Barriers and Strategies for Antiretroviral Therapy Appointment Adherence in Rural South Africa: A Narrative Review with a Focus on the Vhembe District

1.1 Background

Antiretroviral therapy (ART) is widely recognized as the cornerstone in managing human immunodeficiency virus (HIV) infection, effectively reducing morbidity, minimizing transmission, and ultimately improving patient quality of life (Messeri et al., 2019; Tumwikirize et al., 2015). However, the long-term success of ART relies heavily on consistent patient adherence to prescribed regimens and regular attendance at scheduled clinical appointments for drug refills and monitoring (Castillo-Mancilla et al., 2023; Damulak et al., 2021; Demberg & Robert-Guroff, 2012; Dibaba et al., 2021). Maintaining such adherence is particularly challenging in rural settings, where patients may face compounded barriers to accessing and continuing care.

In the rural Vhembe district of Limpopo province, South Africa, various structural, economic, and psychosocial challenges hinder consistent attendance at ART appointments (Kapwata & Manda, 2018; Lowane & Lebese, 2022a, 2022b; Tshivhase et al., 2020). These barriers include long travel distances to clinics, transportation costs, stigma, and competing socioeconomic demands. While several studies have explored these issues individually, there remains a lack of comprehensive synthesis to evaluate intervention strategies that may overcome them and support ART retention in resource-limited environments.

1.2 Rationale and knowledge gap

Although a growing body of literature addresses ART adherence in rural South Africa, there is a need to consolidate and contextualize this knowledge, particularly for localized settings such as Vhembe. While studies have examined general challenges to ART service delivery in rural communities (Campbell et al., 2020; Moomba & Wyk, 2019; Sharer et al., 2019), and others have investigated alternative models such as home delivery or community-based ART refill systems (Cleary et al., 2012; Davis et al., 2018; Gachara et al., 2017; Long et al., 2019; Sharer et al., 2019), few have synthesized these findings specifically to inform district-level interventions.

Furthermore, while interventions like treatment supporter programs (Assefa et al., 2014; Bemelmans et al., 2014; Wang et al., 2023) and combination strategies including reminders (Amankwaa et al., 2018) education, and social support (Peek et al., 2015) show promise, their adaptation to rural South African settings remains underexplored (Grimsrud et al., 2017). The nuanced interplay between patient behaviour, healthcare provider interactions, and accessibility must be understood to design effective strategies (Adefolalu & Nkosi, 2013).

This narrative review seeks to bridge this knowledge gap by critically analyzing current barriers and evidence-based interventions to inform local healthcare strategies in Vhembe.

1.3 Objective

The objective of this review is to explore the multifaceted barriers contributing to poor adherence to ART appointments in rural settings, with a specific focus on the Vhembe district of Limpopo province, South Africa. By evaluating a broad range of intervention strategies shown to be effective in similar contexts, this review aims to provide evidence-based recommendations tailored to strengthen ART service delivery and enhance patient retention in this rural district. The ultimate goal is to support healthcare providers, policymakers, and community stakeholders in implementing sustainable solutions for improving ART adherence outcomes in Vhembe.

3.1 Structural and logistical barriers

One of the foremost challenges in rural ART service delivery is the structural barrier posed by limited access to healthcare facilities. Rural patients often must travel long distances to reach clinics, a situation compounded by sparse public transportation, poor road conditions, and inclement weather. Tseng’s (2024) 5 research highlights that the traditional model, wherein patients must visit clinics every one to three months to collect ART refills, places a significant burden on individuals residing in geographically isolated areas.

Additionally, the congestion of clinics, due to high patient volumes and limited resources, can result in prolonged waiting times and reduced service efficiency. In rural districts like Vhembe, where healthcare infrastructure may be underdeveloped, the logistical challenges can lead to fewer patients adhering to their appointment schedules. These factors create a systemic barrier that not only affects the timeliness of ART refill appointments but also increases the risk of treatment interruption, which in turn jeopardizes viral suppression and clinical outcomes (Figure 1).

Figure 1. Flowchart detailing the integrated model for ART appointment adherence.

3.2 Financial and economic barriers

Financial constraints represent another critical barrier to ART appointment adherence. The direct costs associated with transport, lost wages, and ancillary expenses incurred during clinic visits can be prohibitive for patients living in low-income rural communities. Tseng’s (2024) 5 study provides evidence that even when ART itself is provided free of charge, the indirect costs pose a significant impediment to regular attendance. For many patients, the economic burden of traveling to a clinic far from home outweighs the perceived benefits of strictly adhering to the clinic-based refill model.

Moreover, from a health system perspective, home-delivered ART has been associated with higher operational costs primarily due to increased personnel expenditures. While these higher costs might be offset by multi-month dispensing and economies of scale when implemented in bulk, the initial expenditure remains a significant concern. Thus, addressing the financial barriers for both patients and the healthcare system is essential for improving adherence and ensuring the sustainability of any proposed intervention.

3.3 Health system and service delivery challenges

The design and delivery of ART services themselves can impose barriers to effective appointment adherence. Many clinics operate under strict protocols that limit the duration of ART refills, with most patients being supplied only one to three months of medication at a time. This model not only increases the frequency of required visits but also strains the capacity of urban-based clinics tasked with serving large patient populations.

Health system inefficiencies, such as understaffing and inadequate training of healthcare workers, further exacerbate the problem. In many rural settings, the lack of an integrated, patient-centred approach leaves gaps in follow-up and monitoring of patient adherence. Furthermore, the rigid scheduling systems may not accommodate the socioeconomic realities of rural patients, who often face unpredictable work schedules and family commitments. All these factors contribute to missed appointments and ultimately lead to suboptimal clinical outcomes.

3.4 Psychosocial and individual barriers

In addition to system-level challenges, various psychosocial and individual factors affect ART appointment adherence. Stigma, lack of social support, and fear of disclosure are potent deterrents for many patients. The stigma associated with HIV can discourage individuals from attending clinics, particularly if there is a risk of their status becoming publicly known through repeated public visits. Psychosocial factors such as depression and anxiety, which may be exacerbated by the stress of managing a chronic condition, also play a role in treatment nonadherence.

The systematic review on treatment supporter interventions (Nyoni et al., 2020) underscores that social support from family members, peers, and community health workers can significantly enhance ART adherence. However, when such support is absent or insufficient, patients are more likely to miss appointments. In the context of Vhembe, where cultural norms and close-knit community dynamics can both facilitate and hinder open communication about HIV, addressing psychosocial barriers is a critical component of any comprehensive intervention strategy.

3.5 The influence of public health emergencies

Public health emergencies, such as the COVID-19 pandemic, have magnified existing barriers to ART adherence in rural settings. During the early waves of the pandemic, traditional clinic-based services were disrupted due to lockdowns, fear of virus transmission, and reallocation of health resources to manage the pandemic. Tseng’s (2024) doctoral research, which assessed ART home delivery models in KwaZulu-Natal, found that home-based ART provision yielded comparable clinical outcomes to traditional clinic-based models, particularly during COVID-19 disruptions. Missed-dose rates remained statistically similar across both delivery formats. However, the overall context of the pandemic underscored the vulnerability of existing ART delivery models (Hoke et al., 2021). The increased risk posed by public health emergencies necessitates the exploration of alternative delivery mechanisms that can maintain continuity of care amid crisis conditions.

4.1 Home delivery and community-based ART distribution

One innovative strategy that addresses many structural and logistical barriers is home delivery of ART. Tseng’s (2024) 5 thesis compared the clinical outcomes of home-delivered ART with traditional clinic-based refills and found that home delivery did not result in a significant increase in missed doses during the COVID-19 pandemic. The benefits of this approach include reduced travel burdens on patients, decongestion of overburdened clinics, and the potential for multi-month dispensing, which can further mitigate logistical challenges.

While home delivery has been associated with higher incremental carbon dioxide emissions and greater personnel costs in its observed scenarios, these drawbacks can be attenuated (Limbada et al., 2021). For instance, transitioning to greener delivery vehicles and extending refill durations to six or 12 months could not only improve environmental outcomes but also bring financial benefits when implemented at scale. In the Vhembe district, where rural patients travel long distances to clinics, home delivery could be a viable means of improving appointment adherence while addressing the dual imperatives of cost efficiency and environmental sustainability.

4.2 Treatment supporter interventions

Treatment supporter interventions (TSIs) have demonstrated considerable effectiveness in enhancing ART adherence by introducing robust social support mechanisms. The systematic review and meta-analysis by Nyoni et al. (2020) underscores that treatment supporter interventions, including partners, trained peers, and community health workers, significantly enhance ART adherence, with pooled relative risk estimates showing a 7.6% increase in adherence and a 5% improvement in viral load suppression over standard care. These interventions involve ensuring that patients receive support from partners, family members, friends, community health workers, and, in some cases, HIV-positive peers.

The community-based nature of these interventions makes them particularly suitable for rural areas such as Vhembe. TSIs help to overcome psychosocial barriers, including stigma, isolation, and the fear of disclosure. By enabling patients to receive active and ongoing support, these interventions ensure that the challenges associated with ART appointment adherence are not solely the responsibility of the individual but are shared at the community level.

4.3 Multi-month dispensing and device reminders

Multi-month dispensing (MMD) is another strategic intervention that holds the potential to relieve some of the operational and patient-centric challenges of ART delivery. Under the conventional model, the limited duration of ART refills requires frequent clinic visits. Shifting to MMD, which involves dispensing medication for six or 12 months at a time, can considerably reduce the frequency of appointments. Tseng’s (2024) 5 analysis shows that multi-month refills could mitigate the environmental and financial costs associated with home delivery models while maintaining comparable clinical outcomes (Long et al., 2020).

Device reminders, such as mobile phone text messages, represent an additional strategy to improve adherence. The meta-analysis focusing on pregnant women (Omonaiye et al., 2018) found that device reminder interventions significantly improved ART adherence, with risk ratio (RR) evidence demonstrating a 13% increase in adherence compared to controls. The integration of mobile health (mHealth) solutions is a promising avenue for rural clinics in Vhembe, where cellphone penetration is high even among low-income populations. Such reminders serve as timely prompts, ensuring that patients remain engaged with their treatment schedules.

4.4 Combined socio-structural interventions

While single-component interventions have shown benefits, combinations of interventions appear to be particularly effective. Meta-analytical evidence suggests that interventions combining education, social support, and structural support yield the most significant improvements. According to Omonaiye et al. (2018), interventions integrating education, social support, and structural components yielded a pooled risk ratio (RR) of 2.60 for adherence among pregnant women on ART, indicating a markedly stronger impact than single-mode interventions. Education initiatives, delivered through individualized counselling or group sessions, enhance patients’ understanding of the importance of ART adherence, while social support mechanisms facilitate the practical and emotional aspects of treatment maintenance. Structural interventions, such as the integration of ART services within antenatal clinics or community centres, reduce the logistical burdens on patients.

In rural contexts like the Vhembe district, a tailored blend of these interventions could address multiple barriers simultaneously. For instance, combining MMD with treatment supporter programs and device reminders could create a synergistic effect: reduced frequency of clinic visits, enhanced social engagement, and consistent adherence prompts all contribute to improved appointment adherence and overall treatment outcomes.

5.1 Geographic and demographic considerations

Vhembe is characterized by vast rural expanses, limited healthcare infrastructure, and socioeconomic challenges that mirror those detailed in Tseng’s (2024) thesis. Patients in the Vhembe district often encounter long travel distances and inconsistent transportation options, which heighten the likelihood of missed appointments. In addition, many patients in the district are economically disadvantaged, rendering even modest indirect costs burdensome.

5.2 Health system adaptability

Healthcare facilities in Vhembe may face similar operational challenges to those described in the literature; namely, understaffing, high patient volumes, and inflexible refill systems. Adapting proven strategies such as MMD and decentralizing ART service delivery, including home delivery and community-based approaches, could meaningfully improve appointment adherence. The integration of treatment supporter interventions (Nyoni et al., 2020) into existing community health programs would leverage local networks and encourage greater patient engagement.

5.3 Cultural and psychosocial dimensions

Cultural norms, community values, and the pervasive stigma surrounding HIV remain potent barriers in Vhembe. Given that treatment supporter interventions have been shown to increase adherence by reducing stigma and fostering a supportive environment (Nyoni et al., 2020), their implementation in the Vhembe district, tailored to local cultural contexts, could drive substantial improvements in patient outcomes. In parallel, leveraging mobile phone technology to provide device reminders offers a culturally sensitive method of reinforcing adherence behaviours without demanding extensive infrastructural investments.

5.4 Economic and environmental considerations

Although resource constraints are a persistent challenge in Vhembe, the potential cost savings associated with MMD, when combined with home delivery models deployed at scale, could offset initial expenses. Additionally, strategies aimed at reducing the environmental footprint, such as using electric delivery vehicles, are not only beneficial from a public health perspective but also resonate with broader national developments towards sustainability.

The following visualization illustrates the major barriers to ART appointment adherence in rural contexts and the corresponding strategies that can be adapted for the Vhembe district.

5.5 A proposed integrated model for Vhembe

Drawing on the evidence reviewed, an integrated care model for the Vhembe district, the proposed plan aims to enhance access to antiretroviral therapy (ART) through several key components. First, there will be a focus on decentralized ART delivery. This includes implementing home delivery and mobile clinic services, making it easier for patients to receive their medication (Mash et al., 2021). Additionally, by utilizing multi-month dispensing practices, we can reduce the frequency of clinic visits, ultimately making the process more convenient for patients. Another significant aspect of the plan is the enhancement of social support. Local community health workers and peer supporters will be trained to provide regular follow-up and counselling, ensuring that patients receive the support they need. Moreover, establishing community-based groups will encourage patient engagement and facilitate collective problem-solving, fostering a sense of community and support among those undergoing treatment.

The integration of mobile health (mHealth) tools is also crucial in this plan. By using device reminders, such as SMS notifications, patients will be prompted about upcoming appointments and medication schedules. Digital platforms will be employed to track appointment attendance, enabling timely follow-up interventions for any missed appointments. Strengthening the health system is another key component of the proposal. This involves improving clinic scheduling systems to make appointments more flexible and user-friendly for patients. Additionally, healthcare staff will receive training to manage increased patient loads effectively and to integrate ART services with other primary care services, ensuring a more cohesive approach to patient care.

Lastly, the plan will address environmental and economic efficiency. It will include an evaluation of cost savings derived from a reduction in missed appointments, balanced against the potential increase in personnel costs associated with home delivery. Furthermore, implementing environmentally friendly strategies, such as using electric vehicles for delivery, will help minimize the environmental impact of the program. This comprehensive approach aims to improve the delivery of ART while providing essential support to patients, ultimately leading to better health outcomes and a more effective healthcare system. A schematic overview of this integrated model is presented in the flowchart below.

This flowchart demonstrates how the identification of barriers and subsequent integration of targeted interventions can create a robust system that supports ART adherence in rural regions like Vhembe.