title: Antiretroviral therapy initiation and adherence in rural South Africa: community health workers' perspectives on barriers and facilitators.
abstract: South Africa has the largest global HIV/AIDS epidemic, but barriers along the HIV care continuum prevent patients from initiating and adhering to antiretroviral therapy (ART). To qualitatively explore reasons for poor ART initiation and adherence rates from the unique perspective of community health workers (CHWs), we conducted focus groups during May-August 2014 with 21 CHWs in rural Msinga, KwaZulu-Natal. Interviews were audio-recorded, transcribed, and translated from Zulu into English. Hybrid deductive and inductive analytical methods were applied to identify emergent themes. Multiple psychosocial, socioeconomic, and socio-medical barriers acted at the level of the individual, social network, broader community, and healthcare environment to simultaneously hinder initiation of and adherence to ART. Key themes included insufficient patient education and social support, patient dissatisfaction with healthcare services, socioeconomic factors, and tension between ART and alternative medicine. Fear of lifelong therapy thwarted initiation whereas substance abuse principally impeded adherence. In conclusion, HIV/AIDS management requires patient counselling and support extending beyond initial diagnosis. Treating HIV/AIDS as a chronic rather than acute infectious disease is key to improving ART initiation and long-term adherence. Public health strategies include expanding CHWs' roles to strengthen healthcare services, provide longitudinal patient support, and foster collaboration with alternative medicine providers.
authors.affiliation: a Section of Infectious Diseases , Yale University School of Medicine , New Haven , CT , USA.|b Department of Epidemiology of Microbial Diseases , Yale University School of Public Health , New Haven , CT , USA.
authors.forename: Kelsey B
authors.initials: KB
authors.lastname: Loeliger
authors.affiliation: b Department of Epidemiology of Microbial Diseases , Yale University School of Public Health , New Haven , CT , USA.
authors.forename: Linda M
authors.initials: LM
authors.lastname: Niccolai
authors.affiliation: c Church of Scotland Hospital , Tugela Ferry , KwaZulu-Natal , South Africa.
authors.forename: Lillian N
authors.initials: LN
authors.lastname: Mtungwa
authors.affiliation: c Church of Scotland Hospital , Tugela Ferry , KwaZulu-Natal , South Africa.
authors.forename: Anthony
authors.initials: A
authors.lastname: Moll
authors.affiliation: a Section of Infectious Diseases , Yale University School of Medicine , New Haven , CT , USA.
authors.forename: Sheela V
authors.initials: SV
authors.lastname: Shenoi
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods; D044383:Black People; D003150:Community Health Workers / Q000523:psychology*; D003376:Counseling / Q000379:methods; D017144:Focus Groups; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000523:psychology; D006297:Health Services Accessibility; D006801:Humans; D007407:Interviews as Topic; D059012:Lost to Follow-Up; D008297:Male; D055118:Medication Adherence; D036301:Qualitative Research; D012424:Rural Population; D057545:Social Stigma; D012944:Social Support; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology; D014342:Truth Disclosure
chemical_list: D019380:Anti-HIV Agents; D044966:Anti-Retroviral Agents
keywords: Antiretroviral therapy; South Africa; adherence; barriers to care; community health workers; initiation