Skip to main content

Exploring Treatment Needs and Expectations for People Living with HIV in South Africa: A Qualitative Study


The UNAIDS 90-90-90 treatment targets aim to dramatically increase the number of people who initiate antiretroviral therapy (ART) by 2020. Greater understanding of barriers to ART initiation in high prevalence countries like South Africa is critical. Qualitative semi-structured interviews were conducted with 30 participants in Gugulethu Township, South Africa, including 10 healthcare providers and 20 people living with HIV (PLWH) who did not initiate ART. Interviews explored barriers to ART initiation and acceptability of theory-based intervention strategies to optimize ART initiation. An inductive content analytic approach was applied to the data. Consistent with the Theory of Triadic Influence, barriers to ART initiation were identified at the individual, social, and structural levels. Results suggested high acceptability for intervention strategies involving trained HIV-positive peers among South African PLWH and healthcare providers. Research is needed to evaluate their feasibility and efficacy in high HIV prevalence countries.


Los objetivos de tratamiento de UNAIDS 90-90-90 apuntan a aumentar drásticamente el número de personas que inician la terapia antirretroviral (TAR) para el año 2020. Es fundamental comprender mejor las barreras al inicio del TAR en países de alta prevalencia como Sudáfrica. Se realizaron entrevistas semiestructuradas cualitativas, con 30 participantes en el municipio de Gugulethu, Sudáfrica, incluyendo 10 proveedores de atención médica y 20 personas que viven con el VIH que no iniciaron el tratamiento antirretroviral. Las entrevistas exploraron las barreras al inicio del TAR y la aceptabilidad de las estrategias de intervención basadas en la teoría para optimizar el inicio del TAR. Se aplicó un enfoque analítico de contenido inductivo a los datos. De acuerdo con la Teoría de la Influencia Triádica, las barreras a la iniciación de TAR fueron identificadas a nivel individual, social y estructural. Los resultados sugirieron una alta aceptabilidad para las estrategias de intervención que involucran a compañeros capacitados VIH-positivos entre las personas que viven con el VIH y los proveedores de atención médica sudafricanos. Se necesita investigación para evaluar su viabilidad y eficacia en países de alta prevalencia del VIH.

This is a preview of subscription content, access via your institution.


  1. UNAIDS. 90-90-90: An ambitious treatment target to help end the AIDS epidemic. Geneva, Switzerland; 2014.

  2. World Health Organization. Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV. Switzerland; 2015.

  3. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  4. INSIGHT START Study Group, Lundgren JD, Babiker AG. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. 2015;373:795–807.

    Article  CAS  Google Scholar 

  5. TEMPRANO ANRS 12136 Study Group, Danel C, Moh R. A trial of early antiretrovirals and isoniazid preventive therapy in Africa. N Engl J Med. 2015;373:808–22.

    Article  CAS  Google Scholar 

  6. UNAIDS. The Gap Report. Geneva, Switzerland; 2014.

  7. Flay BR, Snyder F, Petraitis J. The theory of triadic influence. In: DiClemente RJ, Kegler MC, Crosby RA, editors. Emerging theories in health promotion practice and research. 2nd ed. New York: Jossey-Bass; 2009.

    Google Scholar 

  8. Earnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures. AIDS Behav. 2009;13:1160–77.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: Moving toward resilience. Amer Psychol. 2013;68:225–36.

    Article  Google Scholar 

  10. Bavarian N, Flay BR, Ketcham PL, Smit E, Kodama C, Martin M, et al. Using structural equation modeling to understand prescription stimulant misuse: a test of the Theory of Traidic Influence. Drug Alcohol Depend. 2014;138:193–201.

    Article  PubMed  PubMed Central  Google Scholar 

  11. 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(4):704–14.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Bogart LM, Chetty S, Giddy J, et al. Barriers to care among people living with HIV in South Africa: contrasts between patient and healthcare provider perspectives. AIDS Care. 2013;25(7):843–53.

    Article  PubMed  Google Scholar 

  13. Dahab M, Charalambous S, Hamilton R, et al. “That is why I stopped the ART”: patients’ & providers’ perspectives on barriers to and enablers of HIV treatment adherence in a South African workplace programme. BMC Public Health. 2008;8(1):63.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Miller WR, Rollnick S. Motivational interviewing: helping people change. New York: Guilford Press; 2013.

    Google Scholar 

  15. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Amer Psychol. 2000;55(1):68–78.

    Article  CAS  Google Scholar 

  16. Thurston IB, Bogart LM, Wachman M, et al. Adaptation of an HIV medication adherence intervention for adolescents and young adults. Cogn Behav Pract. 2014;21(2):191–205.

    Article  PubMed  Google Scholar 

  17. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. J Clin Psychol. 2009;65(11):1232–45.

    Article  PubMed  Google Scholar 

  18. Naar-King S, Outlaw A, Green-Jones M, Wright K, Parsons JT. Motivational interviewing by peer outreach workers: a pilot randomized clinical trial to retain adolescents and young adults in HIV care. AIDS Care. 2009;21(7):868–73.

    Article  PubMed  Google Scholar 

  19. Outlaw AY, Naar-King S, Parsons JT, Green-Jones M, Janisse H, Second E. Using motivational interviewing in HIV field outreach with young African American men who have sex with men: a randomized clinical trial. Am J Pub Health. 2010;100(S1):S146–51.

    Article  Google Scholar 

  20. Wallston BS, Alagna SW, DeVellis BM, DeVellis RF. Social support and physical health. Health Psychol. 1983;2:367–91.

    Article  Google Scholar 

  21. Koester KA, Morewitz M, Pearson C, et al. Patient navigation facilitates medical and social services engagement among HIV-infected individuals leaving jail and returning to the community. AIDS Patient Care STDS. 2014;28(2):82–90.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Gardner LI, Metsch LR, Anderson-Mahoney P, et al. Efficacy of a brief case management intervention to link recently diagnosed HIV-infected persons to care. AIDS. 2005;19(4):423–31.

    Article  PubMed  Google Scholar 

  23. Craw JA, Gardner LI, Marks G, et al. Brief strengths-based case management promotes entry into HIV medical care: results of the antiretroviral treatment access study-II. J Acquir Immune Defic Syndr. 2008;47(5):597–606.

    Article  PubMed  CAS  Google Scholar 

  24. Gwadz M, Cleland CM, Applegate E, Belkin M, Gandhi M, Solomon N, et al. Behavioral intervention improves treatment outcomes among HIV-infected individuals who have delayed, delicined, or discontinued antiretroviral therapy: a randomized controlled trial of a novel intervention. AIDS Behav. 2015;19(10):1801–17.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Futterman D, Shea J, Besser M, Stafford S, Desmond K, Comulada WS, et al. Mamekhaya: a pilot study combining a cognitive-behavioral intervention and mentor mothers with PMTCT services in South Africa. AIDS Care. 2010;22(9):1093–100.

    Article  PubMed  PubMed Central  Google Scholar 

  26. National Department of Health. The national antenatal sentinel HIV prevalence survey, South Africa, 2013. Pretoria; 2015.

  27. Lawn SD, Little F, Bekker L-G, et al. Changing mortality risk associated with CD4 cell response to antiretroviral therapy in South Africa. AIDS. 2009;23(3):335–42.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Njuguna C, Orrell C, Kaplan R, Bekker L-G, Wood R, Lawn SD. Rates of switching antiretroviral drugs in a primary care service in South Africa before and after introduction of tenofovir. PLoS ONE. 2013;8(5):e63596.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  29. Grimsrud A, Lesosky M, Kalombo C, Bekker L-G, Myer L. Implementation and operational research: community-based adherence clubs for the management of stable antiretroviral therapy patients in Cape Town, South Africa: a cohort study. J Acquir Immune Defic Syndr. 2016;71(1):e16–23.

    PubMed  Google Scholar 

  30. Miles MB, Huberman AM. Qualitative data analysis: a sourcebook. Beverly Hills: Sage Publications; 1994.

    Google Scholar 

  31. SocioCultural Research Consultants, LLC. Dedoose, Version 7.5. Los Angeles, CA. Accessed 28 Aug 2017.

  32. Hodgson I. Attitudes toward people with HIV/AIDS: entropy and health care ethics. J Adv Nurs. 1997;26(2):283–8.

    Article  PubMed  CAS  Google Scholar 

  33. MacPhearson P, MacPhearson EE, Mwale D, Squire SB, Makombe SD, Corbett EL, et al. Barriers and facilitators to linkage to ART in primary care: a qualitative study of patients and providers in Blantyre, Malawi. J Int AIDS Soc. 2012;15(2):18020.

    Google Scholar 

  34. Mshana GH, Wamoyi J, Busza J, et al. Barriers to accessing antiretroviral therapy in Kisesa, Tanzania: a qualitative study of early rural referrals to the national program. AIDS Patient Care STDS. 2006;20(9):649–57.

    Article  PubMed  Google Scholar 

Download references


This study would not have been possible without the dedication of the study participants. The authors thank Ismael Medina for translating the abstract of this article into Spanish.


This publication was made possible with funding from the U.S. National Institute on Drug Abuse K01 DA042881 (Earnshaw); the U.S. National Institute for Mental Health R34 MH108393 (Katz); the Burke Global Health Fellowship, Harvard Global Health Institute (Katz); and the Center for HIV Identification, Prevention, and Treatment (CHIPTS) National Institute for Mental Health Grant P30 MH58107 (Bogart). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Valerie A. Earnshaw.

Ethics declarations

Conflict of interest

The authors declare no conflicts 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.

Informed Consent

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

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Earnshaw, V.A., Bogart, L.M., Courtney, I. et al. Exploring Treatment Needs and Expectations for People Living with HIV in South Africa: A Qualitative Study. AIDS Behav 22, 2543–2552 (2018).

Download citation

  • Published:

  • Issue Date:

  • DOI:


  • HIV
  • Antiretroviral therapy
  • Qualitative
  • South Africa