This review goes beyond presenting barriers and facilitators such as cost and distance from care, which are well known. Rather the systematic review looks broadly at how external influences and personal motivation interact and drive ART adherence and engagement decisions and presents a model for understanding why people do what they do.
The study included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism—these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support.
The mix of all these factors happen over time, so there appears to be a tipping point when patients choose to either engage or disengage from care, with HIV-positive patients potentially cycling in and out of these care states in response to fluctuations in influences over time.