“Gender-based violence is the last thing they will think about”: a qualitative study on multilevel factors affecting gender-based violence screening and response in HIV care, Uganda, 2023

Uganda’s Ministry of Health (MOH) adopted the World Health Organization’s guidelines to incorporate routine gender-based violence (GBV) screening, counseling, and referrals in health care settings, including HIV care; however, considerable implementation barriers exist. This study explored barriers and facilitators to the implementation of the MOH’s GBV protocol in three health facilities. We collected qualitative data in public health facilities in central Uganda in 2023, including from 7 focus group discussions with 53 HIV care providers/staff and 12 individual interviews with community partners (e.g., health leaders). We used thematic analysis guided by the Consolidated Framework for Implementation Research (CFIR). We identified multilevel barriers and facilitators affecting GBV-responsive care, following CFIR. Characteristics of Individuals affecting implementation included provider knowledge, self-efficacy, and stigmatizing attitudes. Intervention Characteristics that affected implementation included documentation complexity and perceived compatibility with biomedical and health-system priorities. Inner Setting constraints included lack of privacy, time pressures, and workforce instability, though access to screening tools and training facilitated response. Outer Setting barriers included weak external referral systems (cosmopolitanism) and community norms that discouraged reporting. This study highlights the need to improve GBV screening and response in HIV settings through targeted, multilevel strategies to bolster provider support, reserve adequate time, identify space in clinics, strengthen external referral systems, and address provider bias and community stigma. NCT05178979.