” S2 facility L, Nurse, 8 years’ experience Use of the World Health Organization’s (WHO) pain ladder [33] was described at one site where palliative care training had been provided: ‘We have a palliative care nurse and I think when someone is in severe pain the way you have called it then we consider morphine. She was trained and she usually

gets the morphine and takes it to the clients. But usually [when] there is that severe pain Inhibitors,research,lifescience,medical they start with the usual pain killers like panadol, indocid–if the pain refuses to go then she results to morphine.’ S5 facility H, Nurse, 4 years’ experience 2. Psychosocial distress a. Description of psychosocial distress The psychosocial distress experienced by patients was a further dominant theme, with stigma described as a primary contributor: ‘If people out there get to know that one is HIV positive, they treat you badly. At times if you are employed you may lose your job if you disclose your status. Even in

the family, if you disclose that you are HIV positive, your people may stop eating with you, they just Inhibitors,research,lifescience,medical ignore you saying that you are useless since you can die any time. You can even be denied a scheme loan because of your sero status–they claim that you can die any time and therefore default.’ P2 facility M, male, age 41, on ART Caregivers also Inhibitors,research,lifescience,medical suffered from the effects of stigma: ‘What hurts me is the way other people look at us–they say that my husband was a proud man so now it is his time to face the problems, so when I hear those words I feel so hurt.’ [Caregiver breaks down in tears] C1 facility H, age 35, patient’s wife Patients and caregivers described how

Inhibitors,research,lifescience,medical stigma exacerbated isolation and loneliness, which could have a negative impact on adherence: ‘Usually you find that these patients have withdrawn Inhibitors,research,lifescience,medical away from the community and their close people. They just stay alone and give up and lose hope in life and also feel that they have already gone to the end of life… because of this negative thinking towards life usually they don’t come for medication’ C2 facility G, age 24, patient’s brother The suffering and ‘psychological torture’ (P6 facility L, female, age 40, on ART) caused by poverty was also highly evident in patients’ and caregivers’ accounts, manifested in worries regarding having enough food to eat and money to pay for transport to collect treatment or children’s education: ‘The [biggest] see more problem that I have had is that of food. I used to Ergoloid live with my sister and I don’t get along with her. When she heard that I have the HIV virus, she chased me away. I now live with other ladies and I don’t work.’ [Starts to cry] P3 facility D, female, age 24, on ART Poverty had a detrimental impact on patients’ adherence to ART: ‘Sometimes you cannot afford to buy food to eat; at times you cannot sustain yourself completely. At times you cannot afford transport costs to come for treatment.