Engagement trajectories and multilevel influences on retention among adult males with advanced HIV disease in Eswatini: a mixed-methods study.

INTRODUCTION: Adult males presenting with advanced HIV disease (AHD) experience disproportionate morbidity and mortality, yet retention in care patterns among this group remain insufficiently characterized. Most studies rely on single time-point retention measures, limiting understanding of how engagement evolves over time. This study examined 6- to 12-month engagement trajectories among adult males with AHD in Eswatini and explored multilevel influences shaping retention, disengagement, and re-engagement. METHODS: A mixed-methods retrospective cohort study was conducted across three high-volume HIV treatment facilities. Quantitative data were abstracted from facility AHD registers and routine clinical records for adult males recorded with AHD and documented 6 and 12-month follow-up outcomes and analyzed descriptively to characterize 6- and 12-month engagement transitions. Twelve-month outcomes were classified as active (being alive and receiving antiretroviral therapy (ART) at the study facility at 12 months, without a documented interruption exceeding 28 days) or unfavourable (death, loss to follow-up, or transfer out). Qualitative data were collected between June and September 2025 through in-depth interviews and focus group discussions with patients and healthcare workers. Thematic analysis was conducted using a socioecological framework. Quantitative and qualitative findings were integrated through joint display. RESULTS: Among 173 participants with documented 12-month outcomes, 137 (94.5%) of men active at 6 months remained engaged at 12 months. Of the 21 men classified as lost to follow-up at 6 months, 12 (57.1%) had re-engaged by 12 months. Demographic and baseline clinical characteristics were largely not associated with 12-month outcomes. Qualitative findings identified individual (stigma, delayed acceptance), interpersonal (non-disclosure, masculinity norms), and health system factors (confidentiality concerns, tracing limitations) shaping engagement trajectories. CONCLUSION: Adult males with AHD exhibited distinct engagement trajectories across the first year of ART. Six-month engagement was strongly aligned with 12-month continuity, suggesting that the early treatment period may represent an important period for retention support. The observed re-engagement among over half of those classified as LTFU at 6 months indicates that interruption within the first year can be reversible. Formalizing early retention review, strengthening case-level fidelity to the AHD package, and integrating structured psychosocial assessment within routine AHD care represent actionable directions for improving long-term engagement among men.