https://orcid.org/0009-0000-1665-0145
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Abstract
Background
Following a strict regimen of highly active antiretroviral therapy (HAART) is the fundamental factor in achieving successful treatment outcomes for HIV/AIDS. Poor adherence to HAART not only amplifies the risk of HIV transmission but also leads to deteriorating health, treatment failures, and a rise in drug-resistant HIV strains, ultimately contributing to increased morbidity and mortality rates. Therefore, the objective of the study is to explore and describe the perceptions of healthcare providers about HAART adherence of women in Southern Ethiopia who are HIV positive.
Methods
Focus group discussions (FGDs) were used among 27 healthcare providers (HCPs) (13 medical doctors and 14 nurses) to determine the extent of HAART adherence among HIV-positive women in Southern Ethiopia. The interviews were conducted in the local Amharic language and were audio recorded with permission from the participants. The FGDs were transcribed verbatim, coded for themes, categories and subcategories, and analyzed using thematic data analysis.
Results
The findings of the study reflected two themes: barriers to and facilitators of HAART medication adherence among HIV-positive women. These included patient-related factors, treatment-related factors, psychosocial-related factors, family- and community-related factors, and healthcare service-related factors. The following were identified as barriers to HAART adherence: Stigma and discrimination, gender roles, lack of money for food and transport, depression, busy schedule, forgetting of doses, religion, drug side-effects, pills burden, and size, dosage frequency, long waiting time, and unavailability of services at weekends. However, perceived benefits of HAART, family responsibility, reminders, family support, dosage formulation, experiencing improved health on HAART, relationship with healthcare providers, adherence counselling and education, and adherence supporting peer groups were identified as facilitators of HAART adherence.
Citation: Demissie AA, Rensburg EJv (2025) Healthcare providers’ perspectives of barriers and facilitators to highly active antiretroviral therapy adherence among HIV-positive women in Southern Ethiopia: A qualitative study. PLoS One 20(9): e0312980. https://doi.org/10.1371/journal.pone.0312980
Editor: Amos Buh, University of Ottawa, CANADA
Received: November 1, 2024; Accepted: August 18, 2025; Published: September 19, 2025
Copyright: © 2025 Demissie, Rensburg. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.
Introduction
Globally, the number of individuals with HIV/AIDS receiving antiretroviral therapy (HAART) has increased significantly, rising from 7.7 million in 2010 to 30.7 million in 2023. Despite significant advancements in enhancing access to HAART, merely 68% of individuals undergoing therapy have attained viral suppression [1]. The global rate of viral suppression among HIV patients is 88.4%, indicating that insufficient adherence to HAART poses a significant barrier to HIV/AIDS treatment [2]. Ethiopia is significantly impacted by HIV epidemics, with a notable prevalence of the virus among women. Currently, women account for a majority of new infections and AIDS-related deaths [3]. A total of 610,000 individuals were diagnosed with HIV in Ethiopia, including 27,000 children under 15 years and 513,990 adults and children are receiving HAART in 2023 [4]. Adherence to HAART is essential for achieving optimal virological outcomes and reducing the likelihood of drug resistance, morbidity, and mortality [5]. A systematic review and meta-analysis conducted in Ethiopia found the pooled prevalence of poor HAART adherence to be 20.68%, which is significantly high [6]. A related study carried out in Ethiopia found that merely 73.1% of patients adhering to their treatment were adherent to HAART [7]. Poor HAART adherence arises from a range of factors, including patient and familial circumstances, economic situations, medication-related obstacles, and the status of healthcare providers and systems. Studies reveal that women face significant challenges in adhering to HAART, particularly related to education, age, poverty, stigma, and socio-familial support [8]. In addition to their other roles, women manage household responsibilities, which can create additional challenges in balancing their family and social lives [9]. There is a lack of studies conducted on the adherence of HIV-positive women to HAART in Ethiopia specifically. To address this gap, organizations, and care providers need to come up with a combination of practical interventions to maximize the adherence of women to HAART based on global and Ethiopian contexts. In light of related research done in Ethiopia, this study aims to address the adherence to HAART among HIV-positive women from a unique perspective by focusing on healthcare providers. While previous studies have explored the barriers and facilitators of adherence from the patients’ viewpoints, this investigation seeks to complement existing literature by examining how healthcare providers perceive and influence adherence behaviors. This approach not only enriches the understanding of adherence dynamics but also provides valuable insights that can inform interventions aimed at improving treatment outcomes for HIV-positive women in South Ethiopia.
As a result, this study attempts to bring about a more comprehensive understanding of the adherence of HIV-positive women to antiretroviral treatment in Southern Ethiopia with the goal of overcoming the gaps in adherence to HAART medications.
Materials and methods
Design and setting
The study used an exploratory qualitative research design to gain new insights and understandings based on the themes, categories, and subcategories that emerged from the data.
The study applied the consolidated criteria for reporting qualitative research (COREQ), which is a set of criteria for reporting qualitative research (see S1 Checklist) [10].
Study setting and sampling procedures.
The researchers used a purposive and convenient sampling procedure to select the Southern Ethiopian region and the three urban hospitals that were studied. This sampling technique was chosen to select the Southern region from the nine regions of Ethiopia and the study hospitals from 21 urban public hospitals found in Southern Ethiopia based on convenience (most accessible to and easily reached by the researchers) and a load of HIV-positive individuals. The purpose of the selection of these three urban public hospitals was due to the high volume (load) of HIV-positive individuals who were taking HAART compared to those in other health facilities in Southern Ethiopia.
Healthcare providers (HCPs) working at the HAART clinics of the study hospitals were purposively and conveniently sampled based on the eligibility criteria. Three FGDs with twenty-seven participants (13 medical doctors and 14 nurses) were purposively and conveniently sampled for the FGDs. Participant distribution across the FGDs was ten, nine, and eight in each respective session.
Eligibility criteria.
Participants were eligible if they were healthcare providers (HCPs) in Southern Ethiopia, working as either a nurse or doctor in the HAART clinic of one of the sampled study hospitals for at least one year, and were willing and available to participate in a focus group.
Focus group discussion guide development and data collection procedure.
A semi-structured FGD guide was developed based on the literature reviewed. The guide was designed to explore and describe the perceptions of healthcare providers regarding HAART adherence among HIV-positive women in Southern Ethiopia (see S1 Data). Focus group discussions were chosen as the primary data collection method for this study due to the sensitivity of the research topic, as this approach fosters a supportive environment that enhances confidentiality and encourages open dialogue among participants. To enhance the credibility of the discussion guides, one FGD was conducted as a pre-test before the actual data collection commenced.
The intended data were collected from healthcare providers (HCPs) working at HAART clinics in the study hospitals located in Southern Ethiopia. The FGDs were guided by the discussion guide, allowing for probing questions to be posed when additional insights were necessary [11]. The focus group discussions were held until data saturation was achieved, that is, where no more themes, concepts and insights would be acquired through subsequent discussions [12]. Field notes were taken to capture behaviors, impressions, nonverbal actions, and contextual elements that may not have been fully recorded through audio during the discussions.
This methodology facilitated rich interactions among participants, enabling them to share their insights and experiences collaboratively. The FGDs provided a comprehensive understanding of the challenges and perspectives related to HAART adherence from the viewpoint of healthcare providers, contributing valuable qualitative data to the research.
Data collection and analysis
We conducted three FGDs with 27 HCPs. The FGDs were audio-recorded (with the participant’s permission). The discussions were conducted in Amharic, a local language that most people in Ethiopia speak. The FGDS lasted approximately 90–120 minutes. The researchers used field notes in the in-depth interviews to substantiate the findings from this qualitative data-gathering technique [13]. The data were collected in June 2023. The researchers translated the audio-recorded data from Amharic into English for analysis. The data from FGDs and field notes were analyzed using the thematic analysis method, which involves searching across a dataset (discussions, field notes, or a range of data) to find repeated patterns of meaning. The researchers used the Nvivo 12 qualitative data analysis computer program for data analysis [14]. The researchers used thematic analysis for the current study since it is recommended as a convenient method for employing a participatory research paradigm with participants as collaborators [15]. Finally, some verbatim quotes from HCPs were used to illustrate the subcategories.
Reflexivity
As part of the important practice of reflexivity, which is essential in qualitative research, the authors acknowledge that as one of the authors is a healthcare provider, he may have had biases regarding the experiences of the individual participants.
Ethical considerations, rigor, and trustworthiness
This study obtained scientific approval from the scientific committee (Department of Health Studies and ethical clearance (Ref: HSHDC/463/2015)) of the College Research Ethics Committee of the University of South Africa (UNISA). Similarly, permission to carry out the study was obtained from the stakeholders, including the Southern Regional Health Bureau and the three public hospitals where the study was conducted. Confidentiality was ensured at all stages of the process. Informed consent was obtained from the participants prior to the interviews. Participants provided written informed consent before enrollment in the study. Participants were assured that refusal to participate or withdrawal from the study would not affect their access to healthcare services at the clinic. The researchers considered the essential values of ethical research, which incorporate respect for human autonomy and dignity, justice, beneficence, and nonmaleficence [16]. To ensure the reliability and validity of the results, different techniques were applied. These included developing a rapport with participants, creating a coding system, implementing peer review for themes and subthemes, triangulating data sources (including FGDs transcripts and field notes), and providing a thorough contextualized data description [17–19].
Results
Socio-demographic characteristics of study participants
A total of twenty-seven healthcare providers, including medical doctors and nurses, who worked in the HAART clinics of the study urban hospitals have participated in the FGDs. Of the participant healthcare providers, 13 of them were medical doctors and the remaining 14 were nurses. Most healthcare providers participating in the focus group discussions were female (14/27, 51.9%), and the remaining (13/27, 48.1%) were male. Table 1 provides the demographic and background characteristics of the healthcare providers involved in the focus group discussions.
Themes, categories, and subcategories
The perception of HCPs about HIV-positive women’s HAART adherence was described in two themes. These themes included barriers to HAART medication adherence and facilitators of HAART medication adherence. Barriers to HAART medication adherence among HIV-positive women were grouped into three categories and twelve subcategories (Table 2). Facilitators of HAART medication adherence were grouped into three categories and nine subcategories (Table 3).
Theme 1: Barriers to HAART adherence.
Category 1: Patient-related factors. Stigma and discrimination: Healthcare providers frequently highlight a common issue, namely, fear of stigma and discrimination faced by HIV-positive women taking HAART in accessing HIV treatment. The fear of stigma and discrimination may lead some HIV-positive women to seek treatment and medical follow-up in other hospitals in other towns, which can cause problems in gaining access to HAART and attending clinic-scheduled appointments. These problems potentially create a substantial influence on HIV-positive women’s ability to adhere to treatment regimens, as well as their overall health and well-being. Health service providers in HAART clinics have often faced this situation.
Gender role: Healthcare providers reported that gender-related issues were one of the difficulties affecting HIV-positive women’s ability to take their HAART medication regimen in the right way as prescribed by healthcare providers. They specifically draw attention to how social norms and expectations would restrict the freedom and mobility of HIV-positive women, making it challenging for them to access healthcare services and follow their HIV treatment without the knowledge of their male partners. This may make it difficult and complex for them to take their medications as prescribed, and it may affect how well they adhere to their HAART medications. Thus, gender-related cultural and societal norms could hamper HIV-positive women, further complicating their ability to manage their condition primarily related to their HIV medication adherence.
Lack of money for food and transport: Participants (healthcare providers) indicated that the lack of economic sources can affect HIV-positive women’s potential to fill their nutritional needs. Proper nutrition is critical for preserving a robust immune system and supporting the effectiveness of HAART. Without access to nutritious food, HIV-positive women may experience malnutrition, a weakened immune system, and high susceptibility to infections. Because of such reasons, HIV-positive women cannot take their medication correctly according to the prescription.
Depression: During the FGDs, healthcare providers reported that depression was one of the barriers affecting HIV-positive women’s ability to take their HAART medication regimen as prescribed by healthcare providers.
Depression negatively influences an HIV-positive individual’s quality of life, social circumstances, HAART adherence, and therapeutic outcomes. It can also increase the likelihood of experiencing other medical and psychiatric issues, unemployment, and disability. Adherence to HAART is considered a dynamic phenomenon that may change over time. It may depend on the mood of HIV-positive individuals and the factors influencing their mood and well-being.
Busy schedule: The healthcare workers who participated in this study indicated that HIV-positive individuals sometimes miss taking their HAART medication due to a busy schedule as they may be away from home or attending social gatherings like Ikub and Idir (gatherings of traditional savings associations), funeral ceremonies, or other family and community responsibilities. These responsibilities can make finding enough time for HAART medication intake challenging, leading to missed doses.
Forgetting doses: Forgetting the HAART doses was among the issues reported by most healthcare providers as a challenge for optimal HAART adherence. HIV-positive women may have a busy lifestyle that includes travelling somewhere away from their homes, engaging in different social affairs (weddings, funerals, social gatherings, and others), and for personal reasons. Thus, these situations may create mental stress and insufficient time to remember or take their doses correctly, resulting in missed HAART doses.
Religion: In the FGDs with the healthcare providers, participants perceived religion to be negatively impacting HIV-positive women’s adherence to HAART. In the view of participants, some patients’ religious beliefs override medical advice, sometimes causing them to miss or discontinue HAART medication. Most healthcare providers revealed that some patients were advised to stop taking HAART after joining some religion because the pastor claimed they would pray for patients to be cured of the disease. Some HIV-positive women stop their medication entirely due to the medically wrong information from religious groups.
Category 2: Treatment-related factors. Drug side effects: In the FGDs, the HCPs noted that many HIV-positive women tell them that HAART is an essential component of HIV treatment due to its effect on improving the immune system, suppressing the virus, and reducing HIV transmission. However, despite recognising its benefit, some HIV-positive women have fears regarding the possible side effects associated with the HAART medication they have been taking. Due to this concern or issue, some HIV-positive women decide to take their medication but skip the pills for some days.
Pill burden and size: From the commonly cited factors that interfere with patients’ adherence, the burden and size of pills are some of the factors that affect adherence in the lifelong treatment regimen of HIV/AIDS. According to healthcare providers, though the HIV treatment medication burden is not such a major problem in recent times, some HIV-positive women still complain about the pill burden regarding their medication. The complaint is not only associated with ARVs but also with some other additional drugs taken in parallel.
Dosage frequency: The healthcare participants indicated that HIV-positive individuals’ adherence to HAART can be affected by multiple frequency dosing in different ways. Challenges to integrating it into a daily routine, forgetting to take daily medication multiple times a day, and treatment fatigue are some of the potential problems that can occur by increased dosing frequency. Individual preferences, lifestyles, and support networks can all impact adherence. While some people might find it burdensome, others might prefer the structure and routine of taking medication several times per day.
Category 3: Healthcare services-related factors. Long waiting time: Participant healthcare providers pointed out that though they usually try to give the required service on time, some patients do not like to wait at the HAART clinic to refill their medication or attend other medical check-ups. They sometimes leave the hospital without refilling their medication because they are tired of waiting. Long waiting time is, therefore, identified as a barrier to optimal adherence to HAART.
Unavailability of services at weekends: Healthcare professional participants indicated that the unavailability of HAART clinic services at weekends may affect HIV-positive individuals’ treatment negatively. This may cause discomfort in these HIV-positive individuals and cause inconsistent clinic attendance and missing HAART regimen doses. Adherence to HAART includes regularly engaging in clinical appointments and taking proper medication as prescribed by healthcare providers. Sometimes, HIV-positive individuals are unable to refill their HAART medications on weekends due to the closures, leading to missed doses.
Theme 2: Facilitators of HAART medication adherence.
Category 1: Patient-related factors. Perceived Benefits of HAART: Healthcare providers explained that most HIV-positive women taking HAART and following their treatment at the HAART clinics have a better understanding of the benefits of their medication. Therefore, though these women have experienced some side effects from their medication, they continue taking the pills because of the benefits they get from HAART.
Family responsibility: In the FGDs, healthcare providers highlighted that there were HIV-positive single mothers whose partners had died. These mothers have been taking their HAART medication regularly as prescribed by healthcare providers to carry out their familial responsibilities, such as being able to do more in their children’s upbringing and well-being.
Reminders: Some healthcare providers in the FGDs highlighted that some HIV-positive women used reminders like a watch or cell phone alarm to remind them of the right time to take their HAART medication. Among the different tools or strategies being used by HIV-positive people are clocks and cell phone alarms, watches, Radios and TVs. A cell phone alarm is a useful medication reminder that many HIV-positive individuals apply to remind them to take their prescribed HAART medication regimen.
Family support: Healthcare providers in this study described how lack of family support is a common problem among HIV-positive individuals. Those who do have support from their family are more likely to adhere to their clinic appointments and HAART medication regimens. The support provided by family members can help these HIV-positive individuals have a more comfortable environment to take their prescribed HAART medication.
Category 2: Treatment-related factors. Dosage formulation: Healthcare providers noted that many HIV-positive women were taking simple HAART regimens, namely a combined single tablet, which makes their dose easy to take at the right time. The formulation of the HAART medication regimen and adherence to HAART are interrelated, and their association is complicated and multifaceted. The number of tablets per dose, the frequency of administration, and the complexity of the medication regimen, including side effects, are some of the factors that possibly affect HIV-positive individuals’ adherence to their prescribed medication.
Experiencing improved health on HAART: In the FGDs, healthcare providers revealed that many HIV-positive women have already experienced various HIV-related illnesses, which can cause various problems and suffering. These patients started to feel better and saw improvements in their health once they started to take HAART medication. They were encouraged to take their HAART medication properly as they understood the improvement to have resulted from taking HAART medication.
Category 3: Healthcare services-related factors. Relationship with healthcare providers: In the FGD, some healthcare providers explained that they have a strong relationship of trust and good communication with HIV-positive women during their treatment at the HAART clinics. Due to that, these women feel comfortable coming to the HAART clinic during their appointments, and thus, this leads to better adherence to their clinic attendance and HAART medication regimen.
Adherence counselling and education: Healthcare providers who participated in the FGD in this research discussed the importance of adherence counselling for HIV-positive individuals who are starting HAART medication or who have been on medication for some time. They emphasized that adherence counselling provided by healthcare providers can help HIV-positive individuals understand the importance of HAART medication and the consequences of poor medication adherence. It also helps HIV-positive individuals address any concerns they have that need medical attention.
Adherence supporting peer groups: Healthcare provider participants indicated that the presence of support groups either at the facility or community level is helpful for HIV-positive individuals in taking HAART medication properly. It also creates a comfortable environment for sharing important experiences regarding proper medication taking and social support. The support provided by support groups encourages and boosts the HIV-positive individuals’ self-esteem, thereby increasing adherence to HAART medication.
Discussion
During the FGDs, the participants shared their valuable views about different barriers they perceived that challenged HIV-positive women’s adherence to their prescribed HAART medication. Based on their experiences and interactions with these HIV-positive women, participants mentioned several key challenges or factors that affect the appropriate taking of HAART regimens. These include stigma and discrimination, gender roles, lack of money for food and transport, depression, busy schedule, forgetting doses, religion, drug side effects, pill burden and size, dosage frequency, long waiting time, and unavailability of services at weekends.
Fear of stigma and discrimination can affect HIV-positive women’s ability to disclose their HIV status to their partners and others. Consequently, this may affect the overall adherence to HAART among HIV-positive women. Most of the healthcare providers from the three study urban public hospitals who participated in the FGDs said stigma and discrimination were still problems for HIV-positive women taking HAART. They mentioned that many HIV-positive women who are receiving their HAART from these hospitals were not free to take their medication in front of others due to the fear of stigma and discrimination if others knew their HIV status. Stigma and discrimination caused HIV-positive individuals trouble in taking, obtaining, and keeping their HIV medications. A study conducted in 2020 in Zambia and South Africa indicated that among the HIV-positive individuals who participated in the study, 25.7% experienced community stigma, 21.5% experienced internalized stigma, and 5.7% a health setting stigma [20]. The study also showed that the probability of stigmatized HIV-positive individuals being non-adherent to their HIV treatment regimen was 1.13 times higher compared to those without stigma and discrimination [21].
The FGD participants also reported that gender-related issues were one of the difficulties affecting HIV-positive women’s ability to take their HAART medication regimen in the right way as prescribed by healthcare providers. They specifically draw attention to how social norms and expectations would restrict the freedom and mobility of HIV-positive women, making it challenging for them to access healthcare services and follow their HIV treatment without the knowledge of their male partners. A study revealed that HAART adherence level is lower in women than in males [22]. These differences in HAART adherence between women and men are related to the discriminatory gender-based duties, responsibilities, and cultural norms that women have in the community and their families. Lack of money for food and transportation was frequently raised as a major concern of HIV-positive women. As reflected by healthcare providers, some of the HIV-positive women were unemployed due to their HIV status, and they often failed to secure money for food and transport to visit the HAART clinic. A study indicated that HIV-positive individuals sometimes forget to take their pills while working for food for a long time at different workplaces [23].
Depression appeared to be one of the major barriers to HAART medication raised by the participants in the FGDs. Research carried out among PLHIV at Gimbi General Hospital, West Ethiopia, demonstrated that depression among individuals diagnosed with HIV does not affect only their health status but also has a negative influence on HAART [24]. Another institutional-based cross-sectional study conducted among individuals diagnosed with HIV and taking HAART in Eastern Ethiopia revealed that depression was found to be a significant contributing factor to poor adherence to HAART [25].
The FGD participants showed that being busy with different activities was found to be one of the many challenges which affect the proper taking of medication among HIV-positive women. This finding was supported by a study conducted in Nigeria [26].Moreover, a systematic review conducted in 2019 showed that being busy with different activities is the main obstacle towards the effect of HIV-positive women’s adherence to HAART [27]. Forgetting the HAART doses was among the issues reported by most healthcare providers as a challenge for optimal HAART adherence. A study conducted in Iran confirmed that from a total of 122 HIV-positive individuals who participated in the study, 26.7% missed their daily HAART doses due to forgetfulness [28]. In a study conducted in Northern Ethiopia, forgetting and being away from home were the most common justifications identified for poor adherence among HIV-positive individuals receiving HAART [29]. Most healthcare providers revealed that some patients were advised to stop taking HAART after joining some religion because the pastor claimed they would pray for patients to be cured of the disease. Some HIV-positive women stop their medication entirely due to the medically wrong information from religious groups. A study conducted in Ethiopia found that seeking spiritual treatment or holy water was a contributing reason for non-adherence to HAART among HIV-positive individuals [30]. The current study also explored the side effects of HAART medication as common challenges for HIV-positive women taking HAART. A cross-sectional study conducted in North-Eastern Ethiopia shared the view that ARV side effects create a barrier for HIV-positive women to take their HAART medication regimen as prescribed by healthcare providers [31]. In another similar study carried out in South-Eastern Nigeria, side effects were found to be one of the major barriers identified to women’s HAART medication adherence. Those women who had developed side effects while on treatment were poorly adhering to their HAART medication [32]. Participants also reported that though the HIV treatment medication burden is not such a major problem in recent times, some HIV-positive women still complain about the pill burden regarding their medication. The complaint is not only associated with ARVs but also with some other additional drugs taken in parallel. If individuals diagnosed with HIV have some inconvenience with their HAART medication regimen, the likelihood of taking their medication at the right time and frequency will be reduced, which results in poor adherence to HAART medication [33]. Moreover, a study conducted in South Korea pointed out that HIV-positive individuals who are taking a low pill burden, namely, a single tablet ARV, sustain a higher level of HAART medication adherence and viral load suppression [34]. Moreover, dosage frequency was explored as a barrier to HAART adherence in this study. The healthcare participants indicated that HIV-positive individuals’ adherence to HAART can be affected by multiple frequency dosing in different ways. Challenges to integrating it into a daily routine, forgetting to take daily medication multiple times a day, and treatment fatigue are some of the potential problems that can occur by increased dosing frequency. Some kinds of HAART medication can have adverse effects, and this situation may be more pronounced during the increased frequency of medication taking time [35]. A complex medication regimen that contains multiple dosing frequencies in a day has an impact on adherence to HAART among HIV-positive individuals [36]. On the other hand, long waiting times and unavailability of services at weekends are the identified barriers by the healthcare participants in the FGDs. Clinic long waiting time is one of the conditions that potentially lead to missing or delayed clinic appointments of HIV-positive people, adversely affecting adherence to HAART. Long waiting times are challenging to people with other commitments like different family and social responsibilities, as they may be unable to allocate sufficient time to wait at the HAART clinic. HIV-positive individuals who are more satisfied with the care they receive are more likely to take their medications as prescribed, attend their scheduled appointments, have more trust in the healthcare staff, and possess better health outcomes [37]. A similar qualitative study done in Mpumalanga Province, South Africa, also reported that long waiting times of HIV-positive individuals taking HAART were a common reason for patients not achieving good adherence [38]. According to the participant healthcare providers, some HIV-positive women could not come to the clinic at the appointed time to collect their HAART medication as they were busy with their different responsibilities and commitments during working days (Monday through Friday). A qualitative study done in Ethiopia pointed out that some HIV-positive individuals who were involved in the study reported that they wanted the HAART service provision time to be on weekdays [39]. Participants described facilitators of HAART adherence as perceived benefits of HAART, family responsibility, reminders, family support, dosage formulation, experiencing improved health on HAART, relationship with healthcare providers, adherence counselling and education, and adherence supporting peer groups.
HIV-positive individuals may be motivated to take medication willingly if they observe an improvement in their health status as a result of taking the prescribed HAART medication [40]. The positive association of perceived benefits of HAART to HAART adherence has also been shown by another study [41]. On the other hand, a qualitative study conducted in Zimbabwe indicated that HAART helped HIV-positive women carry out their responsibilities as mothers in caring for their children and family members [42]. In this study, participants underlined how useful these medication reminders were for ensuring HIV-positive women’s regular and timely HAART medication intake. The importance of reminder devices in medication-taking practices has been revealed in different studies [43,44].Another important issue pointed out by participants as a facilitator of HAART adherence among HIV-Positive women was family support. Researchers have found a positive association between family support and adherence to HAART medication [45]. A study done among HIV-positive individuals revealed that participants with single tablet regimens (STR) had reported better adherence to HAART than those with multi tablet regimen (MTR) [46]. Studies indicated that HIV-positive individuals whose health condition is improved due to HAART become motivated to take their medication correctly and maintain adherence to HAART [47]. HIV-positive individuals who experience a good relationship with their healthcare providers may have a better chance of good clinic attendance and HAART medication adherence in the prescribed way [48]. In this study, it was reported that adherence counseling and education provided by the HAART clinic encouraged participants to follow their HAART medication regimen [49].
Limitations
The study was restricted to and conducted in only three urban hospitals in one region of Ethiopia. Therefore, the findings cannot be generalized to other regions or the whole country. Another limitation of the study was the difficulty in avoiding the possibility of social desirability bias. This was also the case during the face-to-face in-depth interviews, particularly among HIV-positive women who came to HAART clinics to collect their HAART medication, which might increase the chance of interviewees answering questions with more desirable responses instead of actual answers. Despite these limitations, we used face-to-face in-depth interviews with participants who provided a rich and personal understanding of their experiences, allowing for a deeper exploration of the factors influencing adherence to HAART medication.
Conclusions
Adherence to HAART medication is a major challenge among HIV-positive women in Southern Ethiopia. The perception of HCPs rgarding adherence among HIV-positive women need to be explored, and an understanding of the barriers and facilitators of adherence to HAART can be reached. The following were identified as barriers to HAART adherence: stigma and discrimination, gender role, lack of money for food and transport, depression, busy schedule, forgetting doses, religion, drug side-effects, pills burden and size, dosage frequency, long waiting time, and unavailability of services at weekends. However, perceived benefits of HAART, family responsibility, reminders, family support, dosage formulation, experiencing improved health on HAART, relationship with healthcare providers, adherence counselling and education, and adherence supporting peer groups. Therefore, understanding the factors that affect adherence can help in the development of tailored interventions to increase adherence and improve the health outcomes of HIV-positive women.
Supporting information
S1 Checklist. Consolidated criteria for reporting qualitative research (COREQ).
A 32-item checklist for interviews and focus groups. International journal for quality in health care.
https://doi.org/10.1371/journal.pone.0312980.s001
(PDF)
S1 Data. Focus group discussion guide and transcription.
https://doi.org/10.1371/journal.pone.0312980.s002
(PDF)
Acknowledgments
We would like to express our gratitude to all the three sampled public hospitals’ healthcare providers, all the participants and their families, and all of our colleagues who contributed to this study.
References
- 1.
UNAIDS. Documents [Internet]. UNAIDS. 2024. Available from: https://www.unaids.org/en/resources/documents/2024/in-danger-global-aids-pdf
- 2. Kitaw TA, Abate BB, Tilahun BD, Haile RN. Geospatial pattern of HIV seropositivity and its predictors among women in Ethiopia. A spatial and multiscale geographically weighted regression analysis. PLoS One. 2024;19(7):e0306645. pmid:38990932
- 3.
WHO. National consolidated guidelines for comprehensive HIV prevention, care and treatment | WHO | Regional Office for Africa [Internet]. WHO | Regional Office for Africa. 2024. Available from: https://www.afro.who.int/publications/national-consolidated-guidelines-comprehensive-hiv-prevention-care-and-treatment
- 4.
UNAIDS. Documents [Internet]. UNAIDS. 2023. Available from: https://www.unaids.org/en/regionscountries/countries/ethiopia
- 5. Bogale B, Asefa A, Destaw A, Midaksa G, Asaye Z, Alemu Gebremichael M, et al. Determinants of virological failure among patients on first line highly active antiretroviral therapy (HAART) in Southwest Ethiopia: a case-control study. Front Public Health. 2022;10:916454. pmid:36408009
- 6. Aytenew TM, Demis S, Birhane BM, Asferie WN, Simegn A, Nibret G, et al. Non-adherence to anti-retroviral therapy among adult people living with HIV in Ethiopia: systematic review and meta-analysis. AIDS Behav. 2024;28(2):609–24. pmid:38157133
- 7. Muse AI, Osman MO, Ibrahim AM, Wedajo GT, Abdi MM, Roble AK. Non-adherence to antiretroviral therapy and associated factors among adult HIV patients in Somali region public Hospitals, eastern Ethiopia. Int J Afr Nurs Sci. 2023;19:100645.
- 8. Audi C, Jahanpour O, Antelman G, Guay L, Rutaihwa M, van de Ven R, et al. Facilitators and barriers to antiretroviral therapy adherence among HIV-positive adolescents living in Tanzania. BMC Public Health. 2021;21(1):2274. pmid:34903209
- 9. Mussida C, Patimo R. Women’s family care responsibilities, employment and health: a tale of two countries. J Fam Econ Issues. 2021;42(3):489–507. pmid:33324030
- 10. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57. pmid:17872937
- 11. Nassaji H. Good qualitative research. UK: London, England: Sage Publications; 2020. pp. 427–31.
- 12. Ahmed SK. Sample size for saturation in qualitative research: debates, definitions, and strategies. J Med Surg Public Health. 2025;5:100171.
- 13. Busetto L, Wick W, Gumbinger C. How to use and assess qualitative research methods. Neurol Res Pract. 2020;2:14. pmid:33324920
- 14. Braun V, Clarke V. Conceptual and design thinking for thematic analysis. Qualit Psychol. 2022;9(1):3–26.
- 15. Ahmed SK, Mohammed RA, Nashwan AJ, Ibrahim RH, Abdalla AQ, Ameen BM, et al. Using thematic analysis in qualitative research. J Med Surg Public Health. 2025;6:100198. http://dx.doi.org/10.2139/ssrn.5222482
- 16. Hosseini A, Jackson AC, Bahramnezhad F. Ethical considerations in interventional studies: a systematic review ethics and interventional study. Acta Medica Iranica. 2023:609–14.
- 17. Ahmed SK. The pillars of trustworthiness in qualitative research. J Med Surg Public Health. 2024;2:100051.
- 18. Amin MEK, Nørgaard LS, Cavaco AM, Witry MJ, Hillman L, Cernasev A, et al. Establishing trustworthiness and authenticity in qualitative pharmacy research. Res Social Adm Pharm. 2020;16(10):1472–82. pmid:32067887
- 19. Christou PA. How to use thematic analysis in qualitative research. J Qualit Res Tour. 2022;3(2):79–95.
- 20. Audrey J, Kalaij AGI, Michelle F. Assessment of factors associated with suboptimal adherence of HIV antiretroviral therapy in Asia: a systematic review. J Asian Med Stud Assoc. 2020;8(4):11–23.
- 21. Benning L, Mantsios A, Kerrigan D, Coleman JS, Golub E, Blackstock O, et al. Examining adherence barriers among women with HIV to tailor outreach for long-acting injectable antiretroviral therapy. BMC Womens Health. 2020;20(1):152. pmid:32711509
- 22. Tapp C, Milloy M-J, Kerr T, Zhang R, Guillemi S, Hogg RS, et al. Female gender predicts lower access and adherence to antiretroviral therapy in a setting of free healthcare. BMC Infect Dis. 2011;11:86. pmid:21466704
- 23. Abadiga M, Hasen T, Mosisa G, Abdisa E. Adherence to antiretroviral therapy and associated factors among Human immunodeficiency virus positive patients accessing treatment at Nekemte referral hospital, west Ethiopia, 2019. PLoS One. 2020;15(5):e0232703. pmid:32392244
- 24. Tegegne D, Mamo G, Negash B, Habte S, Gobena T, Letta S. Poor adherence to highly active antiretroviral therapy and associated factors among people living with HIV in Eastern Ethiopia. SAGE Open Med. 2022;10. pmid:35769492
- 25. Abdulsamad H, Oche OM, Raji MO, Mohammed Y. Prevalence and factors associated with treatment adherence among patients on highly active antiretroviral therapy (HAART) in Specialist Hospital, Sokoto, Nigeria. Int Arch Med Health Res. 2019;1(2):22–8.
- 26. Paramesha AE, Chacko LK. Predictors of adherence to antiretroviral therapy among PLHIV. Indian J Public Health. 2019;63(4):367–76. pmid:32189660
- 27. Morowatisharifabad MA, Abdolkarimi M, Asadpour M, Fathollahi MS, Balaee P. Study on social support for exercise and its impact on the level of physical activity of patients with type 2 diabetes. Open Access Maced J Med Sci. 2019;7(1):143–7. pmid:30740179
- 28. Gebreagziabher TT, Woldemariam GT. Antiretroviral treatment adherence and determinant factors among adult people infected with human immunodeficiency virus in Eastern Tigray General Hospitals, Northern Ethiopia, 2019. HIV AIDS (Auckl). 2020;12:497–505. pmid:33061661
- 29. Areri H, Marshall A, Harvey G. Exploring self-management of adults living with HIV on antiretroviral therapy in North-West Ethiopia: qualitative study. HIV AIDS (Auckl). 2020;12:809–20. pmid:33312002
- 30. Legesse TA, Reta MA. Adherence to antiretroviral therapy and associated factors among people living with HIV/AIDS in Hara Town and its surroundings, North-Eastern Ethiopia: a cross-sectional study. Ethiop J Health Sci. 2019;29(3):299–308. pmid:31447498
- 31. Opara HC, Iheanacho PN, Nebo B, Ingwu JA, Anetekhai CJ, Anarado AN. Factors affecting adherence to anti-retroviral therapy among women attending HIV clinic of a tertiary health institution in SouthEastern, Nigeria. Afr Health Sci. 2022;22(1):456–64. pmid:36032451
- 32. Aferu T, Doang G, Zewudie A, Nigussie T. Adherence to antiretroviral therapy among HIV-positive pregnant women on followup at Mizan Tepi University Teaching and Tepi General Hospitals, Southwest Ethiopia. J Prim Care Community Health. 2020;11. pmid:32321354
- 33. Oh KS, Han E. A comparison of medication adherence and viral suppression in antiretroviral treatment-naïve patients with HIV/AIDS depending on the drug formulary. PLoS One. 2021;16(1):e0245185. pmid:33417621
- 34. Addo MK, Aboagye RG, Tarkang EE. Factors influencing adherence to antiretroviral therapy among HIV/AIDS patients in the Ga West Municipality, Ghana. IJID Reg. 2022;3:218–25. pmid:35755462
- 35. Akinwunmi B, Buchenberger D, Scherzer J, Bode M, Rizzini P, Vecchio F, et al. Dose-related and contextual aspects of suboptimal adherence to antiretroviral therapy among persons living with HIV in Western Europe. Eur J Public Health. 2021;31(3):567–75. pmid:33462616
- 36. Belete TM, Tadesse SA, Atnafu K, Kelemu M, Asrie AB. Patient satisfaction with antiretroviral therapy service provided by pharmacists in Dembia district health institutions, Northwest Ethiopia. AIDS Res Ther. 2023;20(1):38. pmid:37340505
- 37. Simelane PT, Simelane MS, Amoateng AY. Barriers and facilitators to adherence for antiretroviral therapy: the perspectives of patients from a wellness center in the Mpumalanga Province, South Africa. Afr Health Sci. 2022;22(3):455–62. pmid:36910408
- 38. Belay YA, Yitayal M, Atnafu A, Taye FA. Patient experiences and preferences for antiretroviral therapy service provision: implications for differentiated service delivery in Northwest Ethiopia. AIDS Res Ther. 2022;19(1):30. pmid:35761352
- 39. Lahai M, Theobald S, Wurie HR, Lakoh S, Erah PO, Samai M, et al. Factors influencing adherence to antiretroviral therapy from the experience of people living with HIV and their healthcare providers in Sierra Leone: a qualitative study. BMC Health Serv Res. 2022;22(1):1327. pmid:36348488
- 40. Ahmed A, Saqlain M, Bashir N, Dujaili J, Hashmi F, Mazhar F, et al. Health-related quality of life and its predictors among adults living with HIV/AIDS and receiving antiretroviral therapy in Pakistan. Qual Life Res. 2021;30(6):1653–64. pmid:33582967
- 41. Skovdal M, Maswera R, Kadzura N, Nyamukapa C, Rhead R, Wringe A, et al. Parental obligations, care and HIV treatment: how care for others motivates self-care in Zimbabwe. J Health Psychol. 2020;25(13–14):2178–87. pmid:30027764
- 42. Villiera JB, Katsabola H, Bvumbwe M, Mhango J, Khosa J, Silverstein A, et al. Factors associated with antiretroviral therapy adherence among adolescents living with HIV in the era of isoniazid preventive therapy as part of HIV care. PLOS Glob Public Health. 2022;2(6):e0000418. pmid:36962329
- 43. Damulak PP, Ismail S, Abdul Manaf R, Mohd Said S, Agbaji O. Interventions to improve adherence to antiretroviral therapy (ART) in Sub-Saharan Africa: an updated systematic review. Int J Environ Res Public Health. 2021;18(5):2477. pmid:33802322
- 44. Abdulai MA, Mevissen FEF, Ruiter RAC, Owusu‐Agyei S, Asante KP, Bos AER. A qualitative analysis of factors influencing antiretroviral adherence among persons living with HIV in Ghana. J Commun Appl Soc Psychol. 2021;32(1):135–50.
- 45. Mi T, Li X, Zhou G, Qiao S, Shen Z, Zhou Y. HIV disclosure to family members and medication adherence: role of social support and Self-efficacy. AIDS Behav. 2020;24(1):45–54. pmid:30863978
- 46. Fumaz CR, Muñoz-Moreno JA, Moltó J, Ferrer MJ, López-Blázquez R, Negredo E, et al. Sustained antiretroviral treatment adherence in survivors of the pre-HAART era: attitudes and beliefs. AIDS Care. 2008;20(7):796–805. pmid:18728987
- 47. Tuot S, Sim JW, Nagashima-Hayashi M, Chhoun P, Teo AKJ, Prem K, et al. What are the determinants of antiretroviral therapy adherence among stable people living with HIV? A cross-sectional study in Cambodia. AIDS Res Ther. 2023;20(1):47. pmid:37452342
- 48.
Abdulai MA. Individual and environmental determinants of adherence to antiretroviral therapy among people living with HIV in Ghana. http://dx.doi.org/10.26481/dis.20230710ma. 37452342
- 49. Lukyamuzi Z, Etajak S, Katairo T, Mukunya D, Tetui M, Ssenyonjo A, et al. Effect and implementation experience of intensive adherence counseling in a public HIV care center in Uganda: a mixed-methods study. BMC Infect Dis. 2021;21(1):1168. pmid:34798852