title: Inadequate pre-antiretroviral care, stock-out of antiretroviral drugs and stigma: policy challenges/bottlenecks to the new WHO recommendations for earlier initiation of antiretroviral therapy (CD<350 cells/microL) in eastern Uganda.
abstract: OBJECTIVE
  This study explores reasons for late ART initiation among known HIV positive persons in care from a client/caretaker perspective in eastern Ugandan where ART awareness is presumably high yet AIDS related mortality is a common function of late initiation of ARVs.
  
  
  METHODS
  In Iganga, Uganda we conducted in-depth interviews with clients who started ART at 50-200 CD4 cells/microL and those initiated very late at CD4<50 cells/microL. Focus-group discussions were also conducted with caretakers of clients on ART. Content analysis was performed to identify recurrent themes.
  
  
  RESULTS
  ARV stock-outs, inadequate pre-antiretroviral care and lack of staff confidentiality were system barriers to timely ART initiation. Weak social support and prevailing stigma and misconceptions about ARVs as drugs designed to kill, cause cancer, infertility or impotence were other important factors.
  
  
  CONCLUSIONS
  If the new WHO recommendations (start ART at CD4 350 cells/microL) should be feasible, PLHIV/communities need sensitization about the importance of regular pre-ARV care through the local media and authorities. The ARV supply chain and staff attitudes towards client confidentiality must also be improved in order to encourage timely ART initiation. PLHIV/communities should be sensitization about drug package labeling and the use and importance of ARVs. Stronger social support structures must be created through public messages that fight stigma, enhance acceptance of PLHIV and encourage timely ART initiation.
authors.affiliation: District Health Office, Iganga District Adminstration, Iganga, Uganda. dlmuhamadi@yahoo.co.uk
authors.forename: Lubega
authors.initials: L
authors.lastname: Muhamadi
authors.forename: Xavier
authors.initials: X
authors.lastname: Nsabagasani
authors.forename: Mbona Nazarius
authors.initials: MN
authors.lastname: Tumwesigye
authors.forename: Fred
authors.initials: F
authors.lastname: Wabwire-Mangen
authors.forename: Anna-Mia
authors.initials: AM
authors.lastname: Ekström
authors.forename: Stefan
authors.initials: S
authors.lastname: Peterson
authors.forename: George
authors.initials: G
authors.lastname: Pariyo
mesh_terms: D000328:Adult; D000368:Aged; D019380:Anti-HIV Agents / Q000600:supply & distribution* / Q000627:therapeutic use; D017028:Caregivers; D003219:Confidentiality; D005260:Female; D017144:Focus Groups; D019983:Guideline Adherence; D015658:HIV Infections / Q000188:drug therapy*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D011287:Prejudice; D012944:Social Support; D014454:Uganda; D014944:World Health Organization
chemical_list: D019380:Anti-HIV Agents