Contextual and psychosocial influences on antiretroviral therapy adherence in rural Zimbabwe: towards a systematic framework for programme planners

Great progress has been made in achieving universal access to antiretroviral therapy (ART). However, for successful viral suppression, patients must adhere to rigid and complex treatment regimens. With three quarters of antiretroviral (ARV) users in Africa adhering successfully, African countries have achieved extraordinary levels of adherence given the levels of poverty in which many ARV users live. Nevertheless, one quarter of ARV users still struggle to adhere and run the risk of experiencing viral replication, clinical progression or even drug resistance. Much has been written about ART adherence, but little has been done to systematically categorise the spectrum of factors that influence ART. In this paper, we use a Zimbabwean case study to develop a framework for ART programme planners and implementers seeking to identify and tackle social obstacles to adherence. We draw on interviews and group discussions with 25 nurses and 53 adult ARV users, which we analysed through a three-tiered thematic approach, allowing us to categorise our findings into broader dimensions that can transcend our case study and be applied elsewhere. Our findings suggest that ART adherence is influenced by the material, symbolic, relational and institutional contexts in which ARV users live as well as the patient's motivation, participation and psychosocial responses to ART. This framework allows us to examine both the social context in which ART programmes are located and the psychosocial factors that influence patient behaviours. We offer this framework as a resource for ART programme planners and implementers seeking to improve ART compliance in resource-poor settings.