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‘If I am given antiretrovirals I will think I am nearing the grave’: Kenyan HIV serodiscordant couples’ attitudes regarding early initiation of antiretroviral therapy

Curran, Kathryna,b; Ngure, Kennethb,e,f; Shell-Duncan, Bettinab,c; Vusha, Sophief; Mugo, Nelly R.b,g; Heffron, Reneeb; Celum, Conniea,b,d; Baeten, Jared M.a,b,d

doi: 10.1097/QAD.0000000000000025
Epidemiology and Social

Objectives: Early initiation of antiretroviral therapy (ART) – that is, at higher CD4+ cell counts (>350 cells/μl) – is a potent HIV prevention strategy. The WHO recommends ART initiation by all HIV-infected individuals in HIV serodiscordant relationships to prevent HIV transmission, yet the acceptability of early ART among couples has not been well studied.

Design: Qualitative study exploring HIV serodiscordant couples’ attitudes toward early initiation of ART.

Methods: We conducted eight focus group discussions and 20 in-depth interviews with members of heterosexual HIV serodiscordant couples in Kenya. Investigators iteratively applied inductive and deductive codes, developed matrices to identify patterns in codes, and reached consensus on key attitudes (motivations and barriers) related to early ART and one central, emerging theme.

Results: Most participants expressed interest in early initiation of ART, with maintaining health and preventing HIV transmission as key benefits. However, many identified personal concerns and potential barriers to wider community acceptance, including side-effects, adherence to life-long treatment, and stigma. The meaning of ART emerged as a fundamental consideration, with initiating therapy perceived as emblematic of the final stage of AIDS, when one was ‘nearing the grave.’ One particular challenge was what early ART might signify for someone who looks and feels healthy.

Conclusion: HIV serodiscordant couples recognized the potential benefits of early ART, but ART was frequently viewed as signifying AIDS and approaching mortality. Potential implementation of early ART presents challenges and an opportunity to re-orientate individuals toward a new image of ART as health-preserving for patients and partners.

aDepartment of Epidemiology

bDepartment of Global Health

cDepartment of Anthropology

dDepartment of Medicine, University of Washington, Seattle, Washington, USA

eJomo Kenyatta University of Agriculture and Technology

fKenyatta National Hospital

gKenya Medical Research Institute, Nairobi, Kenya.

Correspondence to Kathryn Curran, Department of Global Health, University of Washington, 325 Ninth Avenue, Box 359927, Seattle, WA 98104, USA. Tel: +1 206 520 3811; e-mail:

Received 27 June, 2013

Revised 25 July, 2013

Accepted 31 July, 2013

These data were presented in part at the 2013 International HIV Treatment as Prevention Workshop, Vancouver, Canada, in April 2013 (Oral abstract #4019).

© 2014 Lippincott Williams & Wilkins, Inc.