# Access to HIV treatment during community-wide flooding: Experiences of people living with HIV and health care workers in Malawi, a mixed methods study

## TL;DR

Flooding in Malawi disrupts HIV treatment access, causing medication interruptions and hardship for patients and healthcare workers.

## Contribution

This study provides insights into how flooding impacts ART delivery and proposes solutions to improve continuity of care during emergencies.

## Key findings

- IIT increased by 24% during the first and 23% during the second flooding period.
- Most ART clients lost homes, crops, livestock, and medication due to flooding.
- Healthcare workers faced stock-outs, lost records, and lacked emergency guidelines for HIV services.

## Abstract

Community-wide flooding in high HIV-burdened districts affects continuity of HIV care, especially in resource-limited countries in sub-Saharan Africa. We explored the lived experiences of antiretroviral therapy (ART) clients and health care workers (HCWs) in Malawi to understand challenges and potential solutions for ART delivery during floods. This was a mixed methods study. In quantitative analysis, we used routine program data from Partners in Hope (PIH) to compare interruption in treatment (IIT) (>28 days without medication) cases in months with and without flooding, October 2021 to December 2023, to understand how flooding influences IIT. In qualitative analysis, we conducted in-depth interviews (IDIs) with ART clients and focus group discussions (FGDs) with HCWs from from six health facilities impacted by flooding in Chikwawa, Nsanje and Mulanje districts. We analyzed data in Atlas.Ti. IIT was far higher in flooding periods. Across 49,152 IIT cases, IIT increased by 24% during the first flooding period and by 23% during the second flooding period. 23 ART clients completed IDIs between July and August 2024: 13 female, median age 40 years, predominantly subsistence farmers (n = 21). A total of 9/23 clients experienced IIT. Flooding negatively impacted nearly all IDI participants: 17/23 lost homes and had to relocate, mainly to government camps. Most clients lost crops, livestock, and ART medication. Many clients travelled to find income and despite uncertainties they were motivated to remain in care. In six FGDs with 34 HCWs, HCWs described facility-level ART stock-outs and loss of medical records, limited stakeholder coordination and the absence of guidelines for HIV services during emergencies. HCWs were also impacted but received little support. IIT cases greatly increased during flooding periods, with both clients and HCWs facing multiple challenges to ART service provision. National flooding guidelines, coordination of stakeholder response, adequate planning and seasonal six-month ART dispensing could improve retention.