Money worries: supporting people on low-income with ART adherence

A South African study on the link between how low-income households manage their money and household members’ ability to adhere to antiretroviral treatment (ART) reveals a complex, often-changing process. 

What is the research about? 

The relationship between managing household income and ART adherence. The study involved 21 adults with HIV (10 men and 11 women) in 13 low-income households in the Western Cape. 

Why is this research important? 

Previous research suggests financial issues (like not being able to afford to travel to a clinic or buy food to take medication with) can cause people to disrupt ART. This puts their health at risk and increases the risk of onward transmission. Understanding these barriers is important for designing more effective adherence support programmes. 

What did they find out? 

Of the 21 participants, 15 said they regularly attended clinic appointments and generally took ART as prescribed, missing the occasional dose. The remaining six participants said they more regularly missed doses or clinic appointments. 

Changes in employment status, household members and other social support affected what household income was prioritised for. And when circumstances changed, people’s ART adherence was also likely to change.  

Some participants reported having to decide between going to a clinic and needing to earn money. Some reported needing to prioritise basics, such as food, electricity and school fees, over HIV care. Only a few people reported prioritising income to cover HIV care-related costs.  

The way individual incomes were managed within a household also made a difference. In households that pooled resources, people with HIV were more likely to adhere to ART. This is because they had more of a safety net than people in households where everyone managed their income separately.  

For example, some households would pool resources to ensure people with HIV had food, medication for side effects or medical care. As Nomfundiso, 45, explained: “Whenever I ate, I’d just vomit, and I lost energy. My brother was working at the supermarket back then. He insisted on giving me R200 [$13] to go to the [private] doctor. The doctor gave me medication to regain strength and referred me to the [local public] clinic.” 

In eight households, people with HIV said they used some of their limited income to buy illegal drugs or alcohol to ‘numb the pain’ of having HIV. This sometimes affected their ability to start ART or adhere to it. For example, Zonke, 28, said: “We just buy alcohol and drink. I will drink and get drunk now and tomorrow the stress [of having HIV] is still there, you see? I’m getting sicker, but I haven’t taken treatment yet.” 

What does this mean for HIV services? 

ART adherence support programme could be more effective if the financial reasons why someone with HIV might not be starting or adhering to treatment were considered, and solutions found if possible.  

Solutions range from lower-cost strategies, such as providing clinic appointments outside working hours, or longer-length prescriptions for people who are stable on ART. More costly solutions include schemes to help households increase their income. These can range from cash transfers to business and vocational skills training to increase people’s earning capacity.  

If people are unable to adhere to ART due to their drug or alcohol use, link them to harm reduction services and counselling if available.  

Working with representatives from that community can be a helpful way to build trust so people feel able to explain why they are struggling to adhere. Representatives from households that pool resources could also mentor other households about this approach.