Quantitative component.

A total of 507 HIV positive pregnant females were enrolled and followed-up at Masaka RRH (184), Mityana GH (213), and Luwero HC IV (110) from October 2013 to March 2016. Study eligibility was HIV positive expectant females seeking ANC services, aged 15–49 years, ART naïve or started on ART for Option B+ within four weeks of enrollment. All women reporting for ANC services at the facilities were assessed for pregnancy either through self-report or pregnancy test and screened for HIV status. The ANC service providers referred all pregnant HIV positive women to the study research staff on site.

A well-trained female research assistant (RA) was stationed at each study facility to enroll and follow up eligible participants. The RA screened the women for study eligibility, administered written informed consent to the eligible women, and subsequently conducted face-to-face interviews using structured pre-tested and standardized questionnaires. The questionnaire used for data collection was adopted with modifications [38–41]. Pre-testing of the questionnaires was done by administering them to a sample of study eligible participants in a non-study site. Thereafter, the investigators met with the RAs to go through the entire tool to correct any unclear questions. This ensured that all participants were asked the same questions in an identical format and responses recorded in a uniform manner. Enrolment was done concurrently at all the three sites until the calculated sample size of 500 participants was obtained. This was the sample size for the parent study and was determined as described elsewhere [29]. Due to simultaneous recruitment at all the study sites, a total of 507 were enrolled. Following a baseline interview at enrolment, follow-up visits were scheduled at every two months intervals up to six months, then every four months up to 18 months post enrolment. Study follow-up interviews were aligned to the scheduled ANC/postnatal care (PNC) clinic visits as much as possible to minimize inconvenience to the women. Baseline questionnaires were administered to all 507 women. Analysis on the characteristics of study participants and prescription of ART was done on 507 women. In this article, uptake of and early adherence to Option B+ medicines at two-month follow-up was analysed for 463 and 410 women who had complete data, respectively. Basing on the sample sizes that we used for the two study outcomes (levels of uptake and early adherence), the study had a 5% level of precision. We conducted a power analysis on associated factors such as HIV positive status disclosure to anyone, and readiness to start ART. We found that our study had sufficient power (≥ 80%) to detect a difference in the study outcome (Early adherence).

Quantitative data collection for this study took place between October 2013 and October 2014.

Qualitative component.

Participants in the qualitative interviews were purposively selected. We planned to interview 10 HIV positive women at each health facility (60 women total) for the in-depth interviews. However, 57 interviews were conducted and the participants were not part of the quantitative component but receiving the same Option B+ services. Use of in-depth interviews enabled the researchers explore women’s lived experience in regards to uptake of and early adherence to ART for Option B+. The women were either expectant or post-delivery. They had been on lifelong ART for a minimum of six months so as to provide sufficient experiences before and after delivery. Based on information from health facility staff and records, the women were considered into three groups: good ART adherers, poor ART adherers, and delayed ART acceptors as defined in the articles that were published elsewhere [28, 29]. Qualitative data collection was conducted from February to May 2014 using pre-tested semi-structured interview guides. Three well-skilled research assistants with vast understanding in qualitative research conducted the in-depth interviews.

Fifty-four key informant interviews out of the targeted 60 interviews (10 at each facility) were used to explore health provider perspectives on uptake and early adherence to Option B+ from all the six facilities. The selected health providers were deemed to have the necessary information on uptake and early uptake of Option B+ ART. Health providers were classified in two categories based on their roles, workstation/department, and experience as described elsewhere [36]. The sample size specification and justification for the qualitative component were predetermined as this was required by the funder, ethics committee, and Ministry of Health (MOH) before the study was implemented [42, 43].

Four of the main investigators (A.M., R.W., E.B., and R.N.) interviewed the key informants. All in-depth interviews s and a few key informant interviews with expert clients were conducted in Luganda the commonly spoken local language. All other key informant interviews were carried out in English. On average, each key informant interview lasted 1.5 hours whereas each in-depth interview lasted between 1 and 2 hours. All qualitative interviews were audio-recorded.

Quantitative data.

Exploratory data analysis was conducted on the independent and dependent variables. Descriptive statistics were generated providing percentages for categorical variables, while means (standard deviation) and median (inter-quartile range, IQR) for continuous variables. Percentages were computed for the socio-demographic characteristics, reported Option B+ ART prescription, taking of ART, reasons for non-prescription and/or refusal to take ART, disclosure of HIV status, willingness to take ART, readiness to initiate ART, motivation for initiating ART, reasons for delay in initiating ART, understanding of how long the participant was supposed to be on ART, and adherence to ART. Bivariate and multivariable analyses were conducted to generate prevalence ratio (PR) as a measure of association, using log-binomial regression model to establish factors associated with optimal adherence. Log-binomial regression was preferred to logistic regression because the later technique tends to overestimate the measures of association when the prevalence of the outcome is 10% or higher [44]. We explored for interaction between some of the factors such as: disclosure of HIV status to anyone; readiness to start ART; health facility level; and knowledge on how long ART should be taken and the outcome (early adherence). After testing for collinearity, interaction and confounding, variables that had p-value of ≤ 0.2 at bivariate analysis were included into the final multivariable regression model. STATA version 14 was used for analysis.

Qualitative data.

Qualitative data were transcribed verbatim. Data in Luganda were simultaneously translated and transliterated into English. Each transcript was reread by AM and one other co-investigator for content and completeness. Additional reviews of selected transcripts were done by RW for quality control and to ensure reflexivity. Final transcriptions were transferred to Atlas software (Atlas.ti, Version 7 software, Berlin, Germany) for analysis. Thematic analysis was done using a predetermined frame with the following themes: [45, 46] willingness of HIV positive pregnant women to start ART, uptake of, readiness and motivation to initiate Option B+ ART, refusal and delay to take Option B+ ART, and early adherence to Option B+ ART as guided by the quantitative and qualitative tools [30]. We identified paragraphs linked to the predetermined themes and then coded these pieces inductively using thematic analysis. Thereafter, codes were grouped into subthemes within each pre-determined theme. Coding was done by AM. The codes and subthemes were discussed and reflected on by the co-authors through regular meetings. Distinctive quotes were identified and used to highlight the main issues identified in the interviews. This was done for both the in-depth and key informant interviews.

Giving HIV positive pregnant women counseling and time to think about starting ART.

Similar to the quantitative results, many key informant and in-depth interview participants said that most HIV positive gravid females were counseled and given time to think about starting lifelong ART. Key informants envisioned that counseling and giving HIV positive expectant females time to think about Option B+ before prescription of ART could enhance acceptability and uptake of, and adherence to, Option B+ ART and retention in HIV care.

“When a woman tests HIV positive, we ask her to decide basing on the counseling she has received. If she says that she’s not ready to start ART we allow her time to think and come back when ready” Health provider, Hospital.

Congruently, many in-depth interview participants indicated that they were willing to initiate ART on the same day they tested HIV positive but the health providers told them to come back later after internalizing issues around lifelong ART.

“The health workers first found me with the virus (HIV positive), they told me to come back and get the medicines [ART] on another day. Even though I wanted it to be given to me on that very day they tested me, I had to come back later after thinking about it well” IDI Participant, Mityana GH

Desire to have an HIV negative baby.

From the in-depth interviews, most participants indicated that they were willing to start on ART the same day they were found to be HIV positive so as to deliver an HIV negative baby. Desire for an HIV negative baby as the main reason for preference of same day ART initiation was also mentioned by key informant interview participants.

“After testing HIV positive, I was willing to start ART immediately but they [health workers] told me to go and think about it, then come back when ready to start on ART. I did not refuse to start immediately, because I was pregnant and I wanted to deliver a healthy [HIV negative] baby” IDI Participant, Masaka RRH.

“The reason why they [women] are willing to test for HIV and start on Option B+ is because they are pregnant and want to prevent their babies from getting HIV infected” Health provider, HC III

The quantitative results showed that three of the four women who were not willing to start ART were from Masaka RRH while the fourth was from Luwero HC IV. Fear of taking ART, being depressed due to the HIV positive status, and lack of a place for hiding ART from family members were the key reasons for not willing to start ART.

Adequate counseling.

The qualitative component revealed that most key informants said that if the HIV positive gravid females were appropriately counselled, they would start swallowing ART on the same prescription day.

“Most of them [women] start swallowing ART on the same day of prescription once they are well counseled. The few who refuse to start on ART do so later after on-going counselling” Health provider, HC III.

Consistently, in-depth interviews s indicated that most women began swallowing their ART on the same day it was prescribed after being tested and counseled by health providers.

“They [health providers] gave me medicines [ART] on the very day I tested HIV positive. I was well counseled and told to choose a particular time when to swallow those medicines at night. I decided to swallow at 9.00pm and I started immediately on that very day” IDI Participant, Katikamu HC III.

“I received good [meaning adequate] counseling from the health providers and I accepted to start on the medication [ART] there and then” IDI Participant, Mityana GH.

More time and information.

Similar to the quantitative findings, in-depth interview participants echoed the need for more time and information before prescription of ART. This was envisioned to enable one to understand how to take ART.

“Health workers should first give us enough time and information before prescribing ART. If one is given the medicines [ART] before he/she has understood well all the necessary dos and don’ts, one may end up taking it poorly or not taking ART at all” IDI Participant, Mityana GH.

“That time I wasn’t given any information, because the health worker didn’t explain well. I didn’t get information on how to swallow the medicines and care for myself” IDI Participant, Masaka RRH.

Desire to remain healthy and deliver an HIV negative baby.

Similar to the quantitative results, in-depth interviews revealed the desire to stay healthy and have an HIV negative baby by women as a motivation to start Option B+ ART. Participants indicated that they needed to be healthy to continue working and look after their families. Most participants felt that when women are given adequate counseling and told the benefits of Option B+ ART, with the majority accepting ART.

“I wanted to save my life, remain healthy so that I can look after my family and deliver a healthy [HIV negative] child too” IDI Participant, Masaka RRH.

Key informant interview participants also alluded to desire for an HIV negative baby as a motivation to take Option B+ ART.

“When these mothers are tested and they are found to be HIV positive, they are advised to start on the medicines [ART]. Most women accept to take the medicines [ART] because they want to give birth to an HIV negative child” Health provider, HC IV.

Perceived effectiveness of Option B+ ART.

All in-depth interview participants who were good ART adherers emphasized that if ART is taken well, they make one healthy and the baby is born HIV negative. This was attributed to the effectiveness of Option B+ ART in comparison to the strategies before the Option B+ era and motivated them to take the ART.

“The good thing I see in this one they brought (meaning Option B+), is that it seems better than the old one which came first [Option A] because most of the time, when women deliver, their children don’t have the sickness (meaning HIV negative babies), unlike in the past, some could deliver, and when you test, they could find the babies infected with the virus” IDI Participant, Mityana GH.

Furthermore, good ART adherers illustrated the experience of women that once on ART, one lives longer than those who were not taking ART. It was noted that this enables HIV positive women to care for their children for a long time.

“Medicines [meaning ART] help us to live longer and look after our children for a number of years” IDI Participant, Katikamu HC III.

Benefits of Option B+ ART to HIV negative spouses.

Most in-depth interviews revealed that participants were either not aware of the benefits of the Option B+ ART to their spouses or were only interested in the benefits for the woman’s health and that of her baby.

“They [health providers] told me that if I concentrate on taking the ART, the baby will not be infected with HIV and I will remain health. I was not told anything in regards to the benefits of ART to my spouse” IDI Participant, Mityana GH.

Doubt of HIV positive results.

Some women who delayed to start taking ART indeed said that if they are given a positive HIV result for the first time, they would go to other health facilities to repeat the test. The women said they would start taking ART after getting a confirmatory HIV positive test.

“When I got the first pregnancy, I was told that I was HIV positive. However, I never believed, but took Septrin tablets only. When I got the second pregnancy, I had not yet started on the big tablets [ART]; I tested for HIV again wanting to prove whether I was truly positive. The test gave the same results [HIV positive]. I had nothing to do but to start taking ART” IDI Participant, Masaka RRH.

Likewise, key informant interview participants indicated that some women doubt positive HIV results and request for repeat tests.

“Some women refuse, ‘am not HIV positive!’ If we test a woman and she doubts the results we have given her, we repeat the test or refer her to another Health facility ‘X’—they believe in it so much. So, we refer them there and wait for the results.” Health provider, HC IV.

Fear to take ART.

Among women who participated in in-depth interviews, fear to take ART was identified as a barrier to start ART. Women expressed a number of fears like taking ART for life, being seen by the spouse, and possible side effects.

“I delayed to start the ART because I was fearing. I feared to swallow it all the time and I kept thinking of the medicines [ART] all the time! But now am no longer thinking like that”. IDI Participant, Masaka RRH.

“I did not start immediately because I had fear, I had to think for some time, like a number of days. I first feared, because people scared us that, the tablet is very big and things like that” IDI Participant, Masaka RRH.

“At first I feared to start swallowing the ART because I did not want the man [spouse] to see me taking medicines. He had told me that, if they test you and you are found with the HIV virus, we will separate [meaning divorce]” IDI Participant, Mityana GH,

A few women had a misconception that some people can even die faster if they start swallowing ART. The community was said to be the source of such misinformation.

“People in the village (those who were swallowing ART), told us that there is that new ART (Option B+ ART) which kills people very fast- some people come when they are sick [have advanced HIV] and they are given what kills fast.” IDI Participant, Ssunga HC III.

Duration of ART.

A number of women indicated that they were scared of taking ART for the rest of their lives. They went ahead to compare taking ART to other short course medicines such anti-malaria medicines, which take only a few days.

“I was worried, because I didn’t know how to swallow the daily medicines [ART] for life. I am used to short treatment: when I am sick of malaria, I swallow two tablets and I know that I am now healed, but I thought of the daily medicines [ART]. . . ..will I manage, I was worried!” IDI Participant, Katikamu HC III.

Disclosure of HIV positive status.

In the qualitative interviews, disclosure of HIV positive status was mentioned both in in-depth and key informant interviews as a facilitator of optimal adherence. Women who disclose their HIV positive status to their partners or a close relative get reinforced to continue taking their ART. However, those who don’t disclose their status end up hiding their ART for fear of being seen by their spouses.

“He [spouse] has helped me a lot, it’s very important to disclose. Those who didn’t disclose have faced problems; they hide the medicines [ART] so that the spouse cannot see them and they end up missing some doses” IDI Participant, Luwero HC IV.

Participation in health education and counseling.

In-depth interview participants who were given health education and satisfactory counseling stated that this helped them to start and remain adherent to the ART.

“The health workers first counseled me. I was told to start the medicines [ART] and from then up to today I have never missed. They [health workers] told me to take it [ART] on time without missing, I started swallowing without missing, and even I swallow at the exact hour/time. I have never missed even a single day”. IDI Participant, Masaka RRH.

On the other hand, lack of health education and counseling were highlighted as barriers to starting and remaining adherent to Option B+ ART. Some of the women who had suboptimal ART adherence attributed it to having not attended the pre-ART health education talks and counseling sessions.

“I used to reach when they had already given health education to other women. Therefore, I was not provided with any pre-ART education and orientation sessions before I started taking ART” IDI Participant, Kyanamukaka HC IV.

“Mmhmmh…they just gave me the tin [meaning the tin containing ART] and I took it home to swallow. I almost I did not get any health education at all. I shouldn’t lie to you” IDI Participant, Mityana GH.

Equally, most key informant interview participants stated that good counseling could result in adherence to clinic appointments and ART.

“For me, I think that if the counseling has been good to the extent that the mother gets to know the benefits of option B+, I believe, she can adhere to her appointments and even take her medicines well for reasons that she wants an HIV negative child” Health Provider, Luwero HC IV

Desire to remain healthy and deliver an HIV negative baby.

Most in-depth interview participants said that they didn’t want to miss any ART doses so as to remain healthy and give birth to HIV negative babies. They anticipated that being adherent to the ART would result in a rise in their CD4 count and thus remain healthy.

“I can’t miss any of my doses because I want my “asikaris” [meaning CD4 cells] to go higher all the time to remain healthy, so that am able to deliver a healthy child [meaning HIV negative]” IDI Participant, Mityana GH.

Busy schedule.

During the in-depth interviews, some participants attributed suboptimal adherence to ART to busy schedules. A number of women had many chores to accomplish which resulted in their forgetting to swallow ART.

“At times you become too busy with many things like house work and digging. Time passes and that’s when you forget to swallow the medicines [ART]” IDI Participant, Kyanamukaka HC IV.

ART side effects.

Side effects due to ART were commonly mentioned as being responsible for suboptimal adherence. In-depth interview participants mentioned varying side effects including dizziness, headache, drowsiness, nausea, vomiting and nightmares.

“At the start, I felt bad whenever I would swallow the ART. I was vomiting, all the time I would feel like vomiting, just like someone suffering from malaria” IDI Participant, Katikamu HC III.