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Background  Very little is known about the barriers and facilitators to antiretroviral therapy (ART) access and adherence among older Africans. Most studies on ART have focused on individuals who are 15–49 years of age.    Methods  We used in-depth interviews with 40 persons living with HIV, aged 50 to 96 years, who had either initiated ART ( n  = 26) or were waiting to initiate ART ( n  = 14), to explore barriers and facilitators to ART access and adherence in rural Uganda.    Results  Guided by the Andersen Behavior Model, thematic content analysis highlighted 21 primary factors related to environment, patient and health behavior. Nine of the factors were common to both access and adherence, the remaining 12 were evenly split between access and adherence. Transportation costs, food insecurity, and healthcare workers’ knowledge, attitudes and behaviors were key barriers.    Conclusions  These barriers were similar to those outlined for younger populations in other studies, but were compounded by age. Despite barriers, either due to the exceptional nature of HIV care or overreporting, both ART access and self-reported adherence were better than expected. Older persons living with HIV highlighted health care needs for non-HIV-related illnesses, suggesting while HIV care is adequate, care for the ailments of “old age” is lagging.    Electronic supplementary material  The online version of this article (10.1186/s12889-019-6463-4) contains supplementary material, which is available to authorized users.

“For us here, we remind ourselves”: strategies and barriers to ART access and adherence among older Ugandans