Why some women shun HIV treatment

A qualitative study of women here in Malawi who chose not to take HIV treatment as part of the Option B+ programme, or who interrupted their treatment, has found that needing more time to think, concerns about partner support, and side-effects were important reasons for declining to take HIV treatment.

While these themes have appeared in other studies of non-adherence to HIV treatment in other settings, they seem to be especially significant in the context of Option B+. In this programme, pregnant women who may feel healthy are asked to begin HIV treatment on the day of their diagnosis and to continue it for the rest of their life.

This is one of the first qualitative studies of the barriers and facilitators to retention in Option B+ programmes. Findings are published in PLOS One and also in Social Science and Medicine.

The Option B+ programme offers antiretroviral therapy (ART) to all pregnant women with HIV, regardless of CD4 cell count or disease stage, with the intention that therapy will be continued after the pregnancy ends. It was designed to be a simple approach to implement in the context of extremely limited resources. Option B+ has helped achieve a dramatic scale-up of HIV treatment in women, but retention remains a challenge—two years after beginning treatment, only 68 percent of women are still in care.

In-depth, qualitative interviews were conducted in 2014 with 65 women who were offered HIV treatment by the Option B+ programme. Ten had refused to begin ART, 26 had started ART and then stopped during their pregnancy, and 29 had begun ART and remained on it. Most women were in their 20’s or 30’s. Two-thirds had completed less than secondary school education and three-quarters were married or cohabiting.

For women who began ART promptly and stayed on it, the desire to prevent transmission and improve health were the most important facilitators.

For the 10 women who did not begin HIV treatment when it was initially offered, the immediacy of beginning treatment could be a challenge. Several women expressed the need for more time, either to come to terms with their diagnosis or to discuss the issue with their partner and family.

Prior to Option B+, people only began HIV treatment when they were clinically unwell or were immunosuppressed. Clinical assessments could take several weeks and this delay could give people the opportunity to come to terms with their health status. However, in Option B+ clinicians recommend treatment immediately after diagnosis.

All women who began treatment took a fixed dose tablet containing efavirenz—a drug that can cause drowsiness, dizziness and vivid dreams. However women may have been attributing some problems associated with pregnancy (e.g. morning sickness) to their HIV treatment.