Since the Durban conference in 2000, the initiatives of access to antiretroviral therapy (ART) have expanded in sub-Saharan Africa. It is of high interest to monitor observance to HAART, in a context of increasing ART use, a rapid increase of patients under HAART, and the sociocultural specificities in Africa. In sub-Saharan Africa the concept of disease without cure does not exist and a disease always has or is attributed an external cause. Optimizing observance is a key element for the success of implementation programs for which we recommend a light monitoring to follow-up patients and the use of first line and effective antiretroviral drugs, with a low genetic barrier (efavirenz, nevirapine). The consequences of non-adherence are extremely negative for a patient in Africa, for whom we have few assessment tools and a limited number of ART. Improvement of adherence requires the involvement of all health care actors including traditional healers.