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Published Online: 8 April 2013

Deterrents to HIV-Patient Initiation of Antiretroviral Therapy in Urban Lusaka, Zambia: A Qualitative Study

Publication: AIDS Patient Care and STDs
Volume 27, Issue Number 4

Abstract

Some people living with HIV (PLHIV) refuse to initiate antiretroviral therapy (ART) despite availability. Between March 2010 and September 2011, using a social ecological framework, we investigated barriers to ART initiation in Lusaka, Zambia. In-depth interviews were conducted with PLHIV who were offered treatment but declined (n=37), ART staff (n=5), faith healers (n=5), herbal medicine providers (n=5), and home-based care providers (n=5). One focus group discussion with lay HIV counselors and observations in the community and at an ART clinic were conducted. Interviews were audio-recorded, transcribed, and translated, coded using Atlas ti, and analyzed using latent content analysis. Lack of self-efficacy, negative perceptions of medication, desire for normalcy, and fear of treatment-induced physical body changes, all modulated by feeling healthy, undermined treatment initiation. Social relationships generated and perpetuated these health and treatment beliefs. Long waiting times at ART clinics, concerns about long-term availability of treatment, and taking strong medication amidst livelihood insecurity also dissuaded PLHIV from initiating treatment. PLHIV opted for herbal remedies and faith healing as alternatives to ART, with the former being regarded as effective as ART, while the latter contributed to restoring normalcy through the promise of being healed. Barriers to treatment initiation were not mutually exclusive. Some coalesced to undermine treatment initiation. Ensuring patients initiate ART requires interventions at different levels, addressing, in particular, people's health and treatment beliefs, changing perceptions about effectiveness of herbal remedies and faith healing, improving ART delivery to attenuate social and economic costs and allaying concerns about future non-availability of treatment.

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References

1.
Joint United Nations Programme on AIDS. Global Report: UNAIDS Report on the Global AIDS EpidemicGenevaWHO2010. 1. Joint United Nations Programme on AIDS. Global Report: UNAIDS Report on the Global AIDS Epidemic. Geneva, WHO, 2010.
2.
Katz ITEssien TMarinda ET et al. Antiretroviral therapy refusal among newly diagnosed HIV-infected adultsAIDS2011252177-2181. 2. Katz IT, Essien T, Marinda ET, et al. Antiretroviral therapy refusal among newly diagnosed HIV-infected adults. AIDS 2011;25:2177–2181.
3.
Murphy RASunpath HTaha B et al. Low uptake of antiretroviral therapy and high mortality after tuberculosis and opportunistic infection in Kwazulu-Natal, South AfricaInt J Tuberc Lung Dis201014903-908. 3. Murphy RA, Sunpath H, Taha B, et al. Low uptake of antiretroviral therapy and high mortality after tuberculosis and opportunistic infection in Kwazulu-Natal, South Africa. Int J Tuberc Lung Dis 2010;14:903–908.
4.
Maisels LSteinberg JTobias C. An investigation of why eligible patients do not receive ARTAIDS Patient Care STDs200115185-191. 4. Maisels L, Steinberg J, Tobias C. An investigation of why eligible patients do not receive ART. AIDS Patient Care STDs 2001;15:185–191.
5.
Beer LFagan JLValverde EBertolli J. Health-related beliefs and decisions about accessing HIV medical care among HIV-infected persons who are not receiving careAIDS Patient Care STDs200923785-792. 5. Beer L, Fagan JL, Valverde E, Bertolli J. Health-related beliefs and decisions about accessing HIV medical care among HIV-infected persons who are not receiving care. AIDS Patient Care STDs 2009;23:785–792.
6.
Gold RSHinchy JBatrouney CG. The reasons behind decisions not to take up antiretroviral therapy among in Australians infected with HIVInt J STDs AIDS200011361-370. 6. Gold RS, Hinchy J, Batrouney CG. The reasons behind decisions not to take up antiretroviral therapy among in Australians infected with HIV. Int J STDs AIDS 2000;11:361–370.
7.
Gold RSRidge DT. “I will start treatment when I think time is right”: HIV positive gay men talk about their decision not to access antiretroviral therapyAIDS Care200113693-708. 7. Gold RS, Ridge DT. “I will start treatment when I think time is right”: HIV positive gay men talk about their decision not to access antiretroviral therapy. AIDS Care 2001;13:693–708.
8.
Alfonso VBermbach NGeller JMontaner JSG. Individual variability in barriers affecting people's decision to take HAART: A qualitative study identifying barriers to being on HAARTAIDS Patient Care STDs200620848-857. 8. Alfonso V, Bermbach N, Geller J, Montaner JSG. Individual variability in barriers affecting people's decision to take HAART: A qualitative study identifying barriers to being on HAART. AIDS Patient Care STDs 2006;20: 848–857.
9.
Gellaitry GCooper VDavies C et al. Patients' perception of information about HAART: Impact on treatment decisionsAIDS Care200517367-376. 9. Gellaitry G, Cooper V, Davies C, et al. Patients' perception of information about HAART: Impact on treatment decisions. AIDS Care 2005;17:367–376.
10.
Zachariah RHarries ADManzi M et al. Acceptance of antiretroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transportPLoS One20101e121. 10. Zachariah R, Harries AD, Manzi M, et al. Acceptance of antiretroviral therapy among patients infected with HIV and tuberculosis in rural Malawi is low and associated with cost of transport. PLoS One 2010;1:e121.
11.
Garland PMValverde EEFagan J et al. HIV counseling, testing and referral experiences of persons diagnosed with HIV who have never entered medical careAIDS Educ Prev201123117-127. 11. Garland PM, Valverde EE, Fagan J, et al. HIV counseling, testing and referral experiences of persons diagnosed with HIV who have never entered medical care. AIDS Educ Prev 2011;23:117–127.
12.
Wringe ARoura MUrassa M et al. Doubts, denial and divine intervention: Understanding delayed attendance and poor retention rates at a HIV treatment programme in rural TanzaniaAIDS Care200921632-637. 12. Wringe A, Roura M, Urassa M, et al. Doubts, denial and divine intervention: Understanding delayed attendance and poor retention rates at a HIV treatment programme in rural Tanzania. AIDS Care 2009;21:632–637.
13.
Central Statistics Office (CSO), Ministry of Health (MoH), Tropical Disease Research Centre (TDRC), University of Zambia, and Macro International Inc. Zambia Demographic and Health Survey2007Calverton, Maryland, USACSO and Macro International Inc.2009. 13. Central Statistics Office (CSO), Ministry of Health (MoH), Tropical Disease Research Centre (TDRC), University of Zambia, and Macro International Inc., Zambia Demographic and Health Survey, 2007. Calverton, Maryland, USA: CSO and Macro International Inc. 2009.
14.
Ministry of HealthAdult and Adolescent Antiretroviral Therapy Protocols2ndLusakaMoH2010. 14. Ministry of Health. Adult and Adolescent Antiretroviral Therapy Protocols (2nd edition). Lusaka, MoH, 2010.
15.
Ministry of Health. Zambia Country Report. Monitoring the Declaration of Commitment on HIV and AIDS and the Universal Access. Biennial Report, January 2010–December 2011. Submitted to the United Nations General Assembly Special Session on AIDSLusakaNAC/MoHMarch2012. 15. Ministry of Health. Zambia Country Report. Monitoring the Declaration of Commitment on HIV and AIDS and the Universal Access. Biennial Report, January 2010–December 2011. Submitted to the United Nations General Assembly Special Session on AIDS. Lusaka, NAC/MoH, March 2012.
16.
Fox MPMazimba ASeidenberg P et al. Barriers to initiation of antiretroviral treatment in rural and urban Zambia: A cross-sectional study of cost, stigma and perception of treatmentJ Int AIDS Soc2010138. 16. Fox MP, Mazimba A, Seidenberg P, et al. Barriers to initiation of antiretroviral treatment in rural and urban Zambia: A cross-sectional study of cost, stigma and perception of treatment. J Int AIDS Soc 2010;13:8.
17.
Murray LKSemrau KMcCauley E et al. Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: A qualitative studyAIDS Care20092178-86. 17. Murray LK, Semrau K, McCauley E, et al. Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: A qualitative study. AIDS Care 2009;21:78–86.
18.
Grant ELogie DMasura M et al. Factors facilitating and challenging access and adherence to antiretroviral therapy in a township in the Zambian Copperbelt: A qualitative studyAIDS Care2008201155-1160. 18. Grant E, Logie D, Masura M, et al. Factors facilitating and challenging access and adherence to antiretroviral therapy in a township in the Zambian Copperbelt: A qualitative study. AIDS Care 2008; 20:1155–1160.
19.
Simpson A. Boys to Men in the Shadow of AIDS: Masculinities and HIV risk in ZambiaPalgrave MacmillanNew York2009. 19. Simpson A. Boys to Men in the Shadow of AIDS: Masculinities and HIV risk in Zambia. Palgrave Macmillan, New York, 2009.
20.
Roura MBusza JWringe A et al. Barriers to sustaining antiretroviral treatment in Kisesa, Tanzania: A follow up study to understand attrition from antiretroviral programmeAIDS Patient Care STDs200923203-210. 20. Roura M, Busza J, Wringe A, et al. Barriers to sustaining antiretroviral treatment in Kisesa, Tanzania: A follow up study to understand attrition from antiretroviral programme. AIDS Patient Care STDs 2009;23:203–210.
21.
Musheke MBond MMerten S. Individual and contextual factors influencing patient attrition from antiretroviral therapy care in an urban community of Lusaka, ZambiaJ Int AIDS Soc20121517366. 21. Musheke M, Bond M, Merten S. Individual and contextual factors influencing patient attrition from antiretroviral therapy care in an urban community of Lusaka, Zambia. J Int AIDS Soc 2012;15:17366.
22.
Latkin CAKnowlton AR. Micro-social structural approaches to HIV prevention: A social ecological perspectiveAIDS Care200517S102-S113. 22. Latkin CA, Knowlton AR. Micro-social structural approaches to HIV prevention: A social ecological perspective. AIDS Care 2005;17:S102–S113.
23.
Skovdal MCampbell CNyamukapa CGregson S. When masculinity interferes with women's treatment of HIV infection: A qualitative study about adherence to antiretroviral therapy in ZimbabweJ Int AIDS Soc20111429. 23. Skovdal M, Campbell C, Nyamukapa C, Gregson S. When masculinity interferes with women's treatment of HIV infection: A qualitative study about adherence to antiretroviral therapy in Zimbabwe. J Int AIDS Soc 2011;14:29.
24.
Merten SKenter EMckenzie O et al. Patient-reported barriers and drivers of adherence to antiretrovirals in sub-Saharan Africa: A meta-ethnographyTrop Med Int Health2010151-18. 24. Merten S, Kenter E, Mckenzie O, et al. Patient-reported barriers and drivers of adherence to antiretrovirals in sub-Saharan Africa: A meta-ethnography. Trop Med Int Health 2010;15:1–18.
25.
Van Servellen GLombardi E. Supportive relationships and medication adherence to antiretroviral therapy in HIV-infected, low income LatinosWest J Nurs Res2005271023-1039. 25. Van Servellen G, Lombardi E. Supportive relationships and medication adherence to antiretroviral therapy in HIV-infected, low income Latinos. West J Nurs Res 2005;27:1023–1039.
26.
Duff PKipp WWild TC et al. Barriers to accessing highly active antiretroviral therapy by HIV-positive women attending an antenatal clinic in a general hospital in Western UgandaJ Int AIDS Soc20101337. 26. Duff P, Kipp W, Wild TC, et al. Barriers to accessing highly active antiretroviral therapy by HIV-positive women attending an antenatal clinic in a general hospital in Western Uganda. J Int AIDS Soc 2010;13:37.
27.
Unge CJohansson AZachariah R et al. Reasons for unsatisfactory acceptance of antiretroviral treatment in the urban Kibera slum, KenyaAIDS Care200820146-149. 27. Unge C, Johansson A, Zachariah R, et al. Reasons for unsatisfactory acceptance of antiretroviral treatment in the urban Kibera slum, Kenya. AIDS Care 2008;20:146–149.
28.
Unge CRagnarsson AEkström AM et al. The influence of traditional medicine and religion on discontinuation of ART in an urban informal settlement in Nairobi, KenyaAIDS Care201123851-858. 28. Unge C, Ragnarsson A, Ekström AM, et al. The influence of traditional medicine and religion on discontinuation of ART in an urban informal settlement in Nairobi, Kenya. AIDS Care 2011;23:851–858.
29.
Graneheim UHLundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthinessNurse Educ Today200424105-112. 29. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004;24:105–112.
30.
Burnard P. A method of analysing interview transcripts in qualitative researchNurse Educ Today199111461-466. 30. Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Educ Today 1991;11:461–466.
31.
McKague MVerhoef M. Understanding of health and its determinants among clients and providers at an urban community health centreQual Health Res200313703-717. 31. McKague M, Verhoef M. Understanding of health and its determinants among clients and providers at an urban community health centre. Qual Health Res 2003;13:703–717.
32.
Siegel KGorey E. HIV-infected women: Barriers to AZT useSoc Sci Med19974515-22. 32. Siegel K, Gorey E. HIV-infected women: Barriers to AZT use. Soc Sci Med 1997;45:15–22.
33.
Siegel KSchrimshaw EWDean L. Symptom interpretation and medicine adherence among late middle age and older HIV infected adultsJ Health Psychol19994247-257. 33. Siegel K, Schrimshaw EW, Dean L. Symptom interpretation and medicine adherence among late middle age and older HIV infected adults. J Health Psychol 1999;4:247–257.
34.
Lumme-Sandt KHervonen AJylha M. Interpretive repertoires of medicine among the oldest-oldSoc Sci Med2000501843-1850. 34. Lumme-Sandt K, Hervonen A, Jylha M. Interpretive repertoires of medicine among the oldest-old. Soc Sci Med 2000;50:1843–1850.
35.
World Health Organization. Antiretroviral therapy for HIV infection in adults and adolescents: Recommendations for a public health approachGenevaWHO2010. 35. World Health Organization. Antiretroviral therapy for HIV infection in adults and adolescents: Recommendations for a public health approach. Geneva, WHO, 2010.
36.
Granich RMGilks CFDye C et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: A mathematical modelLancet200937348-57. 36. Granich RM, Gilks CF, Dye C, et al. Universal voluntary HIV testing with immediate antiretroviral therapy as a strategy for elimination of HIV transmission: A mathematical model. Lancet 2009;373:48–57.
37.
Wong WKTUssher J. How do subjectively constructed meanings ascribed to anti-HIV treatments affect treatment-adherent practice?Qual Health Res200818458-468. 37. Wong WKT, Ussher J. How do subjectively constructed meanings ascribed to anti-HIV treatments affect treatment-adherent practice? Qual Health Res 2008,18:458–468.
38.
Rier DIndyk D. Flexible rigidity: Supporting HIV treatment adherence in a rapidly changing treatment environmentSoc Work Health Care200642133-150. 38. Rier D, Indyk D. Flexible rigidity: Supporting HIV treatment adherence in a rapidly changing treatment environment. Soc Work Health Care 2006;42:133–150.
39.
Skovdal MCampbell CNhongo K et al. Contextual and psychosocial influences on antiretroviral therapy adherence in rural Zimbabwe: towards a systematic framework for programme plannersInt J Health Plann Mgmt201126296-318. 39. Skovdal M, Campbell C, Nhongo K, et al. Contextual and psychosocial influences on antiretroviral therapy adherence in rural Zimbabwe: towards a systematic framework for programme planners. Int J Health Plann Mgmt 2011;26:296–318.
40.
Barton LMWilson IBBowser DMKerr SE. Taking antiretroviral therapy for HIV infection: Learning from patients' storiesJ Gen Intern Med200015848-858. 40. Barton LM, Wilson IB, Bowser DM, Kerr SE. Taking antiretroviral therapy for HIV infection: Learning from patients' stories. J Gen Intern Med 2000;15:848–858.
41.
Munro SALewin SASmith HJ et al. Patient adherence to tuberculosis treatment: A systematic review of qualitative findingsPlos Med20074e238. 41. Munro SA, Lewin SA, Smith HJ, et al. Patient adherence to tuberculosis treatment: A systematic review of qualitative findings. Plos Med 2007;4:e238.
42.
Parker RGEaston DKlein CH. Structural barriers and facilitators in HIV prevention: A review of international researchAIDS200014S22-S32. 42. Parker RG, Easton D, Klein CH. Structural barriers and facilitators in HIV prevention: A review of international research. AIDS 2000;14:S22–S32.
43.
Sumartojo E. Structural factors in HIV prevention: Concepts, examples and implications for researchAIDS200014S3-S10. 43. Sumartojo E. Structural factors in HIV prevention: Concepts, examples and implications for research. AIDS 2000;14:S3–S10.
44.
Chileshe MBond VA. Barriers and outcomes: TB patients co-infected with HIV accessing antiretroviral therapy in rural ZambiaAIDS Care20102251-59. 44. Chileshe M, Bond VA. Barriers and outcomes: TB patients co-infected with HIV accessing antiretroviral therapy in rural Zambia. AIDS Care 2010;22:51–59.
45.
Tuller DMBangsberg DRSenkungu J et al. Transport costs impede sustained adherence and access to HAART in a clinic population in southwestern Uganda: A qualitative studyAIDS Behav201014778-784. 45. Tuller DM, Bangsberg DR, Senkungu J, et al. Transport costs impede sustained adherence and access to HAART in a clinic population in southwestern Uganda: A qualitative study. AIDS Behav 2010;14:778–784.
46.
Hardon APAkurut DComoro C et al. Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in AfricaAIDS Care200719658-665. 46. Hardon AP, Akurut D, Comoro C, et al. Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa. AIDS Care 2007;19:658–665.
47.
National AIDS Council. Zambia Biennial Country Report 2008–2009: Monitoring the declaration of commitment on HIV and AIDS and the universal access. Submitted to the United Nations General Assembly Special Session on AIDSLusakaNACMarch2010. 47. National AIDS Council. Zambia Biennial Country Report 2008–2009: Monitoring the declaration of commitment on HIV and AIDS and the universal access. Submitted to the United Nations General Assembly Special Session on AIDS. Lusaka, NAC, March 2010.
48.
IRIN Plus News (14th March 2010)ZambiaCorruption scandal rocks ARV programmewww.plusnews.orgMay102012. 48. IRIN Plus News (14th March 2010). Zambia: Corruption scandal rocks ARV programme. Available from: www.plusnews.org (last accessed May, 10, 2012).
49.
The Post Newspaper (30th January 2012): Africa is too dependent for AIDS Response, says UNAIDShttp://www.postzambia.comMay182012. 49. The Post Newspaper (30th January 2012): Africa is too dependent for AIDS Response, says UNAIDS. Available from: http://www.postzambia.com (last accessed May, 18, 2012).
50.
Berhanu Z. Holy water as an intervention for HIV/AIDS in EthiopiaJ HIV AIDS Soc Serv20109240-260. 50. Berhanu Z. Holy water as an intervention for HIV/AIDS in Ethiopia. J HIV AIDS Soc Serv 2010;9:240–260.
51.
Tocco JU. ‘Every disease has its cure’: Faith and HIV therapies in Islamic northern NigeriaAfri J AIDS Res20109385-395. 51. Tocco JU. ‘Every disease has its cure’: Faith and HIV therapies in Islamic northern Nigeria. Afri J AIDS Res 2010;9:385–395.
52.
Togarasei L. Christian theology of life, death and healing in an era of antiretroviral therapy: Reflections on the responses of some Botswana churchesAfri J AIDS Res20109429-435. 52. Togarasei L. Christian theology of life, death and healing in an era of antiretroviral therapy: Reflections on the responses of some Botswana churches. Afri J AIDS Res 2010;9:429–435.
53.
Balogun AS. Islamic perspectives on HIV/AIDS and antiretroviral treatment: The case of NigeriaAfri J AIDS Res20109459-466. 53. Balogun AS. Islamic perspectives on HIV/AIDS and antiretroviral treatment: The case of Nigeria. Afri J AIDS Res 2010;9:459–466.
54.
Banda YChapman VGoldenberg RL et al. Use of traditional medicine among pregnant women in Lusaka, ZambiaJ Altern Complement Med200713123-127. 54. Banda Y, Chapman V, Goldenberg RL, et al. Use of traditional medicine among pregnant women in Lusaka, Zambia. J Altern Complement Med 2007;13:123–127.
55.
Morris K. Treating HIV in South Africa—A tale of two health systemsThe Lancet20011190. 55. Morris K. Treating HIV in South Africa—A tale of two health systems. The Lancet 2001;1190.
56.
World Health Organization. In vitro screening of traditional medicines for anti-HIV activity: Memorandum from a WHO meetingBull World Health Organ198987613-618. 56. World Health Organization: In vitro screening of traditional medicines for anti-HIV activity: Memorandum from a WHO meeting. Bull World Health Organ 1989;87:613–618.

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cover image AIDS Patient Care and STDs
AIDS Patient Care and STDs
Volume 27Issue Number 4April 2013
Pages: 231 - 241
PubMed: 23530573

History

Published online: 8 April 2013
Published in print: April 2013
Published ahead of print: 26 March 2013

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Maurice Musheke
Zambia AIDS-related TB Research Project, University of Zambia, Lusaka, Zambia.
Swiss Tropical and Public Health Institute, Basel, Switzerland.
University of Basel, Faculty of Science, Basel, Switzerland.
Virginia Bond
Zambia AIDS-related TB Research Project, University of Zambia, Lusaka, Zambia.
Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Sonja Merten
Swiss Tropical and Public Health Institute, Basel, Switzerland.
University of Basel, Faculty of Science, Basel, Switzerland.

Notes

Address correspondence to:Mr. Maurice MushekeZAMBART ProjectUniversity of Zambia School of MedicineP.O Box 50697LusakaZambia
E-mail: [email protected]

Author Disclosure Statement

No competing financial interests exist.

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