College Station, TX: StataCorp LLC) [28]. Descriptive statistics were summarized using proportions for categorical variables, means with SDs for continuous variables with normal distributions, and medians with interquartile ranges (IQRs) for continuous variables with skewed distributions. The association of return to treatment and categorical variables was assessed using the Chi-square test or Fisher’s exact tests, and associations between return to treatment and numerical variables were assessed using Student’s t-test or Mann–Whitney U tests. We used Poisson generalized estimating equations (GEE) with robust standard errors, accounting for clustering at the health facility level and adjusting for Variables with a p < 0.2 at bivariate analysis and clinically relevant variables identified in the literature. The results were presented as Crude Risk ratios (cRRs) and adjusted Risk Ratios (aRRs) with a 95% confidence interval. A p  value of < 0.05 was considered statistically significant for analysis.

Ethical approval and consent to participate.

The study received ethical approval from Lira University Research and Ethic Committee (LUREC-2024–235). Participants provided written informed consent, and each participant retained a signed copy after the study. Administrative clearance and permission were obtained from the District Health Officer of Katakwi District, the Hospital Medical Superintendent of Katakwi Hospital, and the person in charge of Magoro and Ngariam H/C III. Confidentiality was maintained by ensuring that individual patient-level data obtained was de-identified, encrypted, and passworded to ensure access by only an authorized team of investigators.

Results

Recruitment

Of the 386 clients with a history of treatment interruption who were approached, 20 declined participation, 5 were misclassified as having interrupted treatment, yet they had picked up their ART, and 6 had transferred to other facilities. A total of 355 clients were included in the final analysis (Fig 1).

Fig 1. Study flowchart for the determinants of return to HIV treatment after interruption on ART among HIV positive clients in Katakwi District.

Fig 1

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Baseline characteristics

In this study, the majority of the participants were aged 18–30 years (67.6%, n = 240) with a median age of 44 (interquartile range of 35–52). The majority (57.2%, n = 203) were female. In terms of education, 52.1% (n = 185) had primary education, 27.9% (n = 99) had no formal education, 13.2% (n = 47) had secondary education, and 6.8% (n = 24) had tertiary education. More than three-quarters of respondents had an occupation (93.8%, n = 333). In this study, 65.4% (n = 232) of the participants were married, 22.8% (n = 81) were single, and 11.8% (n = 42) were widowed as shown in Table 1 below.

Table 1. Social demographic characteristics.

Variables Frequency, N = 355 (%)
Median Age: 44 (interquartile range: 36–52)
Age category in years
 18-30 240 67.6
 31-40 70 19.7
 41-50 30 8.5
 50+ 15 4.2
Gender
 Female 203 57.2
 Male 152 42.8
Education level
 None 99 27.9
 Primary 185 52.1
 Secondary 47 13.2
 Tertiary 24 6.8
Occupation
 No 22 6.2
 Yes 333 93.8
Marital Status
 Married 232 65.4
 Single 81 22.8
 Widowed 42 11.8
Duration on ART
  ≤ 5 years 73 20.6
  > 5years 282 79.4
Mode of care
 Community Model 87 24.5
 Facility Model 268 75.5
Treatment line
 First Line 325 91.5
 Second Line 24 6.8
 Third Line 6 1.7
Distance to clinic
  < 5 kms 121 34.1
 5–10 kms 139 39.2
  > 10 kms 95 26.8
Disclosed HIV status
 No 22 6.2
 Yes 333 93.8
Belonging to a community Support Group
 No 116 32.7
 Yes 239 67.3
Beliefs against IIT in the community
 No 186 52.4
 Yes 169 47.6
Community Support networks for follow-up
 No 42 11.8
 Yes 313 88.2
Favourable Clinic Operating Hours
 No 49 13.8
 Yes 306 86.2
Adequate Privacy at the facility
 No 83 23.4
 Yes 272 76.6
Received Reminder calls/SMS for appointment
 No 102 28.7
 Yes 253 71.3
Drug stockouts during refills
 No 222 62.5
 Yes 133 37.5
Availability of enough health workers to offer services.
 No 146 41.1
 Yes 209 58.9
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Prevalence of return to treatment following interruption in treatment

Among the PLHIV, 63.9% (n = 227, CI: 58.8%–68.7%) returned to treatment after an interruption, while 36.1% (n = 128) did not.

Determinants of return to HIV treatment after interruption

In bivariate analysis, mode of care, distance to the clinic, community beliefs about treatment interruption, and adequate privacy during service provision were significantly associated with returning to care.

Clients in the community care model had a higher return rate (83.9%) compared to those in the facility model (57.4%). Furthermore, clients living within 5 km of the clinic were less likely to return to treatment (50.4%) compared to those living 5–10 km away (69.1%) and those living more than 10 km away (73.7%). Clients in communities with beliefs discouraging treatment interruption had a higher rate of return to care (79.3%) compared to those in communities without such beliefs (50.0%). Clients who experienced adequate privacy were more likely to return to treatment (66.9%) compared to those who did not (54.2%), as shown in Table 2.

Table 2. Determinants of return to HIV treatment after interruption in Katakwi District, Uganda.

Variables N = 355 Return to treatment p-value
No (n = 128, 36.1%) Yes (n = 227, 63.9%)
Age category in years
 18-30 240 (67.6) 86 (35.8) 154 (64.2) 0.971
 31-40 70 (19.7) 26 (37.1) 44 (62.9)
 41-50 30 (8.5) 10 (33.3) 20 (66.7)
 51+ 15 (4.2) 6 (40.0) 9 (60.0)
Gender
 Female 203 (57.2) 72 (35.5) 131 (64.5) 0.79
 Male 152 (42.8) 56 (36.8) 96 (63.2)
Education level
 None 99 (27.9) 38 (38.4) 61 (61.6) 0.655
 Primary 185 (52.1) 66 (35.7.0) 119 (64.3)
 Secondary 47 (13.2) 18 (38.3) 29 (61.7)
 Tertiary 24 (6.8) 6 (25) 18 (75)
Occupation
 No 22(6.2) 11 (50.0) 11 (50.0) 0.16
 Yes 333 (93.8) 117 (35.1) 216 (64.9)
Marital Status
 Married 232 (65.4) 82 (35.3) 150 (64.7) 0.219
 Single 81 (22.8) 26 (32.1) 55 (67.9)
 Widowed 42 (11.3) 20 (47.6) 22 (52.4)
Duration on ART
  ≤ 5 years 73 (20.6) 24 (32.9) 49 (67.1) 0.526
  > 5years 282 (79.4) 104 (36.9) 178 (63.1)
Mode of care
 Community Model 87 (24.5) 14 (16.1) 73 (83.9) 0.001*
 Facility Model 268 (75.5) 114 (42.5) 154 (57.4)
Treatment line
 First Line 325 (91.5) 119 (36.6.0) 206 (63.4) 0.402
 Second Line 24 (6.8) 6 (25.0) 18 (75.0)
 Third Line 6 (1.7) 3 (50.0) 3 (50.0)
Distance to clinic
  < 5 kms 121 (34.1) 60 (49.6) 61 (50.4)
 5–10 kms 139 (39.2) 43 (30.9) 96 (69.1) 0.001*
  > 10 kms 95 (26.8) 25 (26.3) 70 (73.7)
Disclosed HIV status
 No 22 (6.2) 5 (22.7) 17 (77.3) 0.179
 Yes 333 (93.8) 123 (36.9) 210 (63.1)
Belonging to a community Support group
 No 116 (32.7) 49 (42.2) 67 (57.8) 0.091
 Yes 236 (67.3) 79 (33.1) 160 (66.9)
Beliefs against IIT in the community
 No 186 (52.4) 93 (50.0) 93 (50.0) 0.001*
 Yes 169 (47.6) 35 (20.7) 134(79.3)
Community Support networks for follow-up
 No 42 (11.8) 13 (31.0) 29 (69.0) 0.463
 Yes 313 (88.2) 115(36.7) 198(63.3)
Favourable Clinic Operating hours
 No 49 (13.8) 20 (40.8) 29 (59.2) 0.455
 Yes 306 (86.2) 108(35.3) 198(64.7)
Adequate Privacy at the facility
 No 83 (23.4) 38 (45.8) 45 (54.2) 0.035*
 Yes 272 (76.6) 90 (33.1) 182(66.9)
Received Reminder calls/SMS for appointment
 No 102 (28.7) 37 (36.3) 65 (63.7) 0.957
 Yes 253 (71.3) 91 (36) 162(64)
Drug stockouts during refills
 No 222 62.5) 85 (38.3) 137(61.7) 0.258
 Yes 133 (37.5) 43 (32.3) 90 (67.7)
Availability of enough health worker facilities to offer services.
 No 146 (41.1) 60 (41.1) 86 (58.9) 0.098
 Yes 209 (58.9) 68 (32.5) 141(67.5)
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Note: * indicate a significant variable at 5%, km = kilometer, SMS = Short Message Service, IIT = interruption in treatment.

In the adjusted multivariate analysis as shown Table 3 below, the factors associated with returning to treatment following an interruption among HIV-positive clients in Katakwi District included having no occupation, living within 5 km of the facility, living in a Community with beliefs against interruption of treatment and Belonging to the community support groups. PLHIV with no occupation were 20% less likely to return to treatment compared to those with an occupation (aRR = 0.80, 95% CI: 0.73–0.88). Those living within 5 km of the facility were 22% less likely to return to treatment than those living 5−10 km away (aRR = 0.78, 95% CI: 0.63–0.95, p = 0.019), living in a Community with beliefs against interruption of treatment was strongly associated with a higher likelihood of returning to treatment (aRR = 1.18, 95% CI: 1.06–1.33, p = 0.003). Similarly, belonging to the community support group was aaociated with a higher likelihood (aRR 1.16, 95% CI: 1.01–1.39, p = 0.04).

Table 3. Multivariable analysis of determinants of return to HIV treatment after interruption in Katakwi District, Uganda.

Variable cRR (95% CI) p-value aRR (95% CI) p-value
Gender
 Male Reference
 Female 1.06 (0.97-1.15) 0.162 1.03 (0.89-1.18) 0.697
Age categories
 50+ Reference
 18-30 1.08 (0.91-1.28) 0.362 1.09 (0.73-1.64) 0.651
 31-40 1.11 (1.00-1.23) 0.05 1.12 (0.95-1.32) 0.164
 41-50 1.08 (0.88-1.33) 0.433 1.06 (0.87-1.30) 0.554
Occupation
 Yes Reference
 No 1.25 (1.19-1.30) <0.001* 0.80 (0.73-0.88) <0.001*
Mode of care
 Community model Reference
 Facility Model 0.98 (0.73-1.32) <0.001* 1.08 (0.77-1.51) 0.641
Distance to facility
 5–10 kms Reference
  < 5 kms 0.78(0.65-0.93) 0.007* 0.78 (0.63-0.95) 0.019*
  > 10 kms 1.85 (0.64-1.13) 0.227 0.87 (0.66-1.14) 0.328
Disclosure Status
 No Reference
 Yes 0.92 (0.81-1.04) 0.189 0.90 (0.71-1.12) 0.362
Beliefs in the community against interruption in Treatment
 No Reference
 Yes 1.18 (1.08-1.30) <0.001* 1.18 (1.06-1.33) 0.003*
Adequate privacy at the facility
 No Reference .
 Yes 0.98 (0.97-0.99) 0.036* 1.01 (0.89-1.13) 0.927
Availability of enough health workers to offer services.
 No Reference
 Yes 0.98 (0.723-1.33) 0.099 1.01 (0.75-1.34) 0.995
Belonging to a community

Support group
 No Reference
 Yes 1.19 (1.02-1.39) 0.026* 1.16 (1.01-1.39) 0.04*
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Note: * indicate significant variable at 5%, km = kilometer, cRR = Crude Risk Ratio, aRR = Adjusted Risk ratio.

Discussion

In this study, we found that 63.9% of HIV-positive clients in Katakwi District returned to treatment after an interruption. This rate of return is notably higher than some of the findings in other studies done in Uganda and South Africa that reported a return to treatment rate of 42% to 70% [9,10,25,29,30], with higher rates typically seen in rural contexts. The higher return rate observed in the study is attributed to localized factors, such as community support, quality improvement initiatives, and active bringing back to care activities by the district health teams and the local implementing partner. Research on return to care has noted disparities with higher rates of up to 70% in rural areas as compared to urban areas, which is particularly due to stronger client navigation support systems and flexibility in these settings [10,12,31].

We found that clients without occupation were less likely to return to HIV treatment than employed individuals. This is consistent with studies done in South Africa and Ethiopia [13,32]. This is because poor economic status is associated with a lack of transport to the clinic and the inability to take medication due to lack of food, among other factors, resulting in interruption in treatment [29,32].

We also found that PLHIV living within 5 kilometers of the facility were less likely to return to treatment, a finding that contrasts with the general understanding that proximity usually supports better adherence [33]. This paradox suggests that in this context, psychosocial barriers, such as increased stigma or reduced motivation, may be more influential than distance. The role of Stigma has as a consistent barrier to treatment re-engagement is well established in the literature [34–36].

Clients from communities with strong beliefs discouraging treatment interruption were more likely to return to treatment than those from communities without such beliefs, a finding consistent with studies in the United States of America and Tanzania [37–39]. This is because positive community beliefs reduce HIV related stigma, create peer pressure for ART adherence, and foster an enabling environment for PLHIV to stay in care [40].

Belonging to community support groups was associated with higher rates of returning to care, aligning with the literature, which emphasizes the importance of social support, interpersonal relationships, and community networks in improving treatment adherence and re-engagement in care [3,4,20,41,42].

Limitations and strengths

Due to the cross-sectional nature of this study, we can identify associations but cannot establish causality or temporal sequence between factors and return to care. We did not include facilities with varying levels of services, which may limit the generalizability of our findings to similar settings, and we did not account for a design effect. However, key strengths of the study include its multi-center design and its focus on a population that has already experienced interruption of treatment, providing direct insights into the re-engagement process.

Conclusions

In this study, a high return-to-care rate was positively associated with participation in a community support group and residence in a community that values treatment adherence, but negatively associated with living <5 km from the facility and being unemployed. These findings highlight patient and health system-related gaps that require tailored interventions to ensure that PLHIV who interrupt treatment return to care for improved health outcomes. We recommend that government health agencies and non-governmental organizations (NGOs) design targeted programs, including economic empowerment initiatives like small business grants and vocational training activities for unemployed PLHIV and strengthened differentiated service delivery models, such as community-based drug distribution and flexible mobile clinics to reduce travel burdens for clients living near facilities. Finally, it’s crucial to scale up community education to combat stigma, alongside robust counseling and peer support programs, to foster a supportive environment for clients struggling to return to care.

Supporting information

S1 Data. Data for Submissionv1.

(CSV)

pone.0337637.s001.csv (41.9KB, csv)
S1 File. IIT ethical approval letter.

(DOCX)

pone.0337637.s002.docx (433.6KB, docx)
S2 File. STROBE-checklist-return to care.

(DOC)

pone.0337637.s003.doc (85.5KB, doc)

Acknowledgments

The authors would like to acknowledge the support rendered by the facility in charge of the Katakwi General Hospital, Magoro Health center III and Ngariam Health center III during the process of data collection for this study. In addition, the author acknowledges the contribution of study participants for their consent and acceptance to participate in this study.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

The author(s) received no specific funding for this work.

References

  • 1.Tomescu S, Crompton T, Adebayo J, Kinge CW, Akpan F, Rennick M, et al. Factors associated with an interruption in treatment of people living with HIV in USAID-supported states in Nigeria: a retrospective study from 2000–2020. BMC Public Health. 2021;21(1). doi: 10.1186/s12889-021-12264-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Ahmed A, Dujaili JA, Jabeen M, Umair MM, Chuah L-H, Hashmi FK, et al. Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan. Front Pharmacol. 2022;12:807446. doi: 10.3389/fphar.2021.807446 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Palacio-Vieira J, Reyes-Urueña JM, Imaz A, Bruguera A, Force L, Llaveria AO, et al. Strategies to reengage patients lost to follow up in HIV care in high income countries, a scoping review. BMC Public Health. 2021;21(1):1596. doi: 10.1186/s12889-021-11613-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Chirambo L, Valeta M, Banda Kamanga TM, Nyondo-Mipando AL. Factors influencing adherence to antiretroviral treatment among adults accessing care from private health facilities in Malawi. BMC Public Health. 2019;19(1):1–11. doi: 10.1186/S12889-019-7768-Z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.UNAIDS. 2024 global AIDS report — The Urgency of Now: AIDS at a Crossroads. http://www.wipo.int/
  • 6.UNAIDS. Miles to go - Global AIDS update 2018. https://www.unaids.org/en/20180718_GR2018
  • 7.Ware NC, Wyatt MA, Geng EH, Kaaya SF, Agbaji OO, Muyindike WR, et al. Toward an understanding of disengagement from HIV treatment and care in sub-Saharan Africa: a qualitative study. PLoS Med. 2013;10(1):e1001369; discussion e1001369. doi: 10.1371/journal.pmed.1001369 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Alizadeh F, Mfitumuhoza G, Stephens J, Habimaana C, Myles K, Baganizi M, et al. Identifying and Reengaging Patients Lost to Follow-Up in Rural Africa: The “Horizontal” Hospital-Based Approach in Uganda. Glob Health Sci Pract. 2019;7(1):103–15. doi: 10.9745/ghsp-d-18-00394 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Brinkhof MWG, Pujades-Rodriguez M, Egger M. Mortality of patients lost to follow-up in antiretroviral treatment programmes in resource-limited settings: systematic review and meta-analysis. PLoS One. 2009;4(6):e5790. doi: 10.1371/journal.pone.0005790 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Wichlinski M, Rajaram R. The Use of RONA/WACC as a Proxy for Investment Quality. JEBS. 2019;10(6A):177–85. doi: 10.22610/jebs.v10i6a.2673 [DOI] [Google Scholar]
  • 11.Farahani M, Kirungi WL, Farley SM, Mugisha V, Hoos D, Smart TF, et al. Progress in the HIV response in Uganda: findings from two sequential population-based HIV impact assessment surveys, 2017-21. Lancet HIV. 2025;12(8):e568–77. doi: 10.1016/S2352-3018(25)00100-6 [DOI] [PubMed] [Google Scholar]
  • 12.Bisnauth MA, Davies N, Monareng S, Buthelezi F, Struthers H, McIntyre J, et al. Why do patients interrupt and return to antiretroviral therapy? Retention in HIV care from the patient’s perspective in Johannesburg, South Africa. PLoS One. 2021;16(9):e0256540. doi: 10.1371/journal.pone.0256540 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Abebe Moges N, Olubukola A, Micheal O, Berhane Y. HIV patients retention and attrition in care and their determinants in Ethiopia: a systematic review and meta-analysis. BMC Infect Dis. 2020;20(1):439. doi: 10.1186/s12879-020-05168-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Koirala S, Deuba K, Nampaisan O, Marrone G, Ekström AM, CAT-S group. Facilitators and barriers for retention in HIV care between testing and treatment in Asia-A study in Bangladesh, Indonesia, Lao, Nepal, Pakistan, Philippines and Vietnam. PLoS One. 2017;12(5):e0176914. doi: 10.1371/journal.pone.0176914 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Berger MB, Sullivan KA, Parnell HE, Keller J, Pollard A, Cox ME, et al. Barriers and Facilitators to Retaining and Reengaging HIV Clients in Care: A Case Study of North Carolina. J Int Assoc Provid AIDS Care. 2016;15(6):486–93. doi: 10.1177/2325957415616491 [DOI] [PubMed] [Google Scholar]
  • 16.Mirzazadeh A, Eshun-Wilson I, Thompson RR, Bonyani A, Kahn JG, Baral SD, et al. Interventions to reengage people living with HIV who are lost to follow-up from HIV treatment programs: A systematic review and meta-analysis. PLoS Med. 2022;19(3):e1003940. doi: 10.1371/journal.pmed.1003940 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Palacio-vieira J. Strategies to reengage patients lost to follow up in HIV care in high-income countries, a scoping review. 2021;1–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Bisnauth MA, Davies N, Monareng S, Struthers H, McIntyre JA, Rees K. Exploring healthcare workers’ experiences of managing patients returning to HIV care in Johannesburg, South Africa. Glob Health Action. 2022;15(1):2012019. doi: 10.1080/16549716.2021.2012019 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Nyakato P, Kiragga AN, Kambugu A, Bradley J, Baisley K. Correction of estimates of retention in care among a cohort of HIV-positive patients in Uganda in the period before starting ART: a sampling-based approach. BMJ Open. 2018;8(4):e017487. doi: 10.1136/bmjopen-2017-017487 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Mtisi EL, Mushy SE, Mkawe SG, Ndjovu A, Mboggo E, Mlay BS, et al. Risk factors for interruption in treatment among HIV-infected adolescence attending health care and treatment clinics in Tanzania. AIDS Res Ther. 2023;20(1):19. doi: 10.1186/s12981-023-00512-4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.PEPFAR. COP. https://www.state.gov/wp-content/uploads/2020/01/COP20-Guidance_Final-1-15-2020.pdf
  • 22.UBOS. National population and housing census 2024 final report volume 1 (main) republic of Uganda. Republic of Uganda. 2024. [Google Scholar]
  • 23.MOH. MoH Uganda - SMS Reporting System. https://dhis.mets.or.ug/dhis-web-commons/security/login.action
  • 24.Beres LK, Schwartz S, Simbeza S, McGready J, Eshun-Wilson I, Mwamba C, et al. Patterns and Predictors of Incident Return to HIV Care Among Traced, Disengaged Patients in Zambia: Analysis of a Prospective Cohort. J Acquir Immune Defic Syndr. 2021;86(3):313–22. doi: 10.1097/QAI.0000000000002554 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Cuschieri S. The STROBE guidelines. Saudi J Anaesth. 2019;13(Suppl 1):S31–4. doi: 10.4103/sja.SJA_543_18 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.NPHC. Uganda Housing and Population - Google Search. https://www.google.com/search?q=Uganda+Housing+and+Population&rlz=1C1GCEU_enUG1088UG1088&oq=Uganda+Housing+and+Population+&gs_lcrp=EgZjaHJvbWUyBggAEEUYOdIBCTI3NDNqMGoxNagCCLACAQ&sourceid=chrome&ie=UTF-8
  • 27.Sample Size Determination. https://nursesrevisionuganda.com/sample-size-determination/
  • 28.Nabaggala MS, Parkes-Ratanshi R, Kasirye R, Kiragga A, Castlenuovo B, Ochaka I, et al. Re-engagement in HIV care following a missed visit in rural Uganda. BMC Res Notes. 2018;11(1):762. doi: 10.1186/s13104-018-3865-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.MOH. Ministry of Health the Republic of Uganda Consolidated Guidelines for the Prevention and Treatment of HIV and AIDS in Uganda. 2022.
  • 30.Tomescu S, Crompton T, Adebayo J, Kinge CW, Akpan F, Rennick M, et al. Factors associated with an interruption in treatment of people living with HIV in USAID-supported states in Nigeria: a retrospective study from 2000-2020. BMC Public Health. 2021;21(1):2194. doi: 10.1186/s12889-021-12264-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.StataCorp LLC. Stata | StataCorp LLC. https://www.stata.com/company/#
  • 32.Udeagu C-CN, Webster TR, Bocour A, Michel P, Shepard CW. Lost or just not following up: public health effort to re-engage HIV-infected persons lost to follow-up into HIV medical care. AIDS. 2013;27(14):2271–9. doi: 10.1097/QAD.0b013e328362fdde [DOI] [PubMed] [Google Scholar]
  • 33.Nsoh M, E Tshimwanga K, A Ngum B, Mgasa A, O Otieno M, Moali B, et al. Predictors of antiretroviral therapy interruptions and factors influencing return to care at the Nkolndongo Health District, Cameroon. Afr H Sci. 2021;21:29–38. doi: 10.4314/ahs.v21i.6s [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Fuente-Soro L, López-Varela E, Augusto O, Bernardo EL, Sacoor C, Nhacolo A, et al. Loss to follow-up and opportunities for reengagement in HIV care in rural Mozambique: A prospective cohort study. Medicine (Baltimore). 2020;99(20):e20236. doi: 10.1097/MD.0000000000020236 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Nhlongolwane N, Shonisani T. Predictors and Barriers Associated with Non-Adherence to ART by People Living with HIV and AIDS in a Selected Local Municipality of Limpopo Province, South Africa. TOAIDJ. 2023;17(1). doi: 10.2174/18746136-v17-230726-2023-2 [DOI] [Google Scholar]
  • 36.Taylor BS, Fornos L, Tarbutton J, Muñoz J, Saber JA, Bullock D, et al. Improving HIV Care Engagement in the South from the Patient and Provider Perspective: The Role of Stigma, Social Support, and Shared Decision-Making. AIDS Patient Care STDS. 2018;32(9):368–78. doi: 10.1089/apc.2018.0039 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Oryokot B, Kazibwe A, Oluka AI, Kagimu D, Bakashaba B, Ssentongo SM, et al. “Swallowing these drugs every day, you get tired”: a mixed-methods study to identify barriers and facilitators to retention and HIV viral load suppression among the adolescents living with HIV in TASO Mbale and TASO Soroti centers of excellence. AIDS Res Ther. 2025;22(1):43. doi: 10.1186/s12981-025-00719-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Grimsrud A, Wilkinson L, Eshun-Wilson I, Holmes C, Sikazwe I, Katz IT. Understanding Engagement in HIV Programmes: How Health Services Can Adapt to Ensure No One Is Left Behind. Curr HIV/AIDS Rep. 2020;17(5):458–66. doi: 10.1007/s11904-020-00522-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Matimbwa H, Lolo SA, Matoy LS, Ndaki R, Ngahyoma S, Mollel HA, et al. Factors Contributing to Retention in Care and Treatment Adherence Among People Living With HIV Returning to Care in South-Eastern Tanzania: A Qualitative Study. HIV AIDS (Auckl). 2025;17:39–57. doi: 10.2147/HIV.S492673 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Kranzer K, Lewis JJ, Ford N, Zeinecker J, Orrell C, Lawn SD, et al. Treatment interruption in a primary care antiretroviral therapy program in South Africa: cohort analysis of trends and risk factors. J Acquir Immune Defic Syndr. 2010;55(3):e17-23. doi: 10.1097/QAI.0b013e3181f275fd [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Camlin CS, Neilands TB, Odeny TA, Lyamuya R, Nakiwogga-Muwanga A, Diero L, et al. Patient-reported factors associated with reengagement among HIV-infected patients disengaged from care in East Africa. AIDS. 2016;30(3):495–502. doi: 10.1097/QAD.0000000000000931 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Chipungu J, Smith H, Mwamba C, Haambokoma M, Sharma A, Savory T, et al. An exploration of multi-level factors affecting routine linkage to HIV care in Zambia’s PEPFAR-supported treatment program in the treat all era. PLOS Glob Public Health. 2024;4(5):e0003094. doi: 10.1371/journal.pgph.0003094 [DOI] [PMC free article] [PubMed] [Google Scholar]

Decision Letter 0

Ibrahim Jahun

12 Sep 2025

Dear Dr. Okello,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

==============================

Please address these comments including all the comments raised by reviewers 1 and 2.

Ethical statement: “Ethical approval and consent to participate. The research protocol was submitted to Lira University's Faculty of Public Health and the Lira University Research and Ethic Committee for approval (LUREC-2024-235)”.

Comment: the statement is unclear whether the study has been approved by the ethics committee or otherwise. Please be explicit about this.

Introduction:

Line 54: In Uganda, out of an estimated 1,492,742 people living with HIV, 1,255,975 are on ARVs (11). Comment: please provide percentage for ease of interpretation

Methods:

Study population: define adults

Sampling: explain how simple random sampling was carried out

Data collection: who collected the data, who conducted the interviews, which variables were collected through data abstraction, and which variables were collected through face-face interview?

Data analysis: please present the section in logical order. The initial step will be data exportation to Stata and then analysis. Also explain whether the data was initially exported from EMR in MS Excel and then imported to Stata for further analysis? How about variables collected via face-face interview, were they electronically collected, manually in MS Excel e.t.c. please be explicit to ease reproducibility.

Results:

Line 169: majority aged 0-30; however, inclusion criterion says 18yrs and above.

Table 2: label column 2. N?

Discussion:

Line 226-227 stated “In this study, we found that PLHIV receiving care in community models had higher rates of return to treatment as compared to those in the facility models.” However, results section Lines 187-188 stated that “Clients in the community care model had a lower return rate (83.9%) compared to those in the facility model (57.4%)”.

Acknowledgement:

Please acknowledge study participants.

==============================

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We look forward to receiving your revised manuscript.

Kind regards,

Jahun Ibrahim, MD, MSC, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1:  Dear Editor,

Thank you for the opportunity to review the manuscript "Factors Associated with Return to Treatment Following Interruption Among HIV-Positive Clients on ART in Public Health Facilities in Katakwi District, North Eastern Uganda".

The study is timely and relevant, addressing the critical issue of treatment interruption and return to HIV care, particularly in rural Uganda—a context often underrepresented in research. Its mixed-methods approach, combining structured quantitative data with contextual insights, enhances understanding of the behavioral and structural factors influencing return to treatment. By grounding the analysis in local realities such as community beliefs, proximity to health facilities, and family support, the findings offer practical value for program design. Furthermore, the use of routine data from the OpenMRS system, triangulated with paper-based records, strengthens the validity and reliability of the results.

However, there is room for improvement. Below are suggestions to help the authors to improve on the current draft and specific recommendations.

General comments

Language and grammar

The manuscript would benefit from language polishing:

• Typo: “client workers” instead of “clients” – Line 165

• Some long sentences, e.g.: “Clients coming from communities with strong beliefs against missing ART or treatment were about three times more likely...” could be re-worded, e.g. “Clients from communities with strong beliefs discouraging treatment interruption were nearly three times more likely to return to care than those from communities without such beliefs—consistent with findings from the United States and Tanzania.” It is not clear how the “strong believe” was measured or how these communities are organized into distinct groups with/without strong beliefs.

Formatting

• Please ensure that the intext citations are properly formatted, e.g., 42 and 30 in line 244 should appear as (42, 30) and not (42)(30). Also check similarly wrongly placed citations, e.g (35)(18) in line 235.

• Some sentences start without a preceding full stop, e.g. the sentence that starts with the words “Facility and home-”

Title

The title is lengthy and will benefit from a revision. For example, a shorter form could be “Determinants of Return to HIV Treatment After Interruption in Katakwi District, Uganda”

Abstract

For better flow, the sentence that starts with the words “Despite these efforts...” needs some modifications to flow better. It is unclear which efforts are referred to.

Introduction

• The introduction is comprehensive but slightly repetitive in describing global/regional return-to-treatment statistics.

• Consider clearly stating the research gap earlier in the introduction.

Methods

• Study design: Though the study follows STROBE, it claims to be mixed-method but only presents structured quantitative data.

o Recommendation: Remove “mixed-method” or clarify any qualitative component.

• Sampling and Exclusion Criteria: The rationale for excluding psychiatric patients and those admitted is not well explained.

• Measurement of outcome (Return to Treatment): Defined as >28 days, which aligns with MOH guidance —but consider justifying the cutoff with references.

• Variable Definitions: Several predictors are mentioned with yes/no responses—consider grouping by domain in a table.

• It may have been helpful to include more facilities with varying levels, since patients may not return to referral facilities since they may prefer to seek care in facilities closest to them. This can be admitted as a limitation.

• It is not clear why the two hospitals were selected as well and also, they seem to be at the same level.

• The sentence “Return to treatment was assessed using frequency counts, percentages, and a 95% confidence interval” can be dropped or re-worded since this is not have been the tool used to assess the outcome variable. Consider describing the measures used for comparison of the proportions in the bivariate analysis.

Results

• Bivariate Table (Table 2): The formatting is inconsistent. For instance, the column “Yes (n=)” is incorrectly formatted. No need to repeat “...of respondent” for the variable Gender. The table title is also long and there is not point stating that the table is about “Bivariate analysis...”

• Please be consistent with the number of decimal places for the p-values. Since the columns figures in brackets are percentages, the symbol can be included in the column headings and that it doesn’t have to be repeated.

• Highlighting of the significant values should be consistent. For example, “Mode of care”. Consider ordering categories for ordinal variables. For example, “Distance to clinic” should start with <5kms.

• Multivariate Table (Table 3): Should be better structured. Include sample size and N per group. Some p-values are misaligned.

Discussion

• Though it has a strong alignment with literature, some considerations on overstating the findings, e.g. in statements like “clients closer to facilities are less likely to return” require cautious interpretation. There may be possible confounding (e.g., stigma, facility congestion) should be hypothesized explicitly. It is surprising that clients who lived <5 kms to the clinic had the highest proportion of IIT, hence it may be challenging to explain why the significance without secondary analysis to rule out or consider stigma as a reason. Stigma alone may also not be the attributable factor since the type of facility and the services may differ depending on the type of facility. Clustering analysis may have been helpful.

• The first sentence in the discussion needs rephrasing since use of the word “only” while referring to 63.9% is countered by the second sentence where the authors indicate that the rate of return is higher than other studies. The rate seems to be within the literature quoted in the second sentence.

• In a vast rural setting, it is possible to contextualize access since some areas may be better connected than others. Hence the sentence “However, the geographical contribution to return to treatment cannot be fully contextualized within this study, as the study sites are in rural settings” may need further thought/reworking.

• It would be helpful to add more explanation on why unemployed clients or those with certain beliefs are more or less likely to return.

• In the limitations section, please remove the word “only” in line 259. In the limitation sentence “...we cannot establish a factor preceded or resulted from return to treatment,” needs substantiation since it is possible to do a competing risk analysis. Additionally, some outcomes such as viral suppression could have been considered since there is a temporal relationship with IIT.

Conclusion

• Thought practical and actionable, it could be more focused. Several recommendations are listed; grouping into themes (e.g., economic support, service delivery flexibility) would enhance clarity.

• The sentence “We noted a high return to care rate that still falls short of the UNAIDS 95% target for return to care” needs to be revised since the commonly known 95-95-95 UNAIDS targets do not reference return to care. Line 261-62

References

Some references are inconsistent, e.g. “11. Country P, Plan O. the People’s. 2020;

12. MOH. The 2019 HIV Epidemiological Surveillance Report for Uganda. file///C/Users/MARTIN%20ODOCHI/Downloads/2019-HIV-Epidemiological- Surveillance report-For print.pdf T 2019 HIV Accessed, 19/07/2021. 2019;(March 2020).”

Reviewer #2: A good write up and wonderful insight. however, to include analysis on age and sex if available regression analysis

need to also include inclusion and exclusion criteria. Can also include other form of graphic apart from tables use only.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2026 Feb 4;21(2):e0337637. doi: 10.1371/journal.pone.0337637.r003

Author response to Decision Letter 1

16 Oct 2025

Subject: Response to Reviewer’s comments

We appreciate your valuable feedback. We have addressed all the comments, and the changes are tracked. Additionally, we have demonstrated in the response letter how each comment was specifically addressed, including the corresponding line and page numbers. We look forward to your favourable editorial decision.

==============================

This is an important study that investigated factors associated with return to care after treatment interruption. Findings will certainly help in designing client-centered strategies that will ensure retention on ART, a requirement for VL suppression and reduction in infection transmission. The study, however, has major gaps as illustrated below, in addition to reviewer 1.

Please address these comments, including all the comments raised by reviewers 1 and 2.

Comment: Ethical statement: “Ethical approval and consent to participate. The research protocol was submitted to Lira University's Faculty of Public Health and the Lira University Research and Ethics Committee for approval (LUREC-2024-235).

The statement is unclear whether the study has been approved by the ethics committee or otherwise. Please be explicit about this.

Response: This has been made clear that the study received Ethical approval from Lira University Research and Ethical Committee (LUREC-2024-235), see lines 152-154, page 7.

Introduction:

Comment: Line 54: In Uganda, out of an estimated 1,492,742 people living with HIV, 1,255,975 are on ARVs (11). Comment: Please provide a percentage for ease of interpretation

Response;

This has been changed to In Uganda, 80.9% of adults living with HIV were aware of their HIV status, and of these, 96.1% were on ART, see lines 50-57.

Methods:

Comment: Study population: define adult

Response: The word adult has been replaced with “aged 18 years and above,” see line 78.

Sampling: explain how simple random sampling was carried out

Response: This has been corrected. Actually, we used a consecutive sampling technique, whereby all eligible clients from this list with appointments within the study period were interviewed, see lines 108-113, page 5

Comment: Data collection: who collected the data, who conducted the interviews, which variables were collected through data abstraction, and which variables were collected through face-to-face interviews?

Response: Data was collected by trained research assistants, who collected data on clients who had missed appointments and returned to care. Then these clients were interviewed. This has been aligned, see lines 134-139, page 6.

Response: The variables collected using face-to-face interviews have been highlighted, see independent variables section, lines 125 to 133, page 6

Comment: Data analysis: Please present the section in logical order. The initial step will be data exportation to Stata and then analysis. Also, explain whether the data was initially exported from EMR in MS Excel and then imported to Stata for further analysis.

How about variables collected via face-to-face interview, were they electronically collected, manually in MS Excel, etc.? Please be explicit to ease reproducibility.

Response: Thanks, this has been done as guided above, see lines 144 to 147, page 6.

Results:

Comment: Line 169: majority aged 0-30; however, the inclusion criterion says 18 years and above.

Response: This was a typo that has been corrected in the table from 0-30 to 18 to 30, which is the study population.

Comment: Table 2: label column 2. N?

Response: Thanks, Column 2 has been labelled N=335 as guided.

Discussion:

Comment: Line 226-227 stated “In this study, we found that PLHIV receiving care in community models had higher rates of return to treatment as compared to those in the facility models.” However, the results section, Lines 187-188, stated that “Clients in the community care model had a lower return rate (83.9%) compared to those in the facility model (57.4%)”.

Response: Thanks. This was an oversight that has been corrected in Lines 187-188 from “lower return rate” to “higher return rate” for clients in the community model.

Acknowledgement:

Comment: Please acknowledge study participants.

Response: This has been done, and study participants acknowledged, see line 299-300, page 17 under acknowledgment

==============================

Journal Requirements:

1. When submitting your revision, we need you to address these additional requirements.

Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. PLOS requires an ORCID ID for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID ID and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new ID or authenticate a pre-existing ID in Editorial Manager.

3. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

Response: This has been done.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

Response: This has been done.

5. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Response: This has been done.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

________________________________________

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

Response Reviewer 1: Thanks, the analysis has been repeated using Poisson generalized estimating equations (GEE) with robust standard errors, accounting for clustering at the health facility level and adjusting for variables with p-value <0.2 and clinically relevant variables identified in the literature. The 0.2 was selected to avoid excluding variables like age, sex, and community support that are key in determining return to care. See table

________________________________________

3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: No

Reviewer #2: Yes

Response to Reviewer 1. The Data has been attached as supplementary material.

________________________________________

4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

Response: Thanks, Review 1 and 2.

________________________________________

5. Review Comments to the Author

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Reviewer #1:

General comments

Language and grammar

Comment: The manuscript would benefit from language polishing:

• Typo: “client workers” instead of “clients” – Line 165

Response: Thanks, “workers” has been deleted see line 162 page 7

Comment; Some long sentences, e.g.: “Clients coming from communities with strong beliefs against missing ART or treatment were about three times more likely...” could be re-worded, e.g. “Clients from communities with strong beliefs discouraging treatment interruption were nearly three times more likely to return to care than those from communities without such beliefs—consistent with findings from the United States and Tanzania.” It is not clear how the “strong believe” was measured or how these communities are organized into distinct groups with/without strong beliefs.

Formatting

Response: Thanks for the guidance given to reword the above statement. Please note your suggestion has been adopted and the statement rewritten as stated by you, see lines 228-230, page 14

Comment: Please ensure that the in-text citations are properly formatted, e.g., 42 and 30 in line 244 should appear as (42, 30) and not (42)(30). Also check similarly wrongly placed citations, e.g, (35)(18) in line 235.

Response: This has been corrected, see line 224 and 227 page 14

Response;

Comment: Some sentences start without a preceding full stop, e.g., the sentence that starts with the words “Facility and home-”

Response: This has been corrected, and all sentences checked for correct punctuation.

Comment;

Title

The title is lengthy and will benefit from a revision. For example, a shorter form could be “Determinants of Return to HIV Treatment After Interruption in Katakwi District, Uganda”

Response: The Title has been modified as guided to Factors Associated with Return to Treatment Following Interruption Among HIV-Positive Clients on ART in Public Health Facilities in Katakwi District, Uganda.

Abstract

Comment: For better flow, the sentence that starts with the words “Despite these efforts...” needs some modifications to flow better.

Response: The statement has been rewritten as “Returning to treatment following interruptions is vital for maintaining optimal HIV care., Uganda faces a 20% treatment interruption rate, with only 58% of clients resuming treatment. However, evidence on factors associated with returning to treatment remains limited” see line 14-16 page 1

It is unclear which efforts are referred to.

Response: The statement effort has been deleted, and the entire paragraph rewritten

Comment; Introduction

• The introduction is comprehensive but slightly repetitive in describing global/regional return-to-treatment statistics.

• Consider clearly stating the research gap earlier in the introduction.

Response: Thanks, this has been corrected as guided

Methods

Comment: Study design: Though the study follows STROBE, it claims to be mixed-method but only presents structured quantitative data.

o Recommendation: Remove “mixed-method” or clarify any qualitative component.

Response: Thanks, this was an oversight. The mixed method statement has been deleted in the abstract on line 19, page 1

Comment: Sampling and Exclusion Criteria: The rationale for excluding psychiatric patients and those admitted is not well explained.

Response: For the psychiatric Patients, they were excluded due to their inability to provide informed consent, see line 99, page 4.

Comment: Measurement of outcome (Return to Treatment): Defined as >28 days, which aligns with MOH guidance —but consider justifying the cutoff with references.

Response: The Statement has been justified with reference to the Ministry of Health guidelines and PEPFAR guidelines, see line 117 - 119, page 5, and references attached

Comment: Variable Definitions: Several predictors are mentioned with yes/no responses—consider grouping by domain in a table.

This has been done, and the section of independent Variables rewritten, and the repetitive statement of Yes/No has been removed. Please see the section on independent Variables, lines 128-136, page 6

Comment: It may have been helpful to include more facilities with varying levels, since patients may not return to referral facilities, and they may prefer to seek care in facilities closest to them. This can be admitted as a limitation.

Response: This has been added as a limitation. Thanks for the guidance. See line 239, 240 page 15

Comment: It is not clear why the two hospitals were selected as well, and also, they seem to be at the same level.

Response: The reason for selecting the facilities has been stated clearly as “These facilities were selected purposively for being facilities with the most clients in care in Katakwi district” and they are of the same level: two are HC III and 1 is the general Hospital, see line 90 page 4

Comment: The sentence “Return to treatment was assessed using frequency counts, percentages, and a 95% confidence interval” can be dropped or reworded since this was not the tool used to assess the outcome variable. Consider describing the measures used for comparison of the proportions in the bivariate analysis.

Response: Thanks for the guidance, this has been re-worded

Results

Comment: Bivariate Table (Table 2): The formatting is inconsistent. For instance, the column “Yes (n=)” is incorrectly formatted.

Response: This has been corrected and aligned. Please see Table 2

Comment: No need to repeat “...of respondent” for the variable Gender. The table title is also long, and there is no point in stating that the table is about “Bivariate analysis...”

Response: Thanks, this has been corrected, word “Respondent” has been deleted from the gender. Please see Table 2

Comment: Please be consistent with the number of decimal places for the p-values. Since the column figures in brackets are percentages, the symbol can be included in the column headings, and it doesn’t have to be repeated.

Response: We have only used 1 decimal point, and the repeated % sign was deleted in both Table 1 and Table 2.

Comment: Highlighting of the significant values should be consistent. For example, “Mode of care”.

Response. This has been done for Significant values only; the p-value is bold with * across Tables 2 and 3.

Comment: Consider ordering categories for ordinal variables. For example, “Distance to clinic” should start with <5kms.

Response. This has been done and the order of categories aligned, starting with < 5kms, then 5 to 10 km, and then >10 km, see tables 1 and 2

Comment: Multivariate Table (Table 3): Should be better structured. Include sample size and N per group. Some p-values are misaligned.

Discussion

• Though it has a strong alignment with literature, some considerations on overstating the findings, e.g., in statements like “clients closer to facilities are less likely to return,” require cautious interpretation. There may be possible confounders (e.g., stigma, facility congestion) that should be hypothesized explicitly. It is surprising that clients who lived <5 km from the clinic had the highest proportion of IIT, hence it may be challenging to explain why the significance without secondary analysis to rule out or consider stigma as a reason. Stigma alone may also not be the attributable factor since the type of facility and the services may differ depending on the t

Attachment

Submitted filename: PLOS ONE Response for review.docx

pone.0337637.s005.docx (34.6KB, docx)

Decision Letter 1

Ibrahim Jahun

11 Nov 2025

Determinants of Return to HIV Treatment After Interruption on ART  Among HIV Positive Clients in Katakwi District, Uganda.

PONE-D-25-25853R1

Dear Dr. Okello,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Academic Editor

PLOS ONE

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Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

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The PLOS Data policy

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Reviewer #2: Yes: Ismail Lawal

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Acceptance letter

Ibrahim Jahun

PONE-D-25-25853R1

PLOS One

Dear Dr. Okello,

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Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    S1 Data. Data for Submissionv1.

    (CSV)

    pone.0337637.s001.csv (41.9KB, csv)
    S1 File. IIT ethical approval letter.

    (DOCX)

    pone.0337637.s002.docx (433.6KB, docx)
    S2 File. STROBE-checklist-return to care.

    (DOC)

    pone.0337637.s003.doc (85.5KB, doc)
    Attachment

    Submitted filename: Response to the Reviewer {20 May 2025}.docx

    pone.0337637.s004.docx (14.6KB, docx)
    Attachment

    Submitted filename: PLOS ONE Response for review.docx

    pone.0337637.s005.docx (34.6KB, docx)

    Data Availability Statement

    All relevant data are within the paper and its Supporting Information files.

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