Barriers to Antiretroviral Adherence for HIV-Positive Patients in Rural Lesotho and Implications for Social Work Practice

Background/ Purpose: In Sub-Saharan Africa, there are 27 million HIV-positive people. As a result, this region has been at the forefront of programs and interventions to treat HIV and AIDS. Effective HIV-treatment depends strongly on adherence to medication regimens. Patients with poor adherence to antiretroviral therapy (ART) have greater risk of experiencing treatment failure and death. The purpose of this study is to identify the barriers to good adherence that exist in a rural community in Lesotho, and the types of community-based interventions that moderate these barriers. It links structural violence theory with social work's person-in-environment approach to determine the factors that impede adherence.

Methods: Ethnographic techniques including participant observation, field notes, semi-structured interviews, and participatory action research (PAR) methods were used at two main sites in order to better understand the challenges produced by the health clinic, and the potential responses of social work interventions. The first field site consisted of observations of 117 patient-healthcare provider interactions during nine visits to four rural clinics between November 2008 and June 2009. Observations were collected only on the days designated for HIV-positive or HIV-exposed patients; therefore the sample is a convenience sample based on treatment schedules of this rural community. Data were collected through participant observations and extensive fieldnotes. The second field site consisted of twelve months of participant observation and PAR with a small non-governmental organization (NGO) that serves the needs of families and orphans coping with HIV/AIDS, as well as a series of semi-structured interviews with their outreach team and clientele. Data for both sites were analyzed using EpiInfo, an epidemiological database, and Atlas.ti, a qualitative data analysis program.

Results/Findings: Analysis of the clinic data show that good adherence to ART is impacted by three factors: a) the interaction between complicated ART regimens and the cultural context, b) barriers generated by the patient and their environment, and c) barriers generated by the healthcare system and providers. Healthcare systems and providers were found to both mediate and exacerbate good adherence. Findings from the NGO data indicate that an intervention model based on a community outreach visiting program helps to augment and support the efforts of healthcare professionals in order to improve patient adherence to ART, and to mitigate the barriers created by the healthcare system, the environment, and the patients themselves.

Implications: In order to improve adherence to ART in rural African communities, social work interventions need to 1) promote collaboration between social workers and health care professionals in monitoring patient adherence, 2) include an outreach component where patients are visited by social workers on a regular basis, 3) consider behavioral as well as structural barriers to adherence such as poverty and poor transportation infrastructure, 4) and improve training of social workers in understanding and promoting good adherence to ART.