Deterrents to HIV-Patient Initiation of Antiretroviral Therapy in Urban Lusaka, Zambia: A Qualitative Study Maurice Musheke, MPH, 1–3 Virginia Bond, PhD, 1,4 and Sonja Merten, PhD 2,3 Abstract Some people living with HIV (PLHIV) refuse to initiate antiretroviral therapy (ART) despite availability. Be- tween March 2010 and September 2011, using a social ecological framework, we investigated barriers to ART initiation in Lusaka, Zambia. In-depth interviews were conducted with PLHIV who were offered treatment but declined (n = 37), ART staff (n = 5), faith healers (n = 5), herbal medicine providers (n = 5), and home-based care providers (n = 5). One focus group discussion with lay HIV counselors and observations in the community and at an ART clinic were conducted. Interviews were audio-recorded, transcribed, and translated, coded using Atlas ti, and analyzed using latent content analysis. Lack of self-efficacy, negative perceptions of medication, desire for normalcy, and fear of treatment-induced physical body changes, all modulated by feeling healthy, undermined treatment initiation. Social relationships generated and perpetuated these health and treatment beliefs. Long waiting times at ART clinics, concerns about long-term availability of treatment, and taking strong medication amidst livelihood insecurity also dissuaded PLHIV from initiating treatment. PLHIV opted for herbal remedies and faith healing as alternatives to ART, with the former being regarded as effective as ART, while the latter contributed to restoring normalcy through the promise of being healed. Barriers to treatment initiation were not mutually exclusive. Some coalesced to undermine treatment initiation. Ensuring patients initiate ART requires interventions at different levels, addressing, in particular, people’s health and treatment beliefs, changing per- ceptions about effectiveness of herbal remedies and faith healing, improving ART delivery to attenuate social and economic costs and allaying concerns about future non-availability of treatment. Introduction D espite the increasingly wider availability of anti- retroviral therapy (ART), only an estimated 37% of people in sub-Saharan Africa (SSA) eligible for treatment were receiving it by end of 2009. 1 One reason given for the low uptake of treatment has been low and inequitable coverage. 1 However, even where treatment is readily available, some people living with HIV (PLHIV) and eligible for medication have opted not to initiate treatment. Previous studies have attributed non-uptake of treatment to personal-level factors such as feeling healthy, 2,3 low self-efficacy to be on life-long treatment, 4 and avoidance of being reminded of having HIV. 5,6 Interpersonal-level factors such as fear of stigma, 5 treatment-related concerns such as drug toxicity 7 and side effects 6,8,9 also undermine treatment uptake. Health-system- related factors such as financial costs of accessing treatment, 10 dissatisfaction with medical care, 5,11 and beliefs about the effectiveness of faith healing 5,12 and traditional medicine 3,12 also dissuade individuals from seeking treatment. With HIV prevalence estimated at 14.3% in the Zambian population aged 15–49 years 13 and an estimated HIV inci- dence of 1.6%, 14 Zambia is one of the countries in SSA worst hit by the pandemic. Since 2005, free ART services have been progressively rolled-out in public sector clinics, resulting in a steady increase in the number of people on ART. However, not everyone eligible for treatment is receiving it. At the end of 2010, out of an estimated 503,284 adults and children in need of ART, only 68.4% were receiving it. 15 While many studies have been conducted on barriers to patient initiation of ART, most of these studies have been conducted outside sub-Saharan Africa (SSA), the sub-continent 1 Zambia AIDS-related TB Research Project, University of Zambia, Lusaka, Zambia. 2 Swiss Tropical and Public Health Institute, Basel, Switzerland. 3 University of Basel, Faculty of Science, Basel, Switzerland. 4 Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom. AIDS PATIENT CARE and STDs Volume 27, Number 4, 2013 ª Mary Ann Liebert, Inc. DOI: 10.1089/apc.2012.0341 1