IFGH 2012: Health Systems Barriers to Adherence to Antiretroviral Treatment Programme in Rural South Africa

January 29, 2012

Authors: van Wyk B.1, Larkan F.2, Saris AJ.3

Author Affiliations: 1School of Public Health, University of the Western Cape, SOUTH AFRICA, 2Centre for GlobalHealth, Trinity College Dublin, IRELAND, 3Department of Anthropology, National University of Ireland, Maynooth

Option 1– Scientific / Empirical Research Findings

Presented as – Oral Presentation


Barriers to access and adherence remain issues of major concern in the Western Cape province of South Africa, in spite of considerable successes in the roll-out of the public antiretroviral treatment (ART) programme. These barriers are fairly complex intertwining political, economic, social-cultural, gender, and biological factors, with health systems policies and organisation of care.


An in-depth ethnographic study was conducted in three settings in the West Coast/Winelands and Cape Metro districts in the Western Cape. Sixty index patients were followed over a two-year period, through individual interviews and participant observations of interactions with health care workers, lay health workers and community-based carers, as well as selected family members. Key informant interviews were conducted with health care workers. Initial analysis was narrative to derive patterns of adherence, and sequential analysis interrogated health systems responses to adherence challenges.


Emerging patterns of adherence indicate pervasive poor adherence, which we classified as: chaotic, weekend-off, unplanned treatment holidays and erratic. These patterns of non-adherence implicate poor communication for treatment literacy and management of anticipated adverse effects, insufficient attention paid to nutrition, ambiguous ‘education’ about use of alcohol and its effect on medication, and non-collaborative partnerships between health worker and patient toward treatment adherence. Our analysis also reveals the notion of “sick clinics”, where ART patients were turned away because of no presenting doctors, and dis-integration between HIV care and general primary care in some health facilities.


Health workers need to be re-oriented and empowered towards a patient-centred and patient-driven system of care, where external barriers related to language and culture, unequal power relations, and internal barriers related to staffing, competency and ethical sensitivity could be more skillfully negotiated.




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