The aim of the study was to investigate the relationship between counseling prior to starting antiretroviral treatment (ART) and adherence to treatment among women enrolled in Option B+ in Zambia. Using convenience sampling, 150 HIV+ women enrolled in an Option B+ treatment regimen in rural and urban districts were recruited. Four generalized Poisson regression models were built to assess the association between counseling and adherence to ART. In all, 75% of the participants reported adherence in the past 7 days. In adjusted analyses, there was a significant positive relationship between counseling and adherence in the rural district (prevalence ratio [PR] 2.52, 95% CI [1.19, 5.35], n = 81) but not in the urban district (PR = 0.77, 95% CI [0.15, 3.91], n = 69). Offering counseling prior to initiating antiretroviral treatment to HIV+ women is particularly important for promoting medication adherence in rural settings of low resourced countries.