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Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa
Global Health Sciences Literature Digest
Published June 18, 2007
Journal Article

Hardon AP, Akurut D, Comoro C, Ekezie C, Irunde HF, Gerrits T, Kglatwane J, Kinsman J, Kwasa R, Maridadi J, Moroka TM, Moyo S, Nakiyemba A, Nsimba S, Ogenyi R, Oyabba T, Temu F, Laing R. Hunger, waiting time and transport costs: Time to confront challenges to ART adherence in Africa. AIDS Care. 2007 May;19(5):658-65.


To identify the main factors challenging adherence to antiretroviral therapy (ART) and to provide health agencies with context-specific recommendations on how to enhance adherence.

Study Design

This evaluation was based on rapid appraisal results, mainly using qualitative methods, including: 1. semi-structured interviews (SSIs) with antiretroviral therapy (ART) users, health workers and key informants; 2. focus group discussions (FGD) with ARV users and key informants; and 3. exit interviews with ART users.


Rapid appraisals were conducted in Tanzania, Uganda, and Botswana.


Between May and September 2005, multidisciplinary teams of researchers and local health professionals conducted rapid appraisals in Tanzania (three public facilities and four private/faith-based facilities in the cities of Arusha and Dar es Salaam), Uganda (one private and one public study site in eastern Uganda), and Botswana (four public study sites located in three of the country’s nine districts). All of the sites selected provide ART free of charge. The appraisals included a total of 54 SSI with health workers; 73 SSI with ART users and other key informants; 34 FGD, and 218 exit interviews with ART users. Due to financial constraints, the health facilities included were selected purposively, with the aim of including a diverse group of facilities and limiting travel costs and time.


None. This study was qualitative and used interviews and focus groups.

Primary Topics

To determine why and when ART users do not achieve optimal adherence levels.


Findings reveal that although patients are highly motivated to take ART as prescribed, there are numerous constraints that challenge the optimal levels of adherence required to ensure positive treatment outcomes and prevent drug resistance. Transport costs and user fees, including the cost associated with traveling from remote areas to clinics, or the registration fees needed in private facilities in Uganda and Tanzania, may limit adherence. Long waiting times may discourage patients from going to clinics. Almost half (42%) of health workers interviewed in Tanzania identified long waiting times as a problem, and in Botswana, 57% of respondents reported that they spend four or more hours at the clinic, with the longest wait being 12 hours. Hunger is also a problem, especially during the initial stages of treatment, when the body needs extra nutrition as it regains strength and weight. Some patients can only take their ART once a day, as that is the only time they have food. Stigma is another problem, with some ART users reporting losing their jobs, being abandoned or badly treated by their partners after disclosure, or being isolated from their communities. Others do not disclose their HIV status, and, thus, do not receive the social support they need and cannot take their drugs on time. Additionally, some ART users skip doses due to the side effects frequently associated with ARV medications. Users are not always provided with effective counseling informing them that side effects often disappear over time. Poor or infrequent counseling may also have adverse affects on ART adherence. Exit interviews indicate that only 21% of ART users see a counselor at each visit. Finally, scale-up of ART with limited personnel makes it difficult for healthcare workers to cope with the large number of patients on clinic days. Despite this problem, patients in all three countries expressed satisfaction with the quality of care at the facilities.


Based on study findings, the authors recommend that 1. healthcare workers better inform patients about adverse effects; 2. ART programs provide transport and food support to patients who are too poor to pay; 3. recurrent costs to users be reduced by providing three-month, rather than the one-month, refills once optimal adherence levels have been achieved; and 4. pharmacists play an important role in follow-up care.

Quality Rating

There is no widely accepted quality-scoring tool for qualitative evaluations such as this.

In Context

Previous studies have provided quantitative estimates of adherence and data on clinical outcomes;(1, 2,3, 4, 5) however, few studies have investigated why and when ART users fail to adhere to their medications.(6, 7,8, 9, 10, 11, 12) Reports on sub-optimal adherence to ART in developed countries indicate that the key factors are patient- and treatment-related, including substance and alcohol abuse, complexity of dosing regimen and pill burden, dietary restrictions, and side effects. (13, 14,15, 16) The few studies conducted in resource-poor settings suggest that economic factors predominate, and a study in Botswana (17) identified financial constraints as the major obstacle to adherence. Similarly, a study in India (18) found that cost of treatment was a major obstacle to adherence. A meta-analysis of ten studies conducted in resource-poor settings found that providing medication free of charge was associated with a 30% higher probability of having an undetectable viral load at 6 and 12 months. (3)

Programmatic Implications

Small-scale studies, using assessment tools and conducted by local researchers in collaboration with health workers, can be used to identify factors that facilitate or constrain adherence and indicate possible solutions. The similarity of the results in multiple settings suggests the importance of these factors. As with all observational findings, however, the impact on effectiveness should be tested in prospective trials.


  1. Coetzee D, Boulle A, Hildebrand K, Asselman V, Van Cutsem G, Goemaere E. Promoting adherence to antiretroviral therapy: the experience from a primary care setting in Khayelitsha, South Africa. AIDS 2004 Jun;18 Suppl 3:S27-31.
  2. Gill CJ, Hamer DH, Simon JL, Thea DM, Sabin LL. No room for complacency about adherence to antiretroviral therapy in sub-Saharan Africa. AIDS 2005 Aug 12;19(12):1243-9.
  3. Ivers LC, Kendrick D, Doucette K. Efficacy of antiretroviral therapy programs in resource-poor settings: a meta-analysis of the published literature. Clin Infect Dis 2005 Jul 15;41(2):217-24.
  4. Koenig SP, Leandre F, Farmer PE. Scaling-up HIV treatment programmes in resource-limited settings: the rural Haiti experience. AIDS 2004 Jun;18 Suppl 3:S21-5.
  5. Orrell C, Bangsberg DR, Badri M, Wood R. Adherence is not a barrier to successful antiretroviral therapy in South Africa. AIDS 2003 Jun 13;17(9):1369-75.
  6. Akileswaran C, Lurie MN, Flanigan TP, Mayer KH. Lessons learned from use of highly active antiretroviral therapy in Africa. Clin Infect Dis 2005 Aug 1;41(3):376-85. Review.
  7. Bennett S, Boerma JT, Brugha R. Scaling up HIV/AIDS evaluation. Lancet 2006 Jan 7;367(9504):79-82. Review. (No abstract available.)
  8. Farmer P, Leandre F, Mukherjee JS, Claude M, Nevil P, Smith-Fawzi MC, et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet 2001 Aug 4;358(9279):404-9. (No abstract available.)
  9. Jaffar S, Govender T, Garrib A, Welz T, Grosskurth H, Smith PG, et al. Antiretroviral treatment in resource-poor settings: public health research priorities. Trop Med Int Health 2005 Apr;10(4):295-9. Review.
  10. Kent DM, McGrath D, Ioannidis JP, Bennish ML. Suitable monitoring approaches to antiretroviral therapy in resource-poor settings: setting the research agenda. Clin Infect Dis 2003 Jul 1;37(Suppl 1):S13-24.
  11. Koenig SP, Leandre F, Farmer PE. Scaling-up HIV treatment programmes in resource-limited settings: the rural Haiti experience.AIDS 2004 Jun;18 Suppl 3:S21-5.
  12. Safren SA, Kumarasamy N, James R, Raminani S, Solomon S, Mayer KH. ART adherence, demographic variables and CD4 outcome among HIV-positive patients on antiretroviral therapy in Chennai, India. AIDS Care 2005 Oct;17(7):853-62.
  13. American Public Health Association (2004). Adherence to HIV treatment regimens: Recommendations for best practices. Chesney MA. Factors affecting adherence to antiretroviral therapy. Clin Infect Dis 2000 Jun;30 Suppl 2:S171-6. Review.
  14. DiMatteo MR. Variations in patients' adherence to medical recommendations: a quantitative review of 50 years of research. Med Care 2004 Mar;42(3):200-9.
  15. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Vermeire, E. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther 2001 Oct;26(5):331-42. Review.
  16. WHO (2004). Adherence to HIV treatment. Geneva, Switzerland: World Health Organization.
  17. Weiser S, Wolfe W, Bangsberg D, Thior I, Gilbert P, Makhema J, 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.
  18. Safren SA, Kumarasamy N, James R, Raminani S, Solomon S, Mayer KH. ART adherence, demographic variables and CD4 outcome among HIV-positive patients on antiretroviral therapy in Chennai, India. AIDS Care 2005 Oct;17(7):853-62.