Although the adherence rates found in this study are comparable to those of other studies in developing countries, these rates are still low for good clinical outcomes. Adherence is a complex issue and multi-dimensional approaches are required to both address the constraints and strengthen the key facilitators of adherence. Efforts to determine the level of adherence among patients on ART is complicated by the general methodological difficulties of adherence assessment. There is no gold standard of adherence assessment. While the two-day recall measure may be useful for on-the-spot individual patient adherence counselling, we recommend the use of the visual analogue scale and the pill counts for routine adherence monitoring.

In this study the critical barriers to adherence identified were: forgetfulness, lack of transport fare to the health facility, non-acceptance of HIV status, fear of discrimination and stigma, alcohol abuse, and non-supportive home and work environments. Although side-effects occur in a significant proportion of users, this was not perceived as a significant barrier to adherence.

Facilitators of adherence were found to include self-efficacy, social support, an effective adherence counselling programme, perceived benefits of the medication, and a desire to stay alive for the sake of others.

Efforts to improve the level of adherence require a collaborative approach involving the patient, the community, health workers and policy-makers, and a focus on ways of addressing environmental and structural constraints.

Some of the recommendations identified include the development of practical guidelines for implementing adherence management strategies. These should include guidelines for: continuous adherence counselling; bringing treatment closer to home; adoption of a family care model approach to ART; use of practical reminders; adherence case management; and the use of medication organizers (pill boxes partitioned to display the daily or weekly sequence of pills to be taken). In addition, the establishment of a transport voucher scheme should be considered for people who genuinely cannot afford the cost of transport to collect their medication. Such interventions should be evaluated to assess their effects on adherence.

Acceptance of HIV status, disclosure and gender were found to be the main emerging themes in the qualitative data. Further studies are needed to explore these variables in greater depth. Programmes targeting men to inform them about HIV-related issues should also be developed. This would help increase the enrolment of men in ART programmes, help them to better understand the gender issues around HIV, and mobilize them to be protectors and supporters of women in the fight against HIV.