To document best practices enabling many ARV users to achieve optimal adherence rates and improve adherence support in resourcepoor, stigmatizing and discriminating settings. There is still scanty research on why some ARV users do not achieve optimal adherence. (Koenig, Léandre and Farmer, 2004; Gill et al., 2005).

Since the beginning of the 1980s the essential drugs concept has become one of the cornerstones of international and national health policy. The selection and rational use of medicines are accepted as key principles of health service quality and management (Hardon, Hodgkin and Fresle, 2004). WHO has defined rational use of drugs as the situation in which ‘Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community’ (WHO, 1985). Common patterns of inappropriate medicine use include; using too many medicines per patient, inappropriate use of antimicrobials, overuse of injections, failure to prescribe according to clinical guidelines, and inappropriate selfmedication (WHO, 2002; Hardon, Hodgkin and Fresle, 2004). Improper prescription, inappropriate use, lack of access to medicines, discrimination and stigma compound the problem of irrational drug use.  After   WHO’s '3 by 5' initiative in 2003, many countries in sub-Saharan Africa have established national antiretroviral treatment (ART) programmes. In 2011, UNAIDS introduced the three zeros: Zero new infection, zero discrimination and zero HIV-related deaths. This underscores issues of access, vigilance and resilience.

This is investigated using a checklist with 7 steps of intervention development (see diagram) during home/Community visits by adherence supporters and targeted intervention approach. The respondents followed included: 54 MSM, 72 females in long term discordant relation, 12 males in long term discordant relation, 13 female sex-workers and 11 male sex-workers. This was in peri-urban and typical rural settings. These outcomes were assessed:  (I). Taking pills on time; (II). Proximity to ART accredited facility; (III).  Accessibility to ART accredited facility; (IV). Presence of nutrition supplements; (V). Presence of adherence supporters; (VI). Means of getting monetary support; (VII). Preventing opportunistic infections; (VIII). Composite of (I), (III), (IV), (VI), (VII) and (IX). Outcomes of composite of (I), (III), (IV), (V), (VII).

A total of 168 participants were followed ( mean 12 months) by identified and trained adherence supporters skilled in unconditional positive regard. For outcome  (VIII), MSM, females in discordant long term relations, females in sex-work and males in sex-work reported 37  negative events and males in discordant long term relations reported only 10 negative events. For outcome (IX), MSM, females in discordant long term relations, females in sex-work and males in sex-work reported 67  negative events including remaining with mother as carers along side their sick-beds and males in discordant long term relations reported only 20 negative events.

Issues of sexuality, sex-work and lack of psycho-social support are related and play a bigger role in adherence to treatment and rational use of drugs for marginalized and rural based persons.


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