The following are presented as suggestions for interventions that we believe may promote ARV adherence rates among patients in Tanzania. They have not yet been evaluated and we would welcome the opportunity to undertake such intervention studies.

• Institute pill counting. Pill counting is an important monitoring and adherence promotion tool for both providers and users. However, in many facilities this system is not used. Although public facilities in Dar es Salaam have started pill counting, the system is weak and many patients do not bring their drugs for counting on clinic days. Pill counting will also help clear up suspicions that some patients are selling their ARVs.

• Employ adequate numbers of well-trained staff. More trained staff are needed to cope with increasing workloads in ART clinics. This will also help clients by reducing waiting times.

• Increase access to ART clinics, as well as improving facility infrastructures and laboratory services. This can be done both by increasing the opening hours of existing clinics and by opening new clinics closer to where people live. Such clinics might be used to review patients who have initiated treatment at a larger hospital facility.

• Establish reliable drug supply. There was some concern that the medicine supply chain is not yet reliable. A reliable supply of medicines needs to be instituted and efforts made to assure clients and providers that the supply chain is reliable.

• Create proper referral networks of ARV users between facilities. Such a referral and transfer network should allow patients to be treated as close to their homes as possible with minimum waiting times and travel costs.

• Train staff in adherence counselling and continuously update their knowledge about HIV and AIDS. This implies that not only pharmacists and dispensers have a responsibility for adherence counselling. Everyone from clerk to nurse to doctor to counsellor has a responsibility to encourage full adherence, recognizing how difficult it is for patients to maintain full adherence.

• Train and support community counsellors who operate from their home (as seen in Arusha). The use of community counsellors has been shown to be effective in other countries as well as in Tanzania. Creating training opportunities for such counsellors and involving them in follow-up and support of ARV patients should occur at every ART facility.

• Prepare IEC material focusing on adherence to ARVs, stigma and disclosure. These materials should emphasize that patients on ARVs need support to achieve optimal adherence and that patients on treatment can be healthy and fully able to work.

• Waive registration and consultation fees. Registration and consultation fees should be waived for AIDS patients.

• Conduct intervention studies. Intervention studies are recommended in order to sustain and promote adherence to ARVs. It is the wish of this research group to continue with intervention studies if funds are made available.

• Loans and food support. Due to the prevailing poverty in the country, loans and food support to ARV users should be considered by the Government and NGOs.