Barriers and facilitators of antiretroviral therapy (ART) adherence habit formation in Sub-Saharan Africa: Evidence from a qualitative study in Kampala, Uganda

• Published in: Social science & medicine (1982) 2023-01, Vol.317, p.115567-115567, Article 115567
• Main Authors: Stecher, Chad, Palimaru, Alina I., Odiit, Mary, Lunkuse, Lillian, Walukaga, Stewart, Linnemayr, Sebastian
• Format: Article
• Language: English
• Subjects: Acquired Immunodeficiency Syndrome; Africa South of the Sahara; Anti-Retroviral Agents - therapeutic use; Antiretroviral therapy; Behavioral economics; COVID-19; Habit formation; Habits; HIV Infections - drug therapy; HIV/AIDS; Humans; Medication Adherence; Pandemics; Sub-saharan africa; Treatment initiators; Uganda
• ISSN: 0277-9536; 1873-5347
• DOI: 10.1016/j.socscimed.2022.115567

In 2020, nearly 40 million people lived with HIV/AIDS (PLWHA) worldwide, of whom 70% were receiving antiretroviral therapy (ART). Two-thirds of PLWHA reside in Sub-Saharan Africa (SSA), where rates of viral load suppression are often suboptimal and frequently attributed to low ART adherence. Strong pill-taking habits are often reported as a key strategy among those who successfully maintain medication adherence, yet not enough is known about the barriers and facilitators in SSA to pill-taking in response to the same contextual cue, which is a necessary step in the habit formation process. To address this knowledge gap and to inform a subsequent intervention to promote context-dependent repetition, called anchoring, we used a formative qualitative approach to collect in-depth narratives about barriers and facilitators of the anchoring intervention for establishing ART pill-taking habits at the Mildmay Hospital in Kampala, Uganda. We conducted interviews with 25 randomly selected patients starting ART, 5 expert patients, and 10 providers at Mildmay, and performed a rapid analysis to inform the intervention in a timely manner. We found that pill taking in response to the same contextual cue, or anchor, was threatened by stigma and food insecurity and that the COVID-19 pandemic exacerbated these barriers. We also determined that important linguistic changes were needed to the instructional materials and reminder messages in the subsequent intervention to avoid words and phrases with negative connotations for this target population. Several important barriers and facilitators to context-dependent pill taking in Uganda were identified through our formative research that helped to inform important revisions to our subsequent intervention. These findings underscore the importance of understanding local barriers and facilitators when designing and planning interventions, particularly when implementing theory-based intervention approaches that have yet to be tested in a new setting. •Context-dependent pill taking is threatened by stigma and food insecurity in Uganda.•Taking pills in one's home facilitates contextually-cued repetition.•The COVID-19 pandemic exacerbated existing barriers to context-dependent pill taking.•We identified regional barriers and facilitators to context-dependent repetition.•Culturally adapting theory-based interventions is crucial for success.