Antiretroviral therapy initiation and adherence in rural South Africa: community health workers’ perspectives on barriers and facilitators

ABSTRACT

South Africa has the largest global HIV/AIDS epidemic, but barriers along the HIV care continuum prevent patients from initiating and adhering to antiretroviral therapy (ART). To qualitatively explore reasons for poor ART initiation and adherence rates from the unique perspective of community health workers (CHWs), we conducted focus groups during May–August 2014 with 21 CHWs in rural Msinga, KwaZulu-Natal. Interviews were audio-recorded, transcribed, and translated from Zulu into English. Hybrid deductive and inductive analytical methods were applied to identify emergent themes. Multiple psychosocial, socioeconomic, and socio-medical barriers acted at the level of the individual, social network, broader community, and healthcare environment to simultaneously hinder initiation of and adherence to ART. Key themes included insufficient patient education and social support, patient dissatisfaction with healthcare services, socioeconomic factors, and tension between ART and alternative medicine. Fear of lifelong therapy thwarted initiation whereas substance abuse principally impeded adherence. In conclusion, HIV/AIDS management requires patient counselling and support extending beyond initial diagnosis. Treating HIV/AIDS as a chronic rather than acute infectious disease is key to improving ART initiation and long-term adherence. Public health strategies include expanding CHWs' roles to strengthen healthcare services, provide longitudinal patient support, and foster collaboration with alternative medicine providers.

KEYWORDS:

• Antiretroviral therapy
• initiation
• adherence
• barriers to care
• community health workers
• South Africa

Acknowledgements

The authors thank Dr Gerald Friedland for his expertise, mentorship, and guidance throughout the course of this project. We also acknowledge Philanjalo staff members Njabulo Malembe, Mxolisi Myeza, and Nkazi Nkomo for their dedicated assistance with participant recruitment. The Isoniazid Preventive Therapy (IPT) team, Intensive Case Finding (ICF) team, and other Philanjalo and Church of Scotland Hospital staff members were invaluable for their insight, guidance, and dedication to patient care. Lastly, we sincerely thank the study participants for their time and willingness to share their stories.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

K. B. Loeliger http://orcid.org/0000-0002-1193-4357

L. N. Mtungwa http://orcid.org/0000-0001-9958-3864

S. V. Shenoi http://orcid.org/0000-0001-7654-4344

Additional information

Funding

Funding was provided by the National Institute of Allergy and Infectious Diseases [grant number K23AI089260] (Shenoi), National Institutes of Health Medical Scientist Training Program at Yale University [grant number TG T32GM007205] (Loeliger), Wilbur G. Downs Fellowship (Loeliger), Infectious Diseases Society of America Education and Research Foundation Medical Scholars Program (Loeliger), Office of Student Research Lowe Funds at Yale University (Loeliger), and Robert E. Leet and Clara Guthrie Patterson Trust Awards Program in Clinical Research, Bank of America, N.A., Trustee [grant number R12525] (Shenoi).