Barriers to initiating antiretroviral therapy during pregnancy: a qualitative study of women attending services in Cape Town, South Africa

Despite the rapid expansion of antiretroviral therapy (ART) programmes, uptake of ART in pregnancy remains suboptimal. Little is known about the barriers to initiating lifelong ART in pregnancy and the challenges to postpartum retention in HIV care, particularly in sub-Saharan African contexts with a high burden of disease. In this qualitative study, 28 HIV-positive pregnant or postpartum women, who either had initiated ART or were eligible for ART, and 21 service providers were interviewed in Cape Town, South Africa, to investigate these barriers. Prevention of vertical transmission of HIV was often the primary motivation for starting treatment. Key challenges to ART initiation included late first presentation, denial of an HIV diagnosis, fear of disclosure, and treatment side-effects. The women expressed difficulties in accepting a lifelong commitment to treatment for maternal health benefit. Pregnant women who require ART face a triple burden of transitioning into pregnancy, accepting the HIV diagnosis, and recognising the urgent requirement to start lifelong ART before delivery. Focused interventions are required to address the psychosocial barriers to ART uptake and the linkages to care for pregnant HIV-positive women.