1. Introduction

The global health community has relentlessly pursued progress in the ongoing efforts to address human immunodeficiency virus (HIV), with the advent and optimization of antiretroviral therapy (ART) testifying to this commitment. Significant progress has been made in the global response to HIV/AIDS, mainly owing to the widespread implementation of ART [1]. The main objective of ART is to achieve viral load suppression (VLS) to undetectable levels, a step that not only improves the health and longevity of people living with HIV (PLHIV) but also eliminates the risk of viral transmission to others, as demonstrated by the Partner Study [2]. By 2025, to meet the UNAIDS 95-95-95 goal of halting the HIV transmission, it is essential to ensure that 95% of PLHIV know their serostatus, 95% of those diagnosed with HIV receive continuous ART, and 95% of those on ART achieve VLS [3]. Current data indicate that a large majority of PLHIV achieve VLS within six months of starting ART, provided that they adhere strictly to their ART regimen [4,5]. In cases where VLS is not achieved within the first six months of ART, seven out of ten PLHIV are able to achieve VLS later on with enhanced support for ART adherence [6]. The World Health Organization (WHO) recommends in-depth counseling on ART adherence for individuals with an unsuppressed viral load (VL) [7]. ART has transformed HIV from a fatal diagnosis into a manageable chronic disease, yet achieving VLS remains a challenge, particularly for adolescents living with HIV (ALHIV). Failure to meet the UNAIDS 95-95-95 targets for children and adolescents in sub-Saharan Africa (SSA), home to 90% of children living with HIV, risks sustaining new infections and HIV-related mortality [8]. This challenge is compounded by the unique developmental issues adolescents face, which may exacerbate the difficulties in managing HIV [9]. Adolescence, a time of psychological and emotional development, is a period when individuals navigate identity formation and complex social dynamics. ALHIV face distinct barriers to ART adherence, often resulting in virological failure and poorer treatment outcomes compared to adults [10,11]. These barriers are particularly pronounced in low- and middle-income countries, where limited healthcare infrastructure, economic constraints, and lack of psychosocial support complicate treatment adherence. Studies such as Audi et al. [12] have shown the positive impact of peer support groups on ART adherence by enhancing knowledge and confidence. However, barriers remain, including the burden of pills, fear of stigma, and lack of resources [13,14]. Researches by Gordon et al. [1] and Izudi et al. [15] have emphasized that achieving VLS requires addressing not just medical but also social and personal factors, including undisclosed HIV status, broken families, stigma, and noncompliance with ART guidelines.

Data on VLS among ALHIV are scarce in the Democratic Republic of the Congo (DRC). Moreover, studies in SSA have shown varying rates of VLS among ALHIV across countries, ranging from 21.15% in Cameroon (Douala) [16] to 32.55% in Kenya [17], 35.05% in Zimbabwe [18], 38.76% in Malawi [19], and 54.08% in Cameroon (Yaoundé) [20]. These challenges are not unique to the DRC but are pervasive in many countries and regions, including urban areas like Lubumbashi, where ALHIV face unique obstacles in accessing comprehensive care and support services due to limited health facility access, stigma, and discrimination [21]. Despite efforts to expand ART coverage, achieving VLS in ALHIV remains a significant challenge in the country. This study aims to investigate the barriers and facilitators of ART adherence and VLS achievement among ALHIV aged 13-19 years in Lubumbashi, in the DRC. By identifying the specific contextual factors influencing ART adherence and VLS achievement, this study seeks to inform the development of targeted interventions to improve HIV care and support services for adolescents in the region.

2. Materials and methods

3. Results

3.1. Characteristics of the study participants

Table 1 presents the characteristics of the ALHIV, their parents/guardians and the HCWs involved in the study. The majority of ALHIV were aged between 16 and 19 years (35/39) and the majority were female (22/39). The majority of ALHIV (33/39) had a suppressed HIV VL and were in secondary school (35/39). In terms of living arrangements, more than half of the adolescents lived with at least one biological parent (20/39), whereas 28.2% lived with non-parental family members. The caregivers were mainly aged between 40 and 59 years (6/14) and were mostly women (9/14). The HIV status of these caregivers varied: just over one-third were HIV-positive (5/14), whereas 42.9% (6/14) did not know their HIV status. Most of the HCW were women (10/16), and most were aged 40 years or over (9/16). The group comprised 4 doctors, 8 nurses, and 4 pharmacists.

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Table 1. Characteristics of the study participants.

https://doi.org/10.1371/journal.pone.0320417.t001

3.2. Barriers to and facilitators of viral load suppression in ALHIV according to the socioecological model

Table 2 below summarizes the barriers and facilitators to achieve VLS among ALHIV aged 13-19 years receiving ART in Lubumbashi, in the DRC, based on the domains of the socioecological model.

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Table 2. Summary of barriers and facilitators to achieve viral load suppression in ALHIV according to the socioecological model.

https://doi.org/10.1371/journal.pone.0320417.t002

4. Discussion

Achieving VLS among ALHIV is a significant public health challenge worldwide. While the context in Lubumbashi, DRC, reflects many of the issues faced in other settings, both in resource-limited and high-income countries, it highlights the universal factors impacting ART success among ALHIV. These challenges—such as poverty, stigma, lack of support, and issues related to medication adherence—are experienced by adolescents across the globe. Using the ecological model, this study identified specific barriers and facilitators to achieving VLS in Lubumbashi, revealing that both success and failure are influenced by multiple factors operating at various levels, including individual, family, interpersonal, health service, and community. These factors have been shown to either hinder or facilitate ART adherence and the achievement of VLS among ALHIV.

The higher proportion of adolescents aged 16-19 years (89.7%) compared to those aged 13-15 years (10.3%) in our study can be attributed to differences in availability during recruitment. Older adolescents are generally more independent and able to attend appointments on their own, whereas younger adolescents often rely heavily on their parents or caregivers to accompany them. This dependency may have limited the participation of younger adolescents, as their attendance was contingent on their caregivers’ availability and willingness to bring them to the study. This recruitment dynamic likely contributed to the age distribution observed in the sample. Participants in our study identified ART side effects, stigma, forgetting medication, lack of food, busy schedules, feeling healthy, travel, non-disclosure of HIV status, broken families, and lack of ART support as barriers to achieving VLS. In contrast, they identified confidence in ART efficacy, understanding ART’s importance, establishing a routine, using reminders, managing side effects, engaging in peer support, maintaining open relationships with healthcare staff, and being motivated for someone else’s sake as strategies for overcoming these barriers. These findings align with those from other qualitative studies identifying barriers and facilitators to achieve VLS. For instance, in Ghana [24] and Sierra Leone [25], healthcare staff support, parental involvement, disease knowledge, and the perception of positive outcomes were emphasized as motivators for PLHIV to achieve VLS. Izudi et al. [15] in Uganda noted the importance of understanding ART adherence, mental health support, peer support, personal reminders, and effective management of ART side effects. Similarly, Curioso et al. [26] in Peru highlighted the role of living for his/her loved ones, reminders from family, routine establishment, positive outcomes, and confidence in drug efficacy as essential facilitators of achieving VLS.

Forgetting medication, stigma, and financial barriers were key obstacles to ART adherence among PLHIV in Ghana and Ethiopia [24,27]. A Botswana study also highlighted ART side effects, lack of food, and financial constraints as barriers for ALHIV [28]. These findings align with ours and other studies [15,23]. In Peru, stigma, dietary challenges, busy schedules, and a sense of good health were identified as barriers to ART adherence [26]. This present study found that some ALHIV faced transportation difficulties, while others forgot medication due to religious activities, reflecting similar findings in Ethiopia [27]. This Ethiopian study showed that forgetting medication leads to unsuppressed VL [27], a phenomenon also observed in our study, where ALHIV experienced interruptions in ART due to busy social lives and school commitments. These findings underscore the necessity for interventions that target both practical and psychological barriers to enhance ART adherence and to achieve VLS.

Stigma and discrimination emerged as significant barriers to achieving VLS among ALHIV in our study, aligning with other studies identifying stigma as a major deterrent to ART adherence and VLS achievement. For instance, perceived stigma related to disclosure was highlighted as a key barrier among ALHIV in Ghana [24]. Interventions to reduce stigma and promote social inclusion are crucial for improving health outcomes in this population. Although community facilitators were not included in our study, prior research underscores their vital role in enhancing ART adherence. Community outreach programs have been shown to reduce stigma, provide support networks, and improve both adherence and the overall quality of life for ALHIV [29,30]. Most ALHIV in our study achieved VLS after receiving counseling and psychological support, particularly when encountering stigma. They also expressed gratitude for the positive relationships with healthcare staff. This underscores the significance of trust and open communication with HCWs, fostering a supportive environment for addressing HIV-related stigma and depression. These results are consistent with other studies that underscore the importance of strong relationships with HCWs and support systems, such as family reminders for medication, in achieving VLS [14,24].

In Lubumbashi, some ALHIV encountered difficulties in maintaining consistent ART intake due to medication side effects, such as gastrointestinal problems, headaches, and fatigue, which hindered ART adherence and VLS achievement. This aligns with prior studies linking concerns about side effects to suboptimal VLS outcomes, despite adherence counseling [31]. Particularly, gastrointestinal issues like nausea, loss of appetite, and diarrhea serve as major barriers to sustained treatment, affecting VLS [15,31].

The finding that a lack of food is a significant barrier to achieving VLS, especially for ALHIV who are orphans or from financially constrained households, highlights the importance of addressing basic nutritional needs as part of ART support. Consistent with previous research [1,15,32], this underscores the necessity of ensuring adequate food intake to improve ART adherence and, by extension, support VLS. Interventions should consider providing nutritional support or financial assistance to enhance medication adherence and prevent complications due to skipped doses. Addressing food insecurity is thus a critical component of comprehensive HIV care for ALHIV, as it directly impacts treatment outcomes and overall health.

This study identified a significant barrier to achieving VLS: the lack of parental supervision during ALHIV medication intake. Despite caregivers administering medication, many became preoccupied with other tasks and did not verify whether the medication was taken. Some ALHIV, facing challenges with their treatment, may conceal non-adherence by pretending to take the medication, which compromises achieving VLS. Similar to findings from a Peruvian study [26], our research also demonstrates that orphaned ALHIV or those from disrupted families encounter challenges that detrimentally impact ART adherence, thereby impeding VLS. The absence of parental support, coupled with emotional and financial instability, plays a role in non-adherence and suboptimal outcomes. Previous studies underscore the crucial importance of family in aiding long-term treatment adherence and offering essential psychosocial support to achieve VLS [23,24,33,34]. These findings collectively emphasize the vital role of family involvement and consistent supervision in ensuring ART adherence and achieving optimal outcomes for ALHIV.

The present study also revealed that many ALHIV were not adhering to ART correctly due to not being informed of their HIV-positive status. This lack of disclosure led to confusion, as some ALHIV thought they were managing a chronic cough rather than HIV. Disclosing HIV status, however, can improve the quality of life, social support, immune recovery, and ART adherence, while non-disclosure increases the risk of loss to follow-up and is a significant barrier to achieving VLS [15,35–37].

In addition, being away from home and having busy schedules were identified as significant barriers to achieve VLS, aligning with findings from other studies [1,26,27] showing that long travel distances and associated costs often result in missed appointments and ART non-adherence. Social support and participation in peer groups were identified as crucial facilitators of VLS, improving HIV knowledge and ART adherence through interpersonal interactions and peer support [1,15,26,29].

This study has several strengths, including a comprehensive exploration of barriers and facilitators to achieving VLS from the perspectives of ALHIV, their caregivers, and HCWs involved in ART adherence. Our sample size was substantial, and interviews continued until thematic saturation was achieved, providing a nuanced understanding of the factors affecting VLS. The application of the socioecological model to guide interview development, data analysis, and result presentation adds to the robustness and potential replicability of the study.

However, there are notable limitations. Firstly, the study’s urban focus may limit the generalizability of the findings to rural settings where socioeconomic conditions and HIV care quality differ. Additionally, the reliance on self-reported data introduces the possibility of social desirability bias, which could affect the accuracy of the responses. Furthermore, the study findings may not fully represent the experiences of ALHIV on second- or third-line ART regimens, as their experiences with ART and HIV control programs may vary.

5. Conclusion

This study, rooted in the socioecological model, highlights that barriers and facilitators to achieving VLS among ALHIV in Lubumbashi occur at multiple levels: personal, interpersonal, family, and community. Key barriers identified include drug side effects, stigma, forgetting to take medication, lack of food, busy schedules, feelings of being healthy, travel, nondisclosure of HIV status, broken families, and lack of assistance in taking ART. Conversely, confidence in drug efficacy, understanding the importance of ART, establishing a routine, using reminder tools, managing drug side effects, engaging in peer support clubs, maintaining open relationships with healthcare staff, and being motivated to stay well for loved ones were found to be critical facilitators.

To enhance VLS rates, HIV control programs ought to prioritize overcoming these barriers by optimizing drug management, reinforcing family and community support systems, and improving health services. Subsequent investigations should delve into inventive interventions aimed at ALHIV and their caregivers, along with tactics to diminish stigma and enhance ART adherence. Implementing practical measures, like broadening peer support initiatives, furnishing useful tools for medication adherence, and customizing counseling methods for ALHIV requirements, is crucial for sustained advancement. By capitalizing on the facilitators and addressing the obstacles uncovered in this study, programs can contribute to actualizing the global objective of achieving 95% VLS among ALHIV.

Supporting information

Acknowledgments

This research was made possible through a HEARD PhD Scholarship at the University of KwaZulu-Natal (UKZN), funded by the Swedish International Development Agency (SIDA). Any opinions, findings, and conclusion or recommendations expressed in this material are those of the authors and do not necessarily reflect the view of HEARD, UKZN, or SIDA.

We express our sincere appreciation to all individuals who played a role in the completion of this study. Our special thanks go to the healthcare workers and personnel at the HIV care facilities in Lubumbashi for their indispensable support in data collection.