The issue of how to ensure that antiretroviral therapy is taken regularly and appropriately has generated considerable discussion and controversy. Some even suggest that the use of antiretroviral therapy in poor countries will only lead to the widespread development of resistance.

They advocate either that resources are not put into making the drugs available or that they are only administered under strictly controlled conditions, such as in the presence of medical staff (along the lines of the DOTS model for TB, although the comparison is complicated by the greater frequency of dosing of antiretroviral therapy and the fact that it is life-long rather than of a limited duration).

However, in Khayelitsha, an approach centred on educating patients and empowering them to be actively involved in the treatment programme has yielded very positive results.

This begins with the careful selection of a regimen that is easy to take - for example a combination of nevirapine and co-formulated AZT/3TC, which amounts to two pills twice a day - and setting the health care facilities within easy reach of the patients (for example, at primary health care level). Once patients begin therapy (after an educational process), a tripartite programme supports adherence:

Research is ongoing to quantify the levels of adherence, but the dramatic improvements in the surrogate markers of changes in viral load and CD4 T cell counts strongly suggest that adherence is good.