Weaving the Net: The Interplay of Micro- and Macrosupport in ART Adherence

Sustained antiretroviral therapy (ART) adherence is fundamental to managing HIV, yet it remains a significant challenge, particularly in resource-limited settings. Adherence is shaped by a complex interplay of support systems, which can be categorized as "microsupport": immediate, informal assistance from personal networks, and "macrosupport": formal, structural interventions from healthcare systems. The interaction and comparative impact of these two systems on long-term adherence are not well understood.

This study aimed to explore the lived experiences of people living with HIV in Ghana as they navigate both micro- and macrosupport systems to inform the development of more effective, multilevel adherence strategies.

A qualitative descriptive design was employed at the Cape Coast Teaching Hospital in Ghana. Data were collected between June and September 2025 through semistructured in-depth interviews and a focus group discussion with 21 purposively sampled adults who had been on ART for at least six months. Thematic analysis, facilitated by NVivo software, was used to analyze the data.

Analysis revealed that adherence is sustained by a delicate balance between the two support systems. Microsupport, manifesting as timely financial lifelines, spousal reminders, and quiet familial aid, was described as an immediate and critical "first line of defence" against missed doses. In contrast, macrosupport, such as peer groups and clinic-based care, was valued for its broad reach but often perceived as unreliable due to structural inefficiencies, such as long wait times and inconsistent resource provision. Consequently, participants expressed a strong desire for combined approaches that integrate the personal, responsive nature of microsupport within the formal structure of macrosupport.

Effective ART adherence depends not on choosing between micro- and macrosupport but on innovatively weaving them together. Microsupport provides an essential, agile safety net, while macrosupport offers a broader structural foundation. To build a resilient ecosystem of care, healthcare systems must formally recognize and bolster microsupport networks while making macrolevel interventions more reliable, personalized, and responsive to patient needs.