Barriers to initiation of antiretroviral treatment in rural and urban areas of Zambia: a cross‐sectional study of cost, stigma, and perceptions about ART

Abstract

BackgroundWhile the number of HIV-positive patients on antiretroviral therapy (ART) in resource-limited settings has increased dramatically, some patients eligible for treatment do not initiate ART even when it is available to them. Understanding why patients opt out of care, or are unable to opt in, is important to achieving the goal of universal access.MethodsWe conducted a cross-sectional survey among 400 patients on ART (those who were able to access care) and 400 patients accessing home-based care (HBC), but who had not initiated ART (either they were not able to, or chose not to, access care) in two rural and two urban sites in Zambia to identify barriers to and facilitators of ART uptake.ResultsHBC patients were 50% more likely to report that it would be very difficult to get to the ART clinic than those on ART (RR: 1.48; 95% CI: 1.21-1.82). Stigma was common in all areas, with 54% of HBC patients, but only 15% of ART patients, being afraid to go to the clinic (RR: 3.61; 95% CI: 3.12-4.18). Cost barriers differed by location: urban HBC patients were three times more likely to report needing to pay to travel to the clinic than those on ART (RR: 2.84; 95% CI: 2.02-3.98) and 10 times more likely to believe they would need to pay a fee at the clinic (RR: 9.50; 95% CI: 2.24-40.3). In rural areas, HBC subjects were more likely to report needing to pay non-transport costs to attend the clinic than those on ART (RR: 4.52; 95% CI: 1.91-10.7). HBC patients were twice as likely as ART patients to report not having enough food to take ART being a concern (27% vs. 13%, RR: 2.03; 95% CI: 1.71-2.41), regardless of location and gender.ConclusionsPatients in home-based care for HIV/AIDS who never initiated ART perceived greater financial and logistical barriers to seeking HIV care and had more negative perceptions about the benefits of the treatment. Future efforts to expand access to antiretroviral care should consider ways to reduce these barriers in order to encourage more of those medically eligible for antiretrovirals to initiate care.

Socio-economic inequity in HIV testing in Malawi

“…While the stigma surrounding HIV infection and test uptake is well documented in this and other settings (44–46), women in Malawi appear to face a more significant risk of social sanction (10, 47). As men hold relatively more power within family structures and the Malawian social hierarchy more broadly, changing male perceptions of female testing will be critical to expanding access to HIV testing among Malawian women.…”

Delay of Antiretroviral Therapy Initiation Is Common in East African HIV-Infected Individuals in Serodiscordant Partnerships

“…ART providers should recognize the intra-person and intra-laboratory variability in CD4 counts, and utilize trends of CD4 count decline and counts provided from referring providers, to avoid misclassifying persons as ART ineligible [24]. Stigma, fear of disclosure and denial of the need to start treatment are important barriers to ART access [25] but may be under-represented among mutually-disclosed clinical trial participants. Among Kenyan HIV serodiscordant couples, fear of ART side effects and stigma were common reasons for reluctance to initiate early ART [26, 27].…”

A Participatory Approach to Improving Retention in HIV Treatment and Care for Newly Diagnosed Patients in a Secondary Health Facility in Sierra Leone

“…Poor service received from healthcare workers have been cited in many studies as a negative predictor of retention [14][15][16][17][18]. The retention of patients in care depends greatly on an able and capable HIV health workforce.…”