False starts in 'test and start' a qualitative study of reasons for delayed antiretroviral therapy in Swaziland

Background
Test and start, antiretroviral therapy (ART) for all HIV-positive individuals, is a WHO-recommended treatment guideline. In Swaziland, test and start has been evaluated through the MaxART implementation study. This article examines why, in MaxART, some newly diagnosed HIV-positive clients delayed initiating ART.

Methods
Thirteen HIV-positive clients who delayed ART for ≥90 d after testing were identified from the MaxART study database and interviewed. Interviews were audio recorded, transcribed and translated into English for qualitative content analysis.

Results
Respondents had often tested positive several times before initiating ART, with the initial diagnosis sometimes completely unexpected. Repeat testing—and delayed ART—was linked to a desire to come to terms with their diagnosis and prepare for a lifelong treatment course. Clients previously enrolled in pre-ART, particularly with high CD4 counts, had internalized past messages about ART as being non-essential and taking care of oneself through other means. Concerns about ART-related adverse events were weighed against these messages. Worries about inadvertent disclosure and its impact on social and economic relationships also discouraged initiation.

Conclusion
Although potentially reducing logistical barriers, expedited ART initiation does not necessarily accommodate some clients’ need for time to come to terms with the diagnosis and the prospect of lifelong treatment.