Skip to main content
Advertisement
  • Loading metrics

Correlates of HIV treatment adherence self-efficacy among adolescents and young adults living with HIV in southwestern Uganda

  • Scholastic Ashaba ,

    Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing

    sashaba@must.ac.ug

    Affiliation Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda

  • Charles Baguma,

    Roles Project administration, Supervision, Writing – original draft, Writing – review & editing

    Affiliation Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda

  • Patricia Tushemereirwe,

    Roles Data curation, Writing – original draft, Writing – review & editing

    Affiliation Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda

  • Denis Nansera,

    Roles Writing – review & editing

    Affiliation Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda

  • Samuel Maling,

    Roles Supervision, Writing – review & editing

    Affiliation Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda

  • Brian C. Zanon,

    Roles Data curation, Writing – review & editing

    Affiliations Department of Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, United States of America, Department of Pediatric Infectious Diseases, Children’s Healthcare of Atlanta, Goergia, United States of America, Department of Pediatric Infectious, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America

  • Alexander C. Tsai

    Roles Conceptualization, Data curation, Project administration, Supervision, Visualization, Writing – review & editing

    Affiliations Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda, Department of Psychiatry, Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, United States of America, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, United States of America

Correction

15 Oct 2024: Ashaba S, Baguma C, Tushemereirwe P, Nansera D, Maling S, et al. (2024) Correction: Correlates of HIV treatment adherence self-efficacy among adolescents and young adults living with HIV in southwestern Uganda. PLOS Global Public Health 4(10): e0003874. https://doi.org/10.1371/journal.pgph.0003874 View correction

Abstract

Adherence to antiretroviral therapy (ART) among adolescents and young adults living with HIV (AYLHIV) in sub-Saharan Africa is sub-optimal compared to younger children and older adults. Adherence self-efficacy is one of the intrapersonal factors most strongly correlated with ART adherence. The role of adherence self-efficacy in ART adherence among AYLHIV is not well studied in Uganda. We enrolled 300 AYLHIV between October and December 2021 from an HIV clinic in southwestern Uganda. We collected information on adherence self-efficacy, HIV stigma, depression, self-management, and social skills. We used linear regression to estimate the association between adherence self-efficacy and the covariates of interest. At multivariable adjustment self-management (b = 0.29, 95% CI 0.23–0.35, p<0.001) and social skills (b = 0.16, 95% CI 0.08–0.24; p<0.001) were statistically significantly associated with adherence self-efficacy. The findings imply that interventions directed at enhancing self-management and social skills in AYLHIV may increase adherence self-efficacy and, potentially, HIV outcomes among AYLHIV.

Introduction

Although availability of and access to antiretroviral therapy has enabled children born with HIV to survive into adolescence and young adulthood [1, 2], HIV remains a leading cause of mortality among adolescents in sub Saharan Africa [3, 4]. In Uganda, there are 170,000 adolescents living with HIV, constituting 12% of the people living with HIV nationwide [5]. HIV treatment among adolescents and young adults is characterized by poor adherence to HIV antiretroviral therapy (ART) and high risk of viral failure, loss to follow up, and overall mortality [610]. Compared to older adults and younger children, adolescents and youth living with HIV (AYLHIV) exhibit worse outcomes across the continuum of treatment related behaviors [11, 12], and in Uganda specifically [13, 14]. Factors associated with ART adherence among AYLHIV include HIV stigma, lack of social support, medication side effects, lack of HIV status disclosure and depression [1519].

Self-efficacy is a primary facilitator of ART adherence among adults living with HIV [20, 21]. Self-efficacy is defined, in the context of HIV treatment, as the belief in one’s ability to effectively consistently take medications, attend clinic appointments and follow treatment guidelines in general [22]. It is considered to be essential for establishing and maintaining specific health behaviors, which explains its effect on ART adherence [23, 24], and has been identified as one of the major intrapersonal factors governing ART adherence [25, 26]. Associations between adherence self-efficacy, treatment adherence, and viral suppression have been documented among people living with HIV including both adults and adolescents [24, 25, 2729]. Self-efficacy provides a buffer against the barriers faced by people living with HIV, allowing them to persist with treatment despite encountering such challenges [25, 3032]. In Uganda, the role of self-efficacy in explaining treatment adherence among AYLHIV has not been studied. Understanding drivers of adherence self-efficacy among AYLHIV will inform development of appropriate interventions to improve ART adherence in this population, especially as they grow towards the eventual transition to adult HIV care (when there will be a greater expectation that they manage their care independently [33, 34]). This analysis focused on identifying correlates of adherence self-efficacy among AYLHIV in rural southwestern Uganda.

Materials and methods

Study setting and participants

Participants were recruited from the HIV clinic at Mbarara Regional Referral Hospital (MRRH). MRRH is located in Mbarara city, in southwestern Uganda, approximately 270 km from the capital city, Kampala. The population of Mbarara city is 195,013 according to the last census conducted by the Uganda Bureau of Statistics [35]. Most of the people who attend the HIV clinic reside in nearby communities and earn their livelihood through subsistence farming, animal husbandry, and small scale trading despite acknowledged challenges of water and food insecurity [36, 37]. According to estimates, the prevalence of HIV in Mbarara District is 13%, which is higher than the 5.8% prevalence nationally [38]. The HIV clinic at MRRH offers a variety of services to people with HIV, including ART, viral testing, and adherence counselling.

We recruited adolescents and young adults living with perinatally acquired HIV (AYLPHIV) aged 15–24 years, who were fully aware of their HIV status (i.e., through disclosure to them by their parents or guardians), living within 60 km of the clinic and able to provide written informed assent and/or consent. We excluded AYLPHIV who could not tolerate the length of the interview, those who were not aware of their HIV status (i.e., because their parents or guardians had not disclosed to them their status), and those who were too cognitively impaired to participate in the interview as assessed by the attending clinician in consultation with a licenced Ugandan psychiatrist.

Enrolment procedure

Participants were recruited consecutively as they came to the HIV clinic for their regular clinical reviews between October and December 2021. A research assistant fluent in both Runyankore and English conducted face to face interviews. Those who met the eligibility criteria were approached by the research assistant who introduced the study and requested their participation. The research assistant administered a questionnaire to those who provided written informed assent or consent to participate.

Study measures

Adherence self-efficacy.

Adherence self-efficacy was assessed using the 12-item HIV treatment adherence self-efficacy scale (HIV-ASES) [25]. The HIV-ASES assesses confidence in carrying out medication related behaviors including adhering to treatment plans, following the treatment regimen, nutritious food, and engaging in exercise, despite the challenges they are likely to face. Sample items include “can stick to your treatment plan even when side effects begin to interfere with daily activities” and “can continue with your treatment even if doing so interferes with your daily activities.” The scale has been translated for use among adults living with HIV in Uganda [39, 40]. Responses for each item were scored on a modified scale ranging from 1 (cannot do at all) to 3 (completely certain can do). We calculated the total score by summing across the items such that the minimum possible score was 12 and the maximum was 36. The scale had a Cronbach’s alpha of 0.96 in this study.

Depression.

Depression was assessed using a 20-item depression scale that was developed in Mbarara, southwestern Uganda for use among adolescents living with HIV [41]. The scale captures both affective and cognitive symptoms of depression. Sample questions include “In the last two weeks, how often have you felt hopeless about the future?” and “In the last two weeks, how often did you feel you had no peace?” Each item is scored on a 4-point Likert-type scale, ranging from 0 (not at all) to 3 (all the time). The minimum possible score is 0 and the maximum possible score is 60. In this study the scale had a Cronbach’s alpha of 0.92.

HIV stigma.

HIV stigma was assessed using the 10-item HIV stigma scale for adolescents living with HIV [42]. The scale was developed among adolescents living with HIV in South Africa and consists of 5 items measuring internalized stigma, 2 items measuring anticipated stigma, and 3 items measuring enacted HIV stigma. Each item is scored on a 3-point Likert-type scale, ranging from 0 (never) to 2 (most of the time) with a minimum possible score of 0 and a maximum possible score of 20. In this study the scale had an overall Cronbach’s alpha of 0.78.

Self-management skills.

Self-management skills were assessed using the 21-item self-management skills assessment guide, a comprehensive self-rated questionnaire for measuring medical self-management and readiness to transition in youth that was developed in Canada [43]. Each item is scored on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) with a minimum possible score of 21 and a maximum possible score of 105. In this study the scale had a Cronbach’s alpha of 0.89.

Social skills.

To assess social skills, we administered the 25-item social skills assessment scale for adolescents. The items were adapted from Goldstein and McGinnis [44]. Each question is scored on a 3-point Likert-type scale ranging from 1 (almost never) to 3 (almost always). The possible minimum score is 25 and the maximum score is 75. Sample questions include “I am good at finding fair ways to solve problems” and “I ask questions about things I don’t understand.” In this study the scale had a Cronbach’s alpha of 0.92.

Data analysis

Data were analysed using Stata version 17. We fit multivariable linear regression models with adherence self-efficacy specified as the dependent variable and HIV stigma, depression, self-management and social skills as the primary explanatory variables of interest. Regression models also adjusted for age, sex, level of education, primary caregiver, age when started ART, duration on ART and marital status.

Ethical considerations

The study was approved by the Research Ethics Committee of the Mbarara University of Science and Technology (#20/08-19) and the Partners Human Research Committee (#2019P003451). The study also received clearance from Uganda National Council for Science and Technology (#HS512ES) and the Office of the President. In accordance with recommendations from the Uganda National Council for Science and Technology [45], emancipated minors—defined as adolescents under the age of 18 who are either pregnant, have a child, or are responsible for their own livelihood—and empowered adolescents—defined as adolescents under the age of 18 who are empowered to take responsibility for their own health—were permitted to give written informed consent without the involvement of their caregivers. All participants received 25,000 Ugandan Shillings (approximately 7 U.S. dollars at the time the study was conducted) to reimburse them for transportation to the clinic/study site.

Results

We enrolled 300 participants. The mean age was 19.1 years (standard deviation [SD] = 2.81; range, 15–24 years), and more than half (57%) were girls and young women. Duration on ART was 15 years (SD = 4.7) and most (87%) had not yet attempted to transition to adult HIV care. The mean adherence self-efficacy score was 29.2 (SD = 5.93) (Table 1).

thumbnail
Table 1. Summary characteristics of the study participants (N = 300).

https://doi.org/10.1371/journal.pgph.0003600.t001

On bivariate analysis, adherence self-efficacy had a statistically significant association with social skills and self-management but not with depression or HIV stigma. In a multivariable linear regression model, both retained a statistically significant association with adherence self-efficacy: self-management (b = 0.29, 95% CI 0.23–0.35; p<0.001) and social skills (b = 0.15, 95% CI 0.07–0.24; P<0.001) (Table 2).

thumbnail
Table 2. Correlates of adherence self-efficacy among the study participants.

https://doi.org/10.1371/journal.pgph.0003600.t002

Thus, a one-standard deviation difference in self-management was associated with a 3.37-point difference in adherence self-efficacy, or a 12% difference relative to the sample mean and 0.57 standard deviation units. Similarly, a one-standard deviation in social skills was associated with a 1.38-point difference in adherence self-efficacy (5% relative to the sample mean and 0.23 standard deviation units).

Discussion

In this study of 300 AYLPHIV recruited from an HIV clinic in rural Uganda, we found that social skills and self-management were significantly associated with adherence self-efficacy. The association between self-management and adherence self-efficacy was both statistically significant and large in magnitude. It echoes findings of previous studies among adolescents and adults living with HIV in Ethiopia and South Africa [46, 47]. The estimated association is likely bidirectional [48, 49]. Self-management comprises motivation, understanding of the illness, confidence in one’s ability to manage the illness and access HIV services, and self-advocacy to seek the necessary support as one navigates HIV care—all of which constitute self-efficacy [50, 51]. Self-efficacy improves self-management behaviors, including adherence to ART [5254]. Enhancing self-efficacy leads to changes in behaviour and improves people’s abilities to manage their illness [55] and has the potential to improve quality of life among people living with HIV [56].

The observed association between social skills and adherence self-efficacy found in our study was smaller in magnitude. It is consistent with the argument that good social skills are associated with a larger social network, which provides opportunities for verbal reassurance, peer learning, and positive reinforcement of adherence behaviour [57]. AYLHIV with high social skills may be more likely to receive financial assistance and other logistical support through their social connections, which may enable them to access HIV care and remain in care [58]. AYLHIV with good social skills may also be more likely to gain social acceptance and reciprocal support, empowerment and personal growth, all of which can increase a sense of self-efficacy [59], treatment adherence, and retention in care [60]. Good social skills have also been associated with patient-provider communication, which has been linked to medication adherence [61].

Contrary to our hypotheses, we did not find an association between HIV stigma and adherence self-efficacy. The finding of no association between HIV stigma and adherence self-efficacy is in agreement with findings of a study among adolescents living with HIV in Kenya [29] but is contrary to findings of previous studies among adults living with HIV [62, 63]. The studies that have reported an association between adherence self-efficacy and HIV stigma focused on enacted stigma and were conducted among adult populations [24, 62]. In one study of adolescents and young adults living with HIV, higher levels of self-efficacy were associated with low levels of internalized HIV stigma [64].

Our results should be interpreted in view of the following limitations. First, we enrolled participants from one HIV treatment facility and over a short period of time (3 months), hence the lack of diversity in terms of geographical location and clinic setting may limit the generalizability of the findings to other populations of AYLHIV in Uganda or other sub-Saharan African countries. Second, we only enrolled adolescents and young adults with perinatally acquired HIV, so our findings may not reflect personal beliefs about HIV treatment behaviours among adolescents and young adults with behaviorally acquired HIV. Third, the study was cross sectional in nature, hence we could not estimate the causal effect of self-management and social skills adherence self-efficacy. Last but not least, we left out other factors that might also be important in assisting in establishing a more comprehensive understanding of the factors influencing adherence self-efficacy among AYLHIV, such as socioeconomic status, access to healthcare services, and peer support networks.

Conclusions

The findings imply that interventions directed at enhancing self-management and social skills in AYLPHIV might increase adherence self-efficacy, which may in turn promote adherence to ART.

Supporting information

Acknowledgments

We would like to express our gratitude to the study participants who volunteered their time to participate and without whom this study would not have been feasible.

References

  1. 1. Dow DE, Shayo AM, Cunningham CK, Reddy EA. Durability of antiretroviral therapy and predictors of virologic failure among perinatally HIV-infected children in Tanzania: a four-year follow-up. BMC infectious diseases. 2014;14(1):567. pmid:25373425
  2. 2. Slogrove AL, Mahy M, Armstrong A, Davies MA. Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic. Journal of the International AIDS Society. 2017;20:21520. pmid:28530036
  3. 3. UNAIDS. Global AIDS update 2018: State of the epidemic. Geneva: UNAIDS, 2018.
  4. 4. Adejumo OA, Malee KM, Ryscavage P, Hunter SJ, Taiwo BO. Contemporary issues on the epidemiology and antiretroviral adherence of HIV‐infected adolescents in sub‐Saharan Africa: a narrative review. Journal of the International AIDS Society. 2015;18(1):20049. pmid:26385853
  5. 5. Uganda AIDS Commission. Uganda HIV & AIDS factsheet. Kampala: Uganda AIDS Commission, 2022.
  6. 6. Evans D, Menezes C, Mahomed K, Macdonald P, Untiedt S, Levin L, et al. Treatment outcomes of HIV-infected adolescents attending public-sector HIV clinics across Gauteng and Mpumalanga, South Africa. AIDS research and human retroviruses. 2013;29(6):892–900. pmid:23373540
  7. 7. Mekuria LA, Prins JM, Yalew AW, Sprangers MA, Nieuwkerk PT. Retention in HIV care and predictors of attrition from care among HIV-infected adults receiving combination anti-retroviral therapy in Addis Ababa. PloS one. 2015;10(6):e0130649. pmid:26114436
  8. 8. Zanoni BC, Sibaya T, Cairns C, Lammert S, Haberer JE. Higher retention and viral suppression with adolescent-focused HIV clinic in South Africa. PLoS One. 2017;12(12):e0190260. pmid:29287088
  9. 9. Enane LA, Vreeman RC, Foster C. Retention and adherence: global challenges for the long-term care of adolescents and young adults living with HIV. Current Opinion in HIV and AIDS. 2018;13(3):212–9. pmid:29570471
  10. 10. Auld AF, Agolory SG, Shiraishi RW, Wabwire-Mangen F, Kwesigabo G, Mulenga M, et al. Antiretroviral therapy enrollment characteristics and outcomes among HIV-infected adolescents and young adults compared with older adults—seven African countries, 2004–2013. Morbidity and Mortality Weekly Report. 2014;63(47):1097. pmid:25426651
  11. 11. Agwu AL, Lee L, Fleishman JA, Voss C, Yehia BR, Althoff KN, et al. Aging and loss to follow-up among youth living with human immunodeficiency virus in the HIV Research Network. Journal of Adolescent Health. 2015;56(3):345–51. pmid:25703322
  12. 12. Nachega JB, Hislop M, Nguyen H, Dowdy DW, Chaisson RE, Regensberg L, et al. Antiretroviral therapy adherence, virologic and immunologic outcomes in adolescents compared with adults in southern Africa. Journal of acquired immune deficiency syndromes (1999). 2009;51(1):65. pmid:19282780
  13. 13. Ministry of Health. Uganda Population-based HIV Impact Assessment (UPHIA) 2016–2017: Final Report. Kampala: Ministry of Health, Uganda; 2019.
  14. 14. Kizito S, Nabayinda J, Neilands TB, Kiyingi J, Namuwonge F, Damulira C, et al. A Structural Equation Model of the Impact of a Family-Based Economic Intervention on Antiretroviral Therapy Adherence Among Adolescents Living With HIV in Uganda. Journal of Adolescent Health. 2023;72(5):S41–S50. pmid:37062583
  15. 15. Hudelson C, Cluver L. Factors associated with adherence to antiretroviral therapy among adolescents living with HIV/AIDS in low-and middle-income countries: a systematic review. AIDS care. 2015;27(7):805–16. pmid:25702789
  16. 16. Kim MH, Mazenga AC, Yu X, Ahmed S, Paul ME, Kazembe PN, et al. High self‐reported non‐adherence to antiretroviral therapy amongst adolescents living with HIV in Malawi: barriers and associated factors. Journal of the International AIDS Society. 2017;20(1):21437. pmid:28406275
  17. 17. Nabukeera-Barungi N, Elyanu P, Asire B, Katureebe C, Lukabwe I, Namusoke E, et al. Adherence to antiretroviral therapy and retention in care for adolescents living with HIV from 10 districts in Uganda. BMC infectious diseases. 2015;15(1):1–10. pmid:26573923
  18. 18. Vreeman RC, McCoy BM, Lee S. Mental health challenges among adolescents living with HIV. Journal of the International AIDS Society. 2017;20:21497. pmid:28530045
  19. 19. Ashaba S, Cooper-Vince CE, Vořechovská D, Rukundo GZ, Maling S, Akena D, et al. Community beliefs, HIV stigma, and depression among adolescents living with HIV in rural Uganda. African Journal of AIDS Research. 2019;18(3):169–80. pmid:31339461
  20. 20. Heestermans T, Browne JL, Aitken SC, Vervoort SC, Klipstein-Grobusch K. Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review. BMJ global health. 2016;1(4):e000125. pmid:28588979
  21. 21. Langebeek N, Gisolf EH, Reiss P, Vervoort SC, Hafsteinsdóttir TB, Richter C, et al. Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis. BMC medicine. 2014;12(1):1–14. pmid:25145556
  22. 22. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychological review. 1977;84(2):191. pmid:847061
  23. 23. Náfrádi L, Nakamoto K, Schulz PJ. Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence. PloS one. 2017;12(10):e0186458. pmid:29040335
  24. 24. Zhang L, Li X, Lin Z, Jacques-Tiura AJ, Xu J, Zhou Y, et al. Side effects, adherence self-efficacy, and adherence to antiretroviral treatment: a mediation analysis in a Chinese sample. AIDS care. 2016;28(7):919–26. pmid:27010870
  25. 25. Johnson MO, Neilands TB, Dilworth SE, Morin SF, Remien RH, Chesney MA. The role of self-efficacy in HIV treatment adherence: validation of the HIV Treatment Adherence Self-Efficacy Scale (HIV-ASES). Journal of behavioral medicine. 2007;30(5):359–70. pmid:17588200
  26. 26. Turan B, Fazeli PL, Raper JL, Mugavero MJ, Johnson MO. Social support and moment-to-moment changes in treatment self-efficacy in men living with HIV: Psychosocial moderators and clinical outcomes. Health Psychology. 2016;35(10):1126. pmid:27089459
  27. 27. Colbert AM, Sereika SM, Erlen JA. Functional health literacy, medication‐taking self‐efficacy and adherence to antiretroviral therapy. Journal of advanced nursing. 2013;69(2):295–304. pmid:22489684
  28. 28. Godin G, Côté J, Naccache H, Lambert L-D, Trottier S. Prediction of adherence to antiretroviral therapy: a one-year longitudinal study. AIDS care. 2005;17(4):493–504. pmid:16036235
  29. 29. Gitahi N, Wahome S, Bukusi EA, Memiah P. The role of self-efficacy in HIV treatment adherence and its interaction with psychosocial factors among HIV positive adolescents in transition to adult care in Kenya. Vulnerable children and youth studies. 2022;17(4):308–19. pmid:36439942
  30. 30. Fisher JD, Fisher WA, Amico KR, Harman JJ. An information-motivation-behavioral skills model of adherence to antiretroviral therapy. Health psychology. 2006;25(4):462. pmid:16846321
  31. 31. Nokes K, Johnson MO, Webel A, Rose CD, Phillips JC, Sullivan K, et al. Focus on increasing treatment self‐efficacy to improve human immunodeficiency virus treatment adherence. Journal of Nursing Scholarship. 2012;44(4):403–10. pmid:23121723
  32. 32. Yigit I, Bayramoglu Y, Weiser SD, Johnson MO, Mugavero MJ, Turan JM, et al. Changes in internalized stigma and HIV health outcomes in individuals new to HIV care: The mediating roles of depression and treatment self-efficacy. AIDS patient care and STDs. 2020;34(11):491–7. pmid:33147084
  33. 33. Ashaba S, Zanoni BC, Baguma C, Tushemereirwe P, Nuwagaba G, Nansera D, et al. Perspectives About Transition Readiness Among Adolescents and Young People Living With Perinatally Acquired HIV in Rural, Southwestern Uganda: A Qualitative Study. Journal of the Association of Nurses in AIDS Care. 2022;33(6):613–23. pmid:35604846
  34. 34. Ashaba S, Zanoni BC, Baguma C, Tushemereirwe P, Nuwagaba G, Kirabira J, et al. Challenges and Fears of Adolescents and Young Adults Living with HIV Facing Transition to Adult HIV Care. AIDS and behavior. 2023;27(4):1189–98. pmid:36129557
  35. 35. Uganda Bureau of Statistics. The population of the regions of the Republic of Uganda and all cities and towns of more than 15,000 inhabitants. Kampala, Uganda: Uganda Ministry of Finance and Economic Planning, 2014.
  36. 36. Mushavi RC, Burns BF, Kakuhikire B, Owembabazi M, Vořechovská D, McDonough AQ, et al. “When you have no water, it means you have no peace”: a mixed-methods, whole-population study of water insecurity and depression in rural Uganda. Social Science & Medicine. 2020;245:112561. pmid:31790879
  37. 37. Tsai AC, Bangsberg DR, Frongillo EA, Hunt PW, Muzoora C, Martin JN, et al. Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Social Science & Medicine. 2012;74(12). pmid:22513248
  38. 38. Ministry of Health. Facts on HIV and AIDS in Uganda based on data ending December 2020. Kampala: Ministry of Health, 2021.
  39. 39. Nakimuli-Mpungu E, Musisi S, Katabira E, Nachega J, Bass J. Prevalence and factors associated with depressive disorders in an HIV+ rural patient population in southern Uganda. Journal of affective disorders. 2011;135(1–3):160–7. pmid:21851986
  40. 40. Nakimuli-Mpungu E, Mojtabai R, Alexandre PK, Musisi S, Katabira E, Nachega JB, et al. Lifetime depressive disorders and adherence to anti-retroviral therapy in HIV-infected Ugandan adults: a case-control study. Journal of affective disorders. 2013;145(2):221–6. pmid:23017542
  41. 41. Ashaba S, Cooper-Vince C, Vořechovská D, Maling S, Rukundo GZ, Akena D, et al. Development and validation of a 20-item screening scale to detect major depressive disorder among adolescents with HIV in rural Uganda: a mixed-methods study. SSM-population health. 2019;7:100332. pmid:30560198
  42. 42. Pantelic M, Boyes M, Cluver L, Thabeng M. ‘They say HIV is a punishment from god or from ancestors’: cross-cultural adaptation and psychometric assessment of an HIV stigma scale for South African adolescents living with HIV (ALHIV-SS). Child Indicators Research. 2018;11(1):207–23. pmid:29497463
  43. 43. Williams T, Sherman E., Mah J. K., Blackman M., Latter J., Mohammed I., et al. Measurement of medical self-management and transition readiness among Canadian adolescents with special health care needs. International Journal of Child and Adolescent Health. 2011;3(Number 4- Special Issue,):527–35.
  44. 44. Goldstein AP, McGinnis E. Skillstreaming the adolescent: New strategies and perspectives for teaching prosocial skills: Research Press; 1997.
  45. 45. Uganda National Council for Science and Technology. National guidelines for research involving humans as research participants. 2007.
  46. 46. Crowley T, van der Merwe A, Kidd M, Skinner D. Adolescent human immunodeficiency virus self-management: Associations with treatment adherence, viral suppression, sexual risk behaviours and health-related quality of life. Southern African Journal of HIV Medicine. 2020;21(1). pmid:32391177
  47. 47. Areri H, Marshall A, Harvey G. Factors influencing self-management of adults living with HIV on antiretroviral therapy in Northwest Ethiopia: a cross-sectional study. BMC Infectious Diseases. 2020;20:1–11.
  48. 48. Nagenda MC, Crowley T. Contextual factors influencing self-management of adolescents and youth living with HIV: A cross-sectional survey in Lesotho. International Journal of Environmental Research and Public Health. 2022;20(1):238. pmid:36612559
  49. 49. Areri HA, Marshall A, Harvey G. Self-efficacy for self-management and its influencing factors among adults living with HIV on antiretroviral therapy in northwest Ethiopia. AIDS care. 2022;34(12):1595–601. pmid:34851784
  50. 50. Crowley T, Rohwer A. Self-management interventions for adolescents living with HIV: a systematic review. BMC Infectious Diseases. 2021;21(1):1–29.
  51. 51. Mutumba M, Musiime V, Mugerwa H, Nakyambadde H, Gautam A, Matama C, et al. Perceptions of HIV self-management roles and challenges in adolescents, caregivers, and health care providers. Journal of the Association of Nurses in AIDS Care. 2019;30(4):415–27. pmid:31241506
  52. 52. Yoo H, Kim CJ, Jang Y, You MA. Self‐efficacy associated with self‐management behaviours and health status of South Koreans with chronic diseases. International journal of nursing practice. 2011;17(6):599–606. pmid:22103826
  53. 53. Chan SW-C. Chronic disease management, self-efficacy and quality of life. Journal of Nursing Research. 2021;29(1):e129. pmid:33427791
  54. 54. Shim M-S, Kim S, Choi M, Choi JY, Park CG, Kim GS. Developing an app-based self-management program for people living with HIV: a randomized controlled pilot study during the COVID-19 pandemic. 2022.
  55. 55. Kennedy A, Rogers A, Crossley M. Participation, roles, and the dynamics of change in a group-delivered self-management course for people living with HIV. Qualitative Health Research. 2007;17(6):744–58. pmid:17582018
  56. 56. Wallston KA, Osborn CY, Wagner LJ, Hilker KA. The perceived medical condition self-management scale applied to persons with HIV/AIDS. Journal of health psychology. 2011;16(1):109–15. pmid:20656769
  57. 57. Lee WK, Milloy MJS, Nosova E, Walsh J, Kerr T. Predictors of antiretroviral adherence self-efficacy among people living with HIV/AIDS in a Canadian setting. Journal of acquired immune deficiency syndromes (1999). 2019;80(1):103. pmid:30300214
  58. 58. Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, et al. Improving antiretroviral therapy adherence in resource‐limited settings at scale: a discussion of interventions and recommendations. Journal of the International AIDS Society. 2017;20(1):21371. pmid:28630651
  59. 59. Okonji EF, Mukumbang FC, Orth Z, Vickerman-Delport SA, Van Wyk B. Psychosocial support interventions for improved adherence and retention in ART care for young people living with HIV (10–24 years): a scoping review. BMC public health. 2020;20(1):1–11.
  60. 60. Antelman G, Jahanpour O, Machalo T, Audi C, van de Ven R, Rutaihwa M, et al. Adolescent support club attendance and self-efficacy associated with HIV treatment outcomes in Tanzania. PLOS Global Public Health. 2022;2(10):e0000065. pmid:36962483
  61. 61. Reif S, Proeschold-Bell RJ, Yao J, LeGrand S, Uehara A, Asiimwe E, et al. Three types of self-efficacy associated with medication adherence in patients with co-occurring HIV and substance use disorders, but only when mood disorders are present. Journal of multidisciplinary healthcare. 2013:229–37. pmid:23836979
  62. 62. Katz IT, Ryu AE, Onuegbu AG, Psaros C, Weiser SD, Bangsberg DR, et al. Impact of HIV‐related stigma on treatment adherence: systematic review and meta‐synthesis. Journal of the International AIDS Society. 2013;16:18640. pmid:24242258
  63. 63. Li X, Huang L, Wang H, Fennie KP, He G, Williams AB. Stigma mediates the relationship between self-efficacy, medication adherence, and quality of life among people living with HIV/AIDS in China. AIDS Patient Care and STDs. 2011;25(11):665–71. pmid:22023316
  64. 64. Kirabira J, Ashaba S, Favina A, Maling S, Nansera D, Zanoni BC. Intrapersonal predictors of internalized stigma among school going adolescents living with HIV in southwestern Uganda. Psychology, Health & Medicine. 2023:1–15. pmid:37005735