Background: Adherence is the cornerstone of antiretroviral therapy (ART) and non-adherence translates into viral non-suppression with the resultant increased risk of HIV transmission and new infections as well as ARV drug resistance. The causes of non-adherence, among others, may be client related and includes stigma, discrimination and non-disclosure. AIC is a private not-for-profit non-governmental organization which provides HIV prevention, care and treatment services for the general public but has a patronage of middle class clients because of the relatively more private clinic setting compared to public (government) facilities.

Materials & Methods: Client tracking activities for clients on ART are undertaken to promote adherence to ART and retention in care. At AIC clients who miss their clinic appointments are tracked through phone calls and/or home visits. From July to December 2019, out of 1,020 clients on ART, 455 missed their scheduled appointments. An assessment of the client tracking activities (specifically for the phone calls) was undertaken in order to document and respond to the reasons for missed appointments of the persistently high numbers of clients with the same.
Results: Of the 455 clients tracked, 84 (41 male, 43 female) didn’t return within a week of phone call follow up. Among reasons clients gave for missing appointments were: forgetting their appointment dates and transport related problems. However 77% (65 clients; 38 male, 27 female) missed appointments because of work related constraints including: busy work schedules, distant workstations and limited time/ days allowed off work for clinic visits.
Additionally, because of non-disclosure and fear of stigma and discrimination, this category of clients do not declare their HIV status to employers and therefore cannot request for addition time/days off for clinic visits; do not have anyone to collect drugs for them and importantly decline alternate Differentiated Service Delivery Models (DSDM) models like community refills preferring facility-based care thus compounding missed visits. Those were virally non-suppressed didn’t adhere to schedules/ appointments for intensive counselling sessions and declined home visits for adherence support and home-based index testing.

Conclusions: Middle class clients prefer more private HIV service delivery options, but their work combined with stigma and non-disclosure puts them at risk for missed visits and therefore non-adherence. There is low uptake of available community DSDM for adherence promotion and therefore alternate community refill options like door-to-door service delivery for these clients may be more appropriate.