title: Facilitators and Barriers of Antiretroviral Therapy Initiation among HIV Discordant Couples in Kenya: Qualitative Insights from a Pre-Exposure Prophylaxis Implementation Study.
abstract: BACKGROUND
  The World Health Organization now recommends antiretroviral therapy (ART) initiation for all HIV-infected individuals regardless of CD4 cell count or disease status. Understanding the facilitators and barriers to initiation of and adherence to ART is essential to successful scale-up of "universal" ART.
  
  
  METHODS
  To investigate facilitators and barriers to ART initiation, we conducted 44 in-depth individual or couple interviews with 63 participants (33 participants with HIV and 30 without HIV) already enrolled in a prospective implementation study of oral antiretroviral-based prevention in Kisumu, Kenya between August and September 2014. A semi-structured interview guided discussions on: 1) perceived advantages and disadvantages of ART; 2) reasons for accepting or declining ART initiation; and 3) influence of prevention of transmission to partner or infant influencing ART use. Transcripts from the interviews were iteratively analyzed using inductive content analysis.
  
  
  RESULTS
  HIV-infected participants indicated that living a healthier life, preventing HIV transmission to others, and appearing "normal" or "healthy" again facilitated their initiation of ART. While appearing "normal" allowed these individuals to interact with their communities without stigmatization, they also perceived community opposition to their initiating ART, because appearing "normal" again prevented community members from easily identifying infected individuals in their community. Denial of diagnosis, disclosure stigma, perceived side-effects, and challenges in obtaining refills were additional barriers to ART initiation.
  
  
  CONCLUSIONS
  Community perceptions play an important role in both facilitating and inhibiting ART initiation. Perceived stigma, including perceived community opposition to widespread ART use, is an important barrier to ART initiation. Addressing such barriers, while capitalizing on facilitators, to ART initiation should be central to universal ART scale-up efforts.
authors.affiliation: Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA, United States of America.
authors.forename: Rena C
authors.identifier: http://orcid.org/0000-0001-9893-5856
authors.initials: RC
authors.lastname: Patel
authors.affiliation: Centre for Microbiologic Research, Kenya Medical Research Institute, Kisumu, Kenya.
authors.forename: Josephine
authors.initials: J
authors.lastname: Odoyo
authors.affiliation: Northwestern University, Chicago, IL, United States of America.
authors.forename: Keerthana
authors.initials: K
authors.lastname: Anand
authors.affiliation: School of Medicine, University of California, San Francisco, CA, United States of America.
authors.forename: Gaelen
authors.initials: G
authors.lastname: Stanford-Moore
authors.affiliation: Centre for Microbiologic Research, Kenya Medical Research Institute, Kisumu, Kenya.
authors.forename: Imeldah
authors.initials: I
authors.lastname: Wakhungu
authors.affiliation: Centre for Microbiologic Research, Kenya Medical Research Institute, Kisumu, Kenya.|Departments of Obstetrics and Gynecology and Global Health, University of Washington, Seattle, WA, United States of America.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Bukusi
authors.affiliation: Departments of Epidemiology, Global Health, and Medicine, University of Washington, Seattle, WA, United States of America.
authors.forename: Jared M
authors.initials: JM
authors.lastname: Baeten
authors.affiliation: Departments of Epidemiology and Biostatistics and Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, CA, United States of America.
authors.forename: Joelle M
authors.initials: JM
authors.lastname: Brown
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D005191:Family Characteristics; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000517:prevention & control* / Q000523:psychology; D006801:Humans; D007407:Interviews as Topic; D007630:Kenya / Q000453:epidemiology; D008297:Male; D010342:Patient Acceptance of Health Care / Q000523:psychology*; D065129:Pre-Exposure Prophylaxis / Q000706:statistics & numerical data*; D036301:Qualitative Research; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents