University of California, San Francisco Logo

University of California, San Francisco | About UCSF | Search UCSF | UCSF Medical Center

Antiretroviral Therapy in Resource-Poor Settings: Decreasing Barriers to Access and Promoting Adherence
Global Health Sciences Literature Digest
Published January 30, 2007
Journal Article

Mukherjee JS, Ivers L, Leandre F, Farmer P, Behforouz H. Antiretroviral Therapy in Resource-Poor Settings: Decreasing Barriers to Access and Promoting Adherence. J Acquir Immune Defic Syndr. 2006 Dec 1;43 Suppl 1:S123-6.


To describe program interventions to overcome structural barriers affecting access to care and adherence to ART among rural poor in Haiti.

Study Design

Programmatic description based on ongoing data collection.


Seven public clinics in rural Haiti managed by Partners in Health, in conjunction with the Haitian Ministry of Health.


Most people served by the participating clinics are poor subsistence farmers or migrant workers from urban areas. The HIV prevalence is 2-5%.


The Partners in Health program was expanded to include public clinics in 2002, and incorporated four strategies designed to address barriers to ART adherence that are poverty-related. The four components are: (1) free health services and medication for HIV-related illness, as well as other healthcare problems; (2) integration of HIV testing, treatment, and care into primary healthcare services, including the use of "opt-out" testing for anyone with a condition possibly related to HIV (such as TB, diarrhea or STIs); (3) minimization of out-of-pocket costs through a monthly transportation stipend for routine clinic and emergency visits, and food subsidies for the neediest patients; (4) use of community health workers who perform active HIV and TB case finding, make home visits, and provide psychosocial support.

Primary Outcomes

Uptake of HIV testing, number of ambulatory primary care visits, and cost of intervention components.


A previously published study (1) reported the impact of these interventions on VCT uptake and use of primary care services from program initiation in 2002 through 2003. Currently, 8000 HIV-infected persons are followed, of whom 2300 are on ART; of the 1500 patients who have been on treatment for more than one year, fewer than 100 have died or have required a switch to second-line ART. In 2005, an additional 40,000 HIV tests were performed. The overall cost of the program is estimated to be $186 per person per year: $6 for waiving user fees, $20 for ancillary tests and monitoring, $60 for transportation fees, and $100 for the community health worker. An additional $150 per person per year is required for first-line ART.


The authors conclude that low rates of treatment failure, mortality, and requirements for second-line ART are due to the high levels of medication adherence and clinical care that have occurred in this program. They claim that providing services free of charge and using community-based programs can promote and maintain adherence, with an overall cost-savings.

Quality Rating


In Context

Adherence to ART in low-resource settings has been shown to be similar or even higher than that in the U.S. and Europe (2,3) as patients are eager and able to take medications regularly if care is accessible. However, other barriers, particularly out-of-pocket cost of health services and medication, transportation, additional economic constraints, and intermittent drug availability are particularly important in resource-limited settings. As ART programs scale up, these structural barriers must be addressed if adherence and clinical management are to be maintained.

Programmatic Implications

ART roll-out programs and interventions to promote adherence must identify and address issues of reduced access and care that exist because of poverty. Barriers that will prevent long-term success include the inability of clients to pay for those costs that are necessary for a person to engage in long-term care, including transportation, HIV testing, general medical services, clinical follow-up, and medication. Finding a way to incorporate these costs into programs will eventually be cost-saving. In addition, integration of HIV testing and treatment within primary care also improves access and supports infrastructure. Although this program in Haiti has been extremely successful, the program area serviced is comparatively small, and costs of ART per year are lower than in many other regions. Thus, the costs of providing these services may be higher elsewhere.


  1. Walton DA, Farmer PE, Lambert W, et al. Integrated HIV prevention and care strengthens primary health care: lessons from rural Haiti. J Public Health Policy 2004;25(2):137-58.
  2. Orrell C, Bangsberg D, Badri M, et al. Adherence Is Not a Barrier to Successful Antiretroviral Therapy in South Africa. AIDS 2003 17(9):1369-1376.
  3. Weiser S, Wolfe W, Bangsberg D, et al. Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana. J Acquir Immune Defic Syndr 2003 Nov 1;34(3):281-8.