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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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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F1000Research 2025, 14 :1294 ( https://doi.org/10.12688/f1000research.168979.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Review Barriers and Strategies for Antiretroviral Therapy Appointment Adherence in Rural South Africa: A Narrative Review with a Focus on the Vhembe District [version 1; peer review: awaiting peer review] Coddyliver Mabasa https://orcid.org/0009-0000-2987-1115 1 , Shonisani Tshivhase 1 , Lufuno Makhado https://orcid.org/0000-0003-1689-9308 1 Coddyliver Mabasa https://orcid.org/0009-0000-2987-1115 1 , Shonisani Tshivhase 1 , Lufuno Makhado https://orcid.org/0000-0003-1689-9308 1 PUBLISHED 21 Nov 2025 Author details Author details 1 Public Health, University of Venda, Thohoyandou, Limpopo, 0950, South Africa Coddyliver Mabasa Roles: Writing – Original Draft Preparation Shonisani Tshivhase Roles: Supervision Lufuno Makhado Roles: Supervision OPEN PEER REVIEW REVIEWER STATUS AWAITING PEER REVIEW This article is included in the Global Public Health gateway. Abstract 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. READ ALL READ LESS Keywords Keywords: Antiretroviral therapy (ART), Appointment adherence, Home delivery, Treatment supporter interventions (TSIs), Healthcare access barriers. Corresponding Author(s) Coddyliver Mabasa ( [email protected] ) Close Corresponding author: Coddyliver Mabasa Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Mabasa C et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Mabasa C, Tshivhase S and Makhado L. Barriers and Strategies for Antiretroviral Therapy Appointment Adherence in Rural South Africa: A Narrative Review with a Focus on the Vhembe District [version 1; peer review: awaiting peer review] . F1000Research 2025, 14 :1294 ( https://doi.org/10.12688/f1000research.168979.1 ) First published: 21 Nov 2025, 14 :1294 ( https://doi.org/10.12688/f1000research.168979.1 ) Latest published: 21 Nov 2025, 14 :1294 ( https://doi.org/10.12688/f1000research.168979.1 ) 1. Introduction 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. 2. Methods This narrative review synthesizes evidence from key studies conducted in rural areas of South Africa and other sub-Saharan regions, drawing heavily on three principal sources. The first source is Tseng’s (2024) , which investigates home delivery models for ART and their associated environmental, financial, and clinical outcomes in rural South Africa. The second source is a systematic review and meta-analysis evaluating the effectiveness of treatment supporter interventions (TSIs) in ART adherence across sub-Saharan Africa ( Nyoni et al., 2020 ). The third source is a meta-analysis focusing on strategies to improve ART adherence among pregnant women in sub-Saharan Africa, emphasizing interventions such as device reminders and combined educational-social support programs ( Omonaiye et al., 2018 ). Although the review did not employ a formal systematic search process, the selection of these studies was guided by their relevance to the challenges encountered in rural ART service delivery, their rigorous methodological designs, and their applicability to the Vhembe district context. The synthesis process involved a close examination of key findings, with attention to structural, economic, and psychosocial barriers that lead to missed appointments, as well as the interventions that have shown promise in overcoming these obstacles. The methodological approach is further elucidated in the following table, which summarizes the characteristics of the included studies ( Table 1 ). Table 1. Summary of key studies and their characteristics. Characteristic Tseng’s (2024) Thesis Treatment supporter systematic review Meta-analysis on ART adherence in pregnancy Study Design Observational, multi-chapter analysis Systematic review and meta-analysis Meta-analysis Geographical Focus Rural South Africa (KwaZulu-Natal) Sub-Saharan Africa Sub-Saharan Africa Intervention Focus Home delivery versus clinic-based ART Treatment supporter interventions (partners, peers) Device reminders, educational, social, and structural support Key Outcome Measures Missed ART doses, incremental costs, and environmental impact ART adherence improvement; viral load suppression ART adherence rates, risk ratios for intervention efficacy Relevance to Vhembe Generalizable to rural settings Emphasizes community-based support, applicable in rural contexts Demonstrates potential for combined interventions adaptable in rural districts This table illustrates that although the geographic focus of the studies varies, the underlying challenges and potential solutions show considerable overlap with the conditions present in the Vhembe district. Insights derived from these studies have been integrated into the subsequent discussion of barriers and intervention strategies ( Table 2 ). Table 2. Major barriers and corresponding strategies for ART appointment adherence in Vhembe. Barriers Impact on Adherence Potential Strategies for Vhembe Geographical distance and transport Increased travel time, inconsistent clinic attendance Home delivery, mobile clinics, multi-month dispensing Financial constraints Indirect costs (transport, lost wages) deter regular appointments Subsidies for transport, integration of cost-saving practices, and MMD Clinic congestion and service inefficiencies Long waiting times, overburdened staff reduce the quality of care Decentralization of services, appointment scheduling improvements Psychosocial challenges (stigma, isolation) Fear of disclosure, low motivation, and affecting adherence Treatment supporter interventions, psychosocial counselling, and community engagement Disruptions due to public health emergencies Service interruptions and increased patient anxiety Flexible service delivery (home delivery, telehealth), multi-month refills 3. Barriers to ART appointment adherence ART appointment adherence in rural settings is influenced by a range of factors that extend beyond individual patient behaviour. The following subsections outline the principal barriers identified in the literature and elucidate their relevance to the context of the Vhembe district. 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. Strategies and interventions to improve ART appointment adherence A diverse range of interventions has been proposed and evaluated to mitigate the barriers to ART appointment adherence. This section reviews the strategies that have shown promise in enhancing adherence and discusses their potential applicability to rural settings, particularly the Vhembe district. 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. Application to the Vhembe District context The Vhembe district, located in Limpopo province, exemplifies the challenges faced by rural communities in ensuring sustained ART appointment adherence. Although not all evidence reviewed directly pertains to Vhembe, the underlying themes from studies conducted in other rural parts of South Africa and sub-Saharan Africa are highly relevant. 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. 6. Identified gaps in research and practice A critical analysis of the existing literature reveals several gaps, both in content and methodological. Improvements in ART appointment adherence in the Vhembe district face significant content and methodological gaps. Research is lacking on context-specific interventions, integrated models combining multiple strategies, and tailored support for youth living with HIV. Methodologically, inconsistent definitions of adherence, limited long-term data, and scarce economic evaluations hinder progress. Additionally, studies often overlook effective implementation strategies, including community health worker training and the integration of digital solutions, which are crucial for scaling interventions within existing health systems. 7. Strengths and limitations of the review This narrative review synthesizes insights from studies on ART delivery models and adherence strategies in rural South Africa and sub-Saharan Africa. It integrates diverse intervention evidence, highlighting structural, economic, and psychosocial factors to address challenges unique to these areas, particularly relevant to the Vhembe district. However, its narrative nature limits the comprehensiveness of included studies, potentially overlooking relevant local data. Additionally, findings from other regions may not fully reflect the cultural and infrastructural specifics of Vhembe, impacting their applicability. 8. Recommendations To enhance adherence to antiretroviral therapy (ART) appointments in the Vhembe district, a comprehensive intervention package is essential. This package should include home delivery of ART, multi-month dispensing, mHealth reminders, and community-based psychosocial support tailored to local needs. Strengthening community-led psychosocial interventions, with training for community health workers, can effectively address stigma and social barriers. Moreover, mobile health solutions must be adapted to fit local languages and accessibility, ensuring that all patients can benefit. Implementing standardized eligibility criteria for differentiated care models will streamline patient selection and improve service delivery. Finally, integrating economic support measures, such as transport reimbursements and food assistance, can alleviate financial burdens on patients. Prioritizing rigorous, long-term research is crucial to evaluate these interventions, ensuring they are evidence-based and scalable across rural settings, ultimately improving ART adherence and health outcomes in the region. 9. Conclusions To improve ART appointment adherence in rural Vhembe, it’s crucial to understand barriers like social stigma, infrastructure issues, and economic constraints. Existing interventions, home delivery, mHealth tools, and community support show promise, but challenges such as disclosure risks and inconsistent protocols persist. Integrated strategies that combine these approaches can address logistical and behavioral hurdles effectively. Tailored community support and standardized care models are vital, along with targeted investments in infrastructure and research. By adopting a comprehensive approach, stakeholders can enhance adherence, improve patient outcomes, and promote public health in the region. Ethics and consent statement This study is a narrative review based entirely on previously published literature and does not involve any human participants or any primary data collection; thus, ethical approval and informed consent were not required. Data availability No new data were generated; all data underlying this article are derived from previously published studies, which are cited within the text and listed in the references. Acknowledgments None. References Adefolalu AO, Nkosi ZZ: The Complex Nature of Adherence in the Management of HIV/AIDS as a Chronic Medical Condition. Diseases. 2013; 1 (1): 18–35. Publisher Full Text Amankwaa I, Boateng D, Quansah DY, et al. : Effectiveness of short message services and voice call interventions for antiretroviral therapy adherence and other outcomes: A systematic review and meta-analysis [Review of Effectiveness of short message services and voice call interventions for antiretroviral therapy adherence and other outcomes: A systematic review and meta-analysis]. PLoS ONE. 2018; 13 (9). Public Library of Science. PubMed Abstract | Publisher Full Text | Free Full Text Assefa Y, Alebachew A, Lera M, et al. : Scaling up antiretroviral treatment and improving patient retention in care: lessons from Ethiopia, 2005-2013. Glob. Health. 2014; 10 (1): 43. PubMed Abstract | Publisher Full Text | Free Full Text Bemelmans M, Baert S, Goemaere E, et al. : Community-supported models of care for people on HIV treatment in sub-Saharan Africa. Trop. Med. Int. Health. 2014; 19 (8): 968–977. PubMed Abstract | Publisher Full Text Campbell L, Masquillier C, Thunnissen E, et al. : Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review [Review of Social and Structural Determinants of Household Support for ART Adherence in Low- and Middle-Income Countries: A Systematic Review]. Int. J. Environ. Res. Public Health. 2020; 17 (11): 3808. Multidisciplinary Digital Publishing Institute. PubMed Abstract | Publisher Full Text | Free Full Text Castillo-Mancilla J, Morrow M, Hunt PW, et al. : Beyond Undetectable: Modeling the Clinical Benefit of Improved Antiretroviral Adherence in Persons With Human Immunodeficiency Virus With Virologic Suppression. Open Forum Infect. Dis. 2023; 10 (5). PubMed Abstract | Publisher Full Text | Free Full Text Cleary S, Birch S, Moshabela M, et al. : Unequal access to ART: exploratory results from rural and urban case studies of ART use. Sex. Transm. Infect. 2012; 88 (2): 141–146. PubMed Abstract | Publisher Full Text Damulak PP, Ismail S, Manaf RA, et al. : Interventions to Improve Adherence to Antiretroviral Therapy (ART) in Sub-Saharan Africa: An Updated Systematic Review [Review of Interventions to Improve Adherence to Antiretroviral Therapy (ART) in Sub-Saharan Africa: An Updated Systematic Review]. Int. J. Environ. Res. Public Health. 2021; 18 (5): 2477. Multidisciplinary Digital Publishing Institute. PubMed Abstract | Publisher Full Text | Free Full Text Davis N, Kanagat N, Sharer M, et al. : Review of differentiated approaches to antiretroviral therapy distribution [Review of Review of differentiated approaches to antiretroviral therapy distribution]. AIDS Care. 2018; 30 (8): 1010–1016. Taylor & Francis. PubMed Abstract | Publisher Full Text Demberg T, Robert-Guroff M: Controlling the HIV/AIDS epidemic: current status and global challenges. Front. Immunol. 2012; 3 . PubMed Abstract | Publisher Full Text | Free Full Text Dibaba D, Kajela G, Cheme MC, et al. : Antiretroviral Treatment Adherence Level and Associated Factors Among Adult HIV-Positive Patients on Both HIV/AIDS Care Models: Comparative Study in Selected Hospitals of Western Ethiopia, 2019. HIV/AIDS - Research and Palliative Care. 2021; 13 : 1067–1078. PubMed Abstract | Publisher Full Text | Free Full Text Gachara G, Mavhandu LG, McQuade ETR, et al. : Evaluating Adherence to Antiretroviral Therapy Using Pharmacy Refill Records in a Rural Treatment Site in South Africa. AIDS Research and Treatment. 2017; 2017 : 1–6. PubMed Abstract | Publisher Full Text | Free Full Text Grimsrud A, Barnabas RV, Ehrenkranz P, et al. : Evidence for scale up: the differentiated care research agenda. J. Int. AIDS Soc. 2017; Vol. 20 . International AIDS Society. PubMed Abstract | Publisher Full Text | Free Full Text Hoke T, Bateganya M, Toyo O, et al. : How Home Delivery of Antiretroviral Drugs Ensured Uninterrupted HIV Treatment During COVID-19: Experiences From Indonesia, Laos, Nepal, and Nigeria. Global Health Science and Practice. 2021; 9 (4): 978–989. PubMed Abstract | Publisher Full Text | Free Full Text Kapwata T, Manda S: Geographic assessment of access to health care in patients with cardiovascular disease in South Africa. BMC Health Serv. Res. 2018; 18 (1): 197. PubMed Abstract | Publisher Full Text | Free Full Text Limbada M, Zijlstra G, Macleod D, et al. : A systematic review of the effectiveness of non- health facility based care delivery of antiretroviral therapy for people living with HIV in sub-Saharan Africa measured by viral suppression, mortality and retention on ART [Review of A systematic review of the effectiveness of non- health facility based care delivery of antiretroviral therapy for people living with HIV in sub-Saharan Africa measured by viral suppression, mortality and retention on ART]. BMC Public Health. 2021; 21 (1). BioMed Central. PubMed Abstract | Publisher Full Text | Free Full Text Long L, Kuchukhidze S, Pascoe S, et al. : Differentiated models of service delivery for antiretroviral treatment of HIV in sub-Saharan Africa: a rapid review protocol [Review of Differentiated models of service delivery for antiretroviral treatment of HIV in sub-Saharan Africa: a rapid review protocol]. Syst. Rev. 2019; 8 (1). BioMed Central. PubMed Abstract | Publisher Full Text | Free Full Text Long L, Kuchukhidze S, Pascoe S, et al. : Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub-Saharan Africa: a rapid systematic review [Review of Retention in care and viral suppression in differentiated service delivery models for HIV treatment delivery in sub-Saharan Africa: a rapid systematic review]. J. Int. AIDS Soc. 2020; 23 (11). International AIDS Society. PubMed Abstract | Publisher Full Text | Free Full Text Lowane MP, Lebese RT: Missing appointments by patients on antiretroviral therapy: Professional nurses’ perspective. Curationis. 2022a; 45 (1): e1–e7. PubMed Abstract | Publisher Full Text | Free Full Text Lowane MP, Lebese RT: Why adult patients on antiretroviral therapy miss clinical appointments in rural villages of Limpopo Province, South Africa: An exploratory study. Health SA Gesondheid. 2022b; 27 . PubMed Abstract | Publisher Full Text | Free Full Text Mash R, Christian C, Chigwanda RV: Alternative mechanisms for delivery of medication in South Africa: A scoping review [Review of Alternative mechanisms for delivery of medication in South Africa: A scoping review]. S. Afr. Fam. Pract. 2021; 63 (1): e1–e8. Taylor & Francis. PubMed Abstract | Publisher Full Text | Free Full Text Messeri P, Yomogida M, Ferat RM, et al. : An HIV health plan patient navigation program: Engaging HIV positive individuals in primary medical care. J. HIV AIDS Soc. Serv. 2019; 19 (1): 55–73. Publisher Full Text Moomba K, van Wyk B : Social and economic barriers to adherence among patients at Livingstone General Hospital in Zambia. African Journal of Primary Health Care & Family Medicine. 2019; 11 (1): e1–e6. PubMed Abstract | Publisher Full Text | Free Full Text Nyoni T, Sallah YH, Okumu M, et al. : The effectiveness of treatment supporter interventions in antiretroviral treatment adherence in sub-Saharan Africa: A systematic review and meta-analysis. AIDS Care. 2020; 32 (Sup2): 214–227. PubMed Abstract | Publisher Full Text Omonaiye O, Kusljic S, Nicholson P, et al. : A meta-analysis of the effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa. Int. J. Infect. Dis. 2018; 74 : 71–82. Publisher Full Text Peek K, Sanson-Fisher R, Mackenzie L, et al. : Interventions to aid patient adherence to physiotherapist prescribed self-management strategies: a systematic review [Review of Interventions to aid patient adherence to physiotherapist prescribed self-management strategies: a systematic review]. Physiotherapy. 2015; 102 (2): 127–135. Elsevier BV. PubMed Abstract | Publisher Full Text Sharer M, Davis N, Makina N, et al. : Differentiated Antiretroviral Therapy Delivery: Implementation Barriers and Enablers in South Africa. J. Assoc. Nurses AIDS Care. 2019; 30 (5): 511–520. PubMed Abstract | Publisher Full Text | Free Full Text Tseng AS: State-of-the-ART Care: Revolutionizing Medication Delivery in Rural Settings with a Person-Centered Care Approach. University of Washington; 2024. (Doctoral dissertation). Tshivhase S, Khoza LB, Tshitangano TG: Loss to follow-up amongst glaucoma patients in selected hospitals of the Limpopo Province, South Africa. African Vision and Eye Health. 2020; 79 (1). Publisher Full Text Tumwikirize S, Torpey K, Adedokun O, et al. : The Value of Support Group Participation in Influencing Adherence to Antiretroviral Treatment among People Living with Human Immunodeficiency Virus (HIV). World Journal of AIDS. 2015; 05 (3): 189–198. Publisher Full Text Wang M, Violette LR, Dorward J, et al. : Delivery of Community-based Antiretroviral Therapy to Maintain Viral Suppression and Retention in Care in South Africa. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2023; 93 (2): 126–133. PubMed Abstract | Publisher Full Text | Free Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 21 Nov 2025 ADD YOUR COMMENT Comment Author details Author details 1 Public Health, University of Venda, Thohoyandou, Limpopo, 0950, South Africa Coddyliver Mabasa Roles: Writing – Original Draft Preparation Shonisani Tshivhase Roles: Supervision Lufuno Makhado Roles: Supervision Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 21 Nov 2025, 14:1294 https://doi.org/10.12688/f1000research.168979.1 Copyright © 2025 Mabasa C et al . 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