Causes for loss-to-follow-up, including early refusals of and stopping antiretroviral therapy (ART), in Malawi’s Option B+ program are poorly understood. This study examines the main barriers and facilitators to uptake and adherence to ART under Option B+. In depth interviews were conducted with HIV-infected women who were pregnant or postpartum in Lilongwe, Malawi (N = 65). Study participants included women who refused ART initiation (N = 10), initiated ART and then stopped (N = 26), and those who initiated ART and remained on treatment (N = 29). The barriers to ART initiation were varied and included concerns about partner support, feeling healthy, and needing time to think. The main reasons for stopping ART included side effects and lack of partner support. A substantial number of women started ART after initially refusing or stopping ART. There were several facilitators for re-starting ART, including encouragement from community health workers, side effects subsiding, decline in health, change in partner, and fear of future sickness. Amongst those who remained on ART, desire to prevent transmission and improve health were the most influential facilitators. Reasons for refusing and stopping ART were varied. ART-related side effects and feeling healthy were common barriers to ART initiation and adherence. Providing consistent pre-ART counseling, early support for patients experiencing side effects, and targeted efforts to bring women who stop treatment back into care may improve long term health outcomes.

In countries throughout sub-Saharan Africa, antiretroviral therapy is seen as the solution to not only treat existing patients, but also to prevent the future spread of HIV. New policies for the prevention of mother-to-child transmission place women on lifelong treatment as soon as they are tested HIV positive. This article looks at how women understand this prescription for lifelong treatment. Drawing on interviews with HIV-positive women in Lilongwe, Malawi (N = 65) during July-September 2014, I examine the process of making treatment decisions, and why - despite increased access - women refuse or stop treatment. Using treatment for preventative purposes transforms the experience of HIV from an acute to a chronic condition where both the symptoms of disease and the efficacy of treatment are unclear. Women look for evidence of the cost and benefit of treatment through their personal experiences with illness and drug-taking. For some women, the benefits were clearer: they interpreted past illnesses as signs of HIV infection, and felt healthier and more economically productive afterwards. For others, taking treatment sometimes led to marital problems, and side effects made them feel worse and disrupted their ability to work. While women understand the health benefits of antiretroviral therapy, taking treatment does not always make sense in their present circumstances when there are costly physical and economic repercussions. This study builds on existing sociological research on medical decision-making by situating decisions in a broader political economy of changing HIV policies, economic conditions, and everyday uncertainty.

Countries in sub-Saharan Africa have been seriously affected by HIV and now face a new pandemic -COVID-19. How have prior experiences with managing HIV prepared countries for To what extent has the structure of the global health field enabled or constrained countries' ability to respond? Drawing on qualitative methods, this article examines the impact of HIV interventions on the healthcare system in Malawi and its implications for addressing COVID-19. I argue that the historical and continued influence of neoliberalism in global health manifests in the structures and routines of clinical practice. In Malawi's health centres, a parallel NGO system of care has become grafted onto state healthcare, with NGOs managing HIV commodities and providing care to HIV patients. While HIV NGOs do support the work of government providers, it is limited to tasks that align with their programmatic goals. Outside of donor priorities, the conditions of public healthcare are left behind, and government providers struggle with shortages of staff, medical resources, and basic infrastructure. In the context of COVID-19, risks are compounded as public healthcare facilities not only struggle with resources to treat patients, but also become a site of risk itself for COVID-19 infection.

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