Readiness for Antiretroviral Therapy: Implications for Linking HIV-Infected Individuals to Care and Treatment

  • Brendan Maughan-Brown
  • Philip Smith
  • Caroline Kuo
  • Abigail Harrison
  • Mark N. Lurie
  • Linda-Gail Bekker
  • Omar Galárraga
Original Paper


Using survey data collected immediately after referral for ART (N = 87), this study examined ART-readiness among individuals (18 years and older) attending a mobile health clinic in South Africa. Most participants reported being very ready (84%) and motivated (85%) to start ART, but only 72% were assessed as ready for ART on all measures. Treatment readiness was lower among individuals who did not think they would test HIV-positive (aOR 0.26, p < 0.05) and among individuals who reported being in good health (aOR 0.44, p < 0.1). In contrast, higher readiness was associated with better ART knowledge (aOR 4.31, p < 0.05) and knowing someone who had experienced positive health effects from ART (aOR 2.65, p < 0.05). Results indicate that post-test counselling will need to be designed to deal with surprise at HIV diagnosis, and that health messaging needs to be carefully crafted to support uptake of ART among HIV-positive but healthy individuals. Further research is needed on effective post-test counselling approaches and effective framing of health messaging to increase awareness of the multiple positive benefits of early ART initiation and corresponding readiness to engage in treatment.


Linkage to care HIV/AIDS Barriers to ART initiation Treatment readiness 



The authors gratefully acknowledge the staff of the Tutu Tester Mobile Clinic for their valuable assistance with developing the study materials and with data collection.


This study was partially funded by the National Research Foundation, South Africa, through the Research Career Advancement Fellowship. Data collection for this study was partially funded by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (award number R24HD077976). Support was provided by the National Institutes of Health through the Brown University Population Studies and Training Center (PSTC) (P2CHD041020-16). Support was provided to CK and ML by the National Institute of Mental Health of the National Institutes of Health (award numbers K01096646 and 1R01 MH106600-01). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The Human Research Ethics Committee, Faculty of Health Sciences, University of Cape Town provided study approval (ref: 849/2014).

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Bor J, Herbst AJ, Newell M-L, Bärnighausen T. Increases in adult life expectancy in rural South Africa: valuing the scale-up of HIV treatment. Science. 2013;339:961–5.CrossRefPubMedGoogle Scholar
  2. 2.
    Johnson LF, Mossong J, Dorrington RE, et al. Life expectancies of South African adults starting antiretroviral treatment: collaborative analysis of cohort studies. PLOS Med. 2013;10:e1001418.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493–505.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Montaner JSG, Lima VD, Barrios R, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010;376:532–9.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Tanser F, Bärnighausen T, Grapsa E, Zaidi J, Newell ML. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal. South Africa. Sci. 2013;339:966–71.Google Scholar
  6. 6.
    UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic [Internet]. Geneva: Joint United Nations Programme on HIV/AIDS; 2014 [updated 08 October 2014]. Available from: Accessed 27 September 2016.
  7. 7.
    Bassett IV, Wang B, Chetty S, et al. Loss to care and death before antiretroviral therapy in Durban, South Africa. J Acquir Immune Defic Syndr. 2009;51:135–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Kranzer K, Zeinecker J, Ginsberg P, et al. Linkage to HIV care and antiretroviral therapy in Cape Town South Africa. PLoS ONE. 2010;5:e13801.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Lamb MR, Fayorsey R, Nuwagaba-Biribonwoha H, et al. High attrition before and after ART initiation among youth (15–24 years of age) enrolled in HIV care. AIDS. 2014;28:559–68.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Maman D, Chilima B, Masiku C, et al. Closer to 90–90–90. The cascade of care after 10 years of ART scale-up in rural Malawi: a population study. J Int AIDS Soc. 2016;19:1–8.CrossRefGoogle Scholar
  11. 11.
    McGrath N, Glynn JR, Saul J, et al. What happens to ART-eligible patients who do not start ART? Dropout between screening and ART initiation: a cohort study in Karonga. Malawi. BMC Public Health. 2010;10:601.CrossRefPubMedGoogle Scholar
  12. 12.
    Plazy M, Dray-Spira R, Orne-Gliemann J, Dabis F, Newell M-L. Continuum in HIV care from entry to ART initiation in rural KwaZulu-Natal. South Africa. Trop. Med. Int. Health. 2014;19:680–9.CrossRefPubMedGoogle Scholar
  13. 13.
    UNAIDS. Fact Sheet 2015: Global Statistics [Internet]. Geneva: UNAIDS; 2015 [updated 01 September 2015]. Available from: Accessed 27 September 2016.
  14. 14.
    UNAIDS. The Gap Report. Geneva: Joint United Nations Programme on HIV/AIDS; 2014. Available from: Accessed 13 December 2016.
  15. 15.
    WHO. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV [Internet]. Geneva: WHO; 2015 [updated 30 September 2015. Available from: Accessed 27 September 2016.
  16. 16.
    UNAIDS. South Africa takes bold step to provide HIV treatment for all [Internet]. UNAIDS. Geneva: Joint United Nations Programme on HIV/AIDS; 2016. Available from: Accessed 13 December 2016.
  17. 17.
    Losina E, Bassett IV, Giddy J, et al. The “ART” of linkage: pre-treatment loss to Care after HIV diagnosis at two PEPFAR sites in Durban. South Africa. PLOS ONE. 2010;5:e9538.CrossRefPubMedGoogle Scholar
  18. 18.
    Kranzer K, Govindasamy D, Ford N, Johnston V, Lawn SD. Quantifying and addressing losses along the continuum of care for people living with HIV infection in sub-Saharan Africa: a systematic review. J Int AIDS Soc. 2012;15:17383.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Bassett IV, Regan S, Luthuli P, et al. Linkage to care following community-based mobile HIV testing compared with clinic-based testing in Umlazi Township, Durban. South Africa. HIV Med. 2014;15:367–72.PubMedGoogle Scholar
  20. 20.
    Naik R, Doherty T, Jackson D, et al. Linkage to care following a home-based HIV counselling and testing intervention in rural South Africa. J Int AIDS Soc. 2015;18:19843.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Ingle SM, May M, Uebel K, et al. Outcomes in patients waiting for antiretroviral treatment in the free state Province. South Africa: Prospective linkage study. AIDS. 2010;24:2717–25.PubMedGoogle Scholar
  22. 22.
    Patten GE, Wilkinson L, Conradie K, et al. Impact on ART initiation of point-of-care CD4 testing at HIV diagnosis among HIV-positive youth in Khayelitsha. South Africa. J Int AIDS Soc. 2013;16:18518.PubMedGoogle Scholar
  23. 23.
    Larson BA, Schnippel K, Brennan A, et al. Same-day CD4 testing to improve uptake of HIV care and treatment in South Africa: point-of-care is not enough. AIDS Research and Treatment. 2013;2013:1–7.CrossRefGoogle Scholar
  24. 24.
    Govindasamy D, Kranzer K, van Schaik N, et al. Linkage to HIV, TB and Non-communicable disease care from a mobile testing unit in Cape Town, South Africa. PLoS ONE. 2013;8:e80017.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Iwuji CC, Orne-Gliemann J, Larmarange J, et al. Uptake of home-based HIV testing, linkage to care, and community attitudes about ART in Rural KwaZulu-Natal, South Africa: descriptive results from the first phase of the ANRS 12249 TasP cluster-randomised trial. PLOS Med. 2016;13:e1002107–18.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Tabana H, Nkonki L, Hongoro C, et al. A cost-effectiveness analysis of a home-based HIV counselling and testing intervention versus the standard (facility based) HIV testing strategy in rural South Africa. PLoS ONE. 2015;10:e0135048.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Van Rooyen H, Barnabas RV, Baeten JM, et al. High HIV testing uptake and linkage to care in a novel program of home-based HIV counseling and testing with facilitated referral in KwaZulu-Natal, South Africa. J Acquir Immune Defic Syndr. 2013;64:e1–8.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Sabapathy K, Van den Bergh R, Fidler S, Hayes R, Ford N. Uptake of home-based voluntary HIV testing in sub-saharan Africa: a systematic review and meta-analysis. PLOS Med. 2012;9:e1001351.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Amuron B, Namara G, Birungi J, et al. Mortality and loss-to-follow-up during the pre-treatment period in an antiretroviral therapy programme under normal health service conditions in Uganda. BMC Public Health. 2009;9:290.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Balfour L, Tasca GA, Kowal J, et al. Development and validation of the HIV Medication readiness scale. Assessment. 2007;14:408–16.CrossRefPubMedGoogle Scholar
  31. 31.
    Katz IT, Dietrich J, Tshabalala G, et al. Understanding treatment refusal among adults presenting for HIV-testing in Soweto, South Africa: a qualitative study. AIDS Behav. 2015;19:704–14.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Operario D, Kuo C, Sosa-Rubi SG, Galárraga O. Conditional economic incentives for reducing HIV risk behaviors: integration of psychology and behavioral economics. Health Psychol. 2013;32:932–40.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Fowler ME. Recognizing the phenomenon of readiness: concept analysis and case study. J Assoc Nurses AIDS Care. 1998;9:72–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Department of Health, Republic of South Africa. National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults [Internet]. Pretoria: Department of Health; 2014. [updated 24 December 2014]. Available from: Accessed 27 September 2016.
  35. 35.
    Grimes RM, Grimes DE. Readiness: the state of the science (or the Lack Thereof). Curr HIV/AIDS Rep. 2010;7:245–52.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Nordqvist O, Södergård B, Tully MP, Sönnerborg A, Lindblad ÅK. Assessing and achieving readiness to initiate HIV medication. Patient Educ Couns. 2006;62:21–30.CrossRefPubMedGoogle Scholar
  37. 37.
    Sodergard B. Readiness to start HIV treatment. IJAR. 2013;1:1.Google Scholar
  38. 38.
    Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot. 1997;12:38–48.CrossRefPubMedGoogle Scholar
  39. 39.
    Grimes RM, Grimes DE. Patient readiness to adhere to HAART. J Int Assoc Physicians AIDS Care. 2009;8:364–6.CrossRefGoogle Scholar
  40. 40.
    Fernández MI, Hosek S, Warren JC, et al. Development of an easy to use tool to assess HIV treatment readiness in adolescent clinical care settings. AIDS Care. 2011;23:1492–9.CrossRefPubMedPubMedCentralGoogle Scholar
  41. 41.
    Enriquez M, Gore PA, O’Connor MC, McKinsey DS. Assessment of readiness for adherence by HIV-positive males who had previously failed treatment. J Assoc Nurses AIDS Care. 2004;15:42–9.CrossRefPubMedGoogle Scholar
  42. 42.
    Katz IT, Essien T, Marinda ET, et al. Antiretroviral therapy refusal among newly diagnosed HIV-infected adults. AIDS. 2011;25:2177–81.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Hachfeld A, Ledergerber B, Darling K, et al. Reasons for late presentation to HIV care in Switzerland. J Int AIDS Soc. 2015;18:20317.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    DeSalvo KB, Fan VS, McDonell MB, Fihn SD. Predicting mortality and healthcare utilization with a single question. Health Serv Res. 2005;40:1234–46.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Kessler RC, Andrews G, Colpe LJ, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;32:959–76.CrossRefPubMedGoogle Scholar
  46. 46.
    Otieno PA, Kohler PK, Bosire RK, Brown ER, Macharia SW, John-Stewart GC. Determinants of failure to access care in mothers referred to HIV treatment programs in Nairobi. Kenya. AIDS Care. 2010;22:729–36.CrossRefPubMedGoogle Scholar
  47. 47.
    Kubler-Ross E. On death and dying. New York: Scribner; 1997.Google Scholar
  48. 48.
    Hatcher AM, Turan JM, Leslie HH, et al. Predictors of linkage to care following Community-based HIV counseling and testing in rural Kenya. AIDS Behav. 2012;16:1295–307.CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Chakrapani V, Velayudham J, Shunmugam M, Newman PA, Dubrow R. Barriers to antiretroviral treatment access for injecting drug users living with HIV in Chennai. South India. AIDS Care. 2014;26:835–41.CrossRefPubMedGoogle Scholar
  50. 50.
    Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991;50:179–211.CrossRefGoogle Scholar
  51. 51.
    Crocker J. Social stigma and self-esteem: situational construction of self-worth. J Exp Soc Psychol. 1999;35:89–107.CrossRefGoogle Scholar
  52. 52.
    Nyblade L, Pande R, Mathur S, et al. Disentangling HIV and AIDS stigma in Ethiopia, Tanzania and Zambia. Washington D.C.: International Center for Research on Women. 2003. Available from: Accessed 27 September 2016.
  53. 53.
    Govindasamy D, van Schaik N, Kranzer K, Wood R, Mathews C, Bekker L-G. Linkage to HIV care from a mobile testing unit in South Africa by different CD4 count strata. J Acquir Immune Defic Syndr. 2011;58:344–52.CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Kigozi IM, Dobkin LM, Martin JN, et al. Late-disease stage at presentation to an HIV Clinic in the era of free antiretroviral therapy in sub-saharan Africa. J Acquir Immune Defic Syndr. 2009;52:280–9.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Mugglin C, Estill J, Wandeler G, et al. Loss to programme between HIV diagnosis and initiation of antiretroviral therapy in sub-Saharan Africa: systematic review and meta-analysis. Trop Med Int Health. 2012;17:1509–20.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Auld AF, Shiraishi RW, Mbofana F, et al. Lower levels of antiretroviral therapy enrollment among men with HIV compared with women-12 Countries, 2002-2013. Morb Mortal Wkly Rep. 2015;64:1281–6.CrossRefGoogle Scholar
  57. 57.
    Nakigozi G, Atuyambe L, Kamya M, et al. A qualitative study of barriers to enrollment into free HIV care: perspectives of never-in-care HIV-positive patients and providers in Rakai. Uganda. BioMed Research International. 2013;2013:470245–7.PubMedGoogle Scholar
  58. 58.
    Ahmed I, Gugsa ST, Lemma S, Demissie M. Predictors of loss to follow-up before HIV treatment initiation in Northwest Ethiopia: a case control study. BMC Public Health. 2013;13:867.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Bengtson AM, Chibwesha CJ, Westreich D, et al. A risk score to identify HIV-infected women most likely to become lost to follow-up in the postpartum period. AIDS Care. 2016;28:1035–45.CrossRefPubMedGoogle Scholar
  60. 60.
    Shaikh N, Abdullah F, Lombard C, Smit L. Masking through averages-intraprovincial heterogeneity in HIV prevalence within the Western Cape. S Afr Med J. 2006;96:538–43.PubMedGoogle Scholar
  61. 61.
    Palekar R, Pettifor A, Behets F, MacPhail C. Association between knowing someone who died of AIDS and behavior change among South African youth. AIDS Behav. 2008;12:903–12.CrossRefPubMedGoogle Scholar
  62. 62.
    Fox MP, Mazimba A, Seidenberg P, Crooks D, Sikateyo B, Rosen S. Barriers to initiation of antiretroviral treatment in rural and urban areas of Zambia: a cross-sectional study of cost, stigma, and perceptions about ART. J Int AIDS Soc. 2010;13:8.CrossRefPubMedPubMedCentralGoogle Scholar
  63. 63.
    Kunihira NR, Nuwaha F, Mayanja R, Peterson S. Barriers to use of antiretroviral drugs in Rakai district of Uganda. African Health Sciences. 2010;10:120–9.PubMedPubMedCentralGoogle Scholar
  64. 64.
    Unge C, Johansson A, Zachariah R, Some D, Van Engelgem I, Ekstrom AM. Reasons for unsatisfactory acceptance of antiretroviral treatment in the urban Kibera slum. Kenya. AIDS Care. 2008;20:146–9.CrossRefPubMedGoogle Scholar
  65. 65.
    Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver MM. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013;17:1785–95.CrossRefPubMedPubMedCentralGoogle Scholar

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© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  1. 1.Southern Africa Labour and Development Research UnitUniversity of Cape TownCape TownSouth Africa
  2. 2.The Desmond Tutu HIV CentreUniversity of Cape TownCape TownSouth Africa
  3. 3.Department of Behavioral and Social SciencesBrown University School of Public HealthProvidenceUSA
  4. 4.Department of Psychiatry and Mental HealthUniversity of Cape TownCape TownSouth Africa
  5. 5.Department of EpidemiologyBrown University School of Public HealthProvidenceUSA
  6. 6.Department of Health Services, Policy & Practice (HSPP)Brown University School of Public HealthProvidenceUSA

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