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

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Background and Objective Antiretroviral therapy (ART) is the cornerstone of HIV treatment, but its effectiveness depends heavily on consistent patient adherence to scheduled appointments. Rural regions, such as the Vhembe district in South Africa, face persistent structural, economic, and psychosocial challenges that hinder ART adherence and continuity of care. This narrative review synthesizes evidence on the multifaceted barriers affecting ART appointment adherence in rural settings and evaluates intervention strategies that have demonstrated success across sub-Saharan Africa. It emphasizes the relevance of these findings to the Vhembe district context. Methods The review draws on three key evidence sources: a doctoral study evaluating home delivery models for ART, a systematic review on treatment supporter interventions (TSIs), and a meta-analysis on adherence among pregnant women using digital and educational tools. The selected studies were critically examined for their applicability to rural service delivery and adherence outcomes. Results The review identifies major adherence barriers, including poor transport infrastructure, high indirect costs, clinic overcrowding, limited refill durations, stigma, and the impact of public health emergencies. Strategies such as home delivery, multi-month dispensing (MMD), mHealth device reminders, and community-based support programs (TSIs) are shown to mitigate these challenges effectively. Combined socio-structural interventions yield the most substantial improvements in adherence outcomes. Conclusions Improving ART appointment adherence in Vhembe requires an integrated model tailored to local realities. Combining decentralized care, social support structures, mHealth solutions, and financial incentives offers a sustainable path forward. However, research gaps in implementation science, cost-effectiveness, and context-specific interventions must be addressed to scale these solutions effectively.

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