Adherence at the earliest stages of treatment is likely to be influenced by prior illness trajectories and future expectations, best captured (and addressed) before treatment begins. We examined the influence of illness trajectories and treatment expectations on psychosocial readiness to start antiretroviral therapy (ART) in Jinja, Uganda. In-depth interviews were conducted between October 2005 and April 2006 with 41 members of an AIDS support organisation on their first day of treatment. Transcribed texts were translated, coded and analysed thematically using NVIVO-7 software. Results indicated that acute fear of death and progressive withdrawal from social, economic and sexual roles narrowed focus on survival, while efficacy-enhancing experiences with septrin prophylaxis and trust in counsellors reinforced belief in HIV diagnosis and importance of adherence. Most enjoyed supportive home environments after disclosing their serostatus. Lack of money for food and transport was anticipated as the main barriers to future adherence, particularly among women. Integrating strong counselling support with ART provision helped channel the power of shared illness experience into positive motivation to adhere at the onset of treatment. Keywords: HIV, antiretroviral therapy, adherence, qualitative, Africa.Brent Wolff is a senior social scientist at the MRC/UVRI Uganda Research Unit on AIDS. His interests are in couple and family context of AIDS risk and ART adherence in east and southern Africa.Martin Mbonye is a social science research associate at the MRC/UVRI Uganda Research Unit on AIDS. He was responsible for coordinating data collection in the qualitative sub-study. Alex Coutinho is the Executive Director of the Infectious Diseases Institute of Makerere University in Uganda.Barbara Amuron is a medical doctor at the MRC/UVRI Uganda Research Unit on AIDS. She was responsible for the co-ordination of field and clinical activities and data collection of the main trial.Robert Nkabala is a counselling coordinator at The AIDS Support Organization (TASO), Uganda. His interests are in clients' families and communities' risk reduction behaviours to HIV prevention at the grass-root level.