The strength of this study lies in the qualitative data, in which we present views about adherence by reporting statements from the study participants themselves. This qualitative data supports the quantitative findings reported in other studies, such as the Tanzania and Botswana studies.

We anticipate that as ART is rolled out in Uganda, optimal adherence will be difficult to achieve. The costs involved in terms of transport, waiting times and other overhead costs are already impeding adherence and some patients are dropping out of treatment as a result.

Hunger is usually a major concern among those who have just started therapy. One organization reported that 100 patients were threatening to stop taking their ARVs because of increased food needs which they could not meet. This is a serious threat to adherence. Unless programmes are designed to provide food assistance in the first months of ART, optimal adherence is going to be difficult to achieve.

In this study, it was reported that the level of infrastructure for service provision and the quality of care provided were better at the private ART-providing facility than at the public facility. Structural problems at the public facility included overcrowding at the ART clinic, lack of training for health workers and the inability of the few that are trained to cope with the growing number of people on ART. Unless these kind of structural issues are addressed by the Government as ART is rolled out in Uganda, it will be difficult to ensure adherence. Other challenges that will also have to be addressed include the lack of social support, stigma and discrimination, and treatment fatigue.

Uganda has made a good start in scaling up ART and this is widely appreciated. However, Uganda appears to be moving very quickly to scale up access to ARVs without addressing critical issues such as the problem of additional costs, hunger and excessive time spent at the facilities, as well as the need for pill counting, training of adherence counsellors, community sensitization and home-based care services.

Efforts to minimize constraints and improve adherence levels will require the efforts of the community, health workers and patients as well as Government commitment to resolve key structural problems.