Malawi has been seriously affected by the HIV pandemic. By 2010 there were more than 900,000 persons living with HIV/AIDS, of whom close to 225,000 were receiving antiretroviral therapy (ART) in a free national ART programme that has rapidly expanded since 2004 . ART is offered at government, faith-based and private hospitals and health centers. According to the national ART guidelines , ART clinics should provide services that include management of opportunistic infections, malignancies and toxicities of ART as a minimum.
It is uncertain to what extent patients use their own ART clinic in case of intercurrent medical problems, such as HIV associated illnesses and side effects of ART. In the context of rapid scale up of ART, clinic populations have increased enormously and in combination with limited space and shortages of ART staff that are present in many clinics, aspects of the quality of ART services may be under pressure. As a result, patients might decide to use other facilities than their own ART clinic, anticipating less overcrowded circumstances, shorter waiting times and more privacy than experienced during previous ART visits. In the National ART programme, pre-ART counseling content may recommend patients to utilize closer-by health facilities for minor illnesses that are not ART toxicities.
Several studies have given insight into patterns of health care utilization in patients in the ART era in affluent countries, but these mainly focused on the quantity of health care consumption. In two American studies, the rate of emergency department admissions and hospitalizations was increased with not being on ART , having medical insurance, having high levels of pain, using illicit drugs, consuming alcohol and being female . Studies from the USA and Canada showed that poor adherence to ART  and low CD4 counts and high viral loads  were associated with high health care utilization, while in Australia this was the case with ART patients with mental health problems . It is unlikely that these results apply to circumstances in Malawi, where ART is provided with a public health approach under great human and financial resource strains. Few studies in sub-Saharan Africa have addressed health care utilization of ART patients. A retrospective cohort study of 212 South Africans found that health care utilization (defined as in- and outpatient hospital services, but excluding primary care visits) significantly decreased after the initiation of ART . We could find only one study that specifically investigated the extent to which HIV patients looked for care outside their own clinic in case of illness and the reasons thereof. A study of 32 HIV infected persons from Johannesburg, South Africa found that many made simultaneous use of public, private and traditional health facilities, but after starting ART, patients more uniformly utilized their ART clinic as the primary source of health care .
Theoretically it can have several disadvantages if patients utilize other health care facilities instead of their own clinic in case of illness: the previous ART history or even the positive HIV status may not be communicated by the patient, detailed information concerning the treatment history will not be available, and smaller facilities may not be familiar with the less commonly used antiretroviral drug regimens that are prescribed in larger, central hospitals. If other health care facilities are utilized, it may also deprive the ART clinic of feedback about illness episodes of their patients, information that can provide important clues about (severe) toxicities, drug interactions and ART failure.
We therefore did a survey to evaluate the health care utilization of patients of the ART clinic of Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi for intercurrent illness, and to find out the reasons for utilizing other health care facilities than their own clinic. We also assessed the patients' perception of the quality of care offered at their ART clinic. Such knowledge may help in improving the services that ART clinics offer.