title: 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: BACKGROUND
  While 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.
  
  
  METHODS
  We 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.
  
  
  RESULTS
  HBC 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.
  
  
  CONCLUSIONS
  Patients 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.
authors.affiliation: Center for Global Health and Development, Boston University, MA, USA. mfox@bu.edu
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Fox
authors.forename: Arthur
authors.initials: A
authors.lastname: Mazimba
authors.forename: Phil
authors.initials: P
authors.lastname: Seidenberg
authors.forename: Denise
authors.initials: D
authors.lastname: Crooks
authors.forename: Bornwell
authors.initials: B
authors.lastname: Sikateyo
authors.forename: Sydney
authors.initials: S
authors.lastname: Rosen
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use; D017281:Cost of Illness; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics / Q000523:psychology*; D006297:Health Services Accessibility / Q000191:economics; D006801:Humans; D008297:Male; D008875:Middle Aged; D010465:Perception; D012424:Rural Population; D057545:Social Stigma; D014505:Urban Population; D055815:Young Adult; D015024:Zambia
chemical_list: D019380:Anti-HIV Agents