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.