Automated Medication Dispensing System: Are We Meeting Patient Needs? Insights from People Living with HIV’s Perspectives in Eswatini

Automated Medication Dispensing System: Are We Meeting Patient Needs? 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Insights from People Living with HIV’s Perspectives in Eswatini Deus Bazira, Thokozani Maseko, Weijun Yu, Liyandza Mamba, Samson Haumba, and 13 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8145607/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Introduction While automated medication dispensing systems (ADMS) have been implemented in developed countries for some time to improve efficiency and enhance provider and patient experience, they are relatively a new phenomenon in Sub-Sahara Africa. There is limited evidence to date about how AMDS implementation has improved patient satisfaction in resource limited settings. This study aimed to generate evidence on patient experience by assessing satisfaction of patients living with HIV who adopted the ADMS to access medication for chronic disease care management in Eswatini. Methods A mixed methods study was conducted using an explanatory sequential design to collect data from 717 outpatients aged 18 and above accessing HIV care at five health facilities that implemented the AMDS in Manzini and Lubombo regions of Eswatini. Data was collected between November 1, 2023, through March 31, 2024. In-depth survey data was collected from 100 participants through 20-minute exploratory phone interviews. Descriptive statistics described participants’ demographic characteristics and their use of the AMDS. Thematic analysis was used to examine qualitative interview data, and word frequency analysis was conducted for visualization. Results Most participants (81%) were from the Manzini region, and 99.9% had been on antiretroviral therapy (ART) for at least one year. Most participants found the AMDS easy to use (91.9%), and 94% reported experiencing the shortest waiting times (< 10 minutes). Key advantages cited for using the AMDS included convenience (31.2%), rapid processing (67.4%), reduced queuing time (59.7%), and immediate access to medication (55.9%). Only a small portion of participants (11.2%) expressed dissatisfaction with the AMDS. Thematic analysis revealed AMDS enhanced patient experience through: convenience in accessing ART; optimized adherence to treatment; held potential to benefit more clients if scaled up; and was perceived as less burdensome compared to conventional pharmacy window drug pick up. Conclusion Patients expressed strong user acceptance of the AMDS for medication delivery among people living with HIV receiving chronic care. Participants found the system convenient, easy to use, and supportive of adherence through increased autonomy. While some limitations were raised, the AMDS shows great potential to improve medication access in Eswatini and should be further evaluated for broader implementation. Automated Medication Dispensing System (AMDS) People living with HIV (PLHIV) Medication adherence Noncommunicable diseases (NCD) Mixed methods study Figures Figure 1 Introduction Drug dispensing is a critical step in therapeutic intervention continuum in health care delivery. Medicine dispensing function remains a purview of pharmaceutical staff led by a trained pharmacist in developed and resource rich settings. In resource-limited settings, however, the dispensing role has been task-shifted to other health care professional cadres including nurses 1 , 2 . With advances in technology the labor-intensive function is getting further task-shifted to automated dispensing systems 3 . In chronic disease management process such as HIV/AIDS care, long term treatment adherence remains a concern – considering more than 39.9 people million live with HIV 4 . Globally, HIV/AIDS remains a major public health challenge, with 39.9 million people living with HIV (PLHIV) in 2023 and over 30 million accessing antiretroviral therapy (ART) 4 , 5 . Community-based delivery models, including decentralized clinics and peer support systems, have expanded ART access in remote regions 6 . However, persistent challenges such as fragile health infrastructure, medication supply interruption, workforce shortages, and sociopolitical instability continue to undermine the progress 7 . Stigma, discrimination, and rising HIV drug resistance further threaten gains, particularly in low-resource and high-burden settings 6 , 7 . Interruptions in ART delivery pose serious public health risks by increasing viral replication, accelerating disease progression, and heightening transmission rates 8 , 9 , 10 , 11 . Inconsistent adherence also drives the emergence of drug-resistant HIV strains, undermining treatment efficacy and narrowing future therapeutic options 12 . HIV/AIDS life-long care and treatment nature presents strain on the health system and demands more patient commitment. AMDS seeks to alleviate the onerous time demands on patients seeking their medication re-fills and enhances their experience to strengthen long term treatment adherence to HIV anti-retroviral therapy and retention in care. Eswatini, a developing country in Southern Africa carries a huge HIV epidemic burden leading to sustain chronic shock to the country’s resource constrained health system. In addition, the country faces a growing need for chronic care, driven by a high burden of both non-communicable diseases (NCD) and HIV. In 2019, NCD accounted for 46% of all deaths 13 . Meanwhile, advances in antiretroviral therapy (ART) have transformed HIV into a chronic condition, leading to an aging population of people living with HIV (PLHIV) increasingly facing NCDs co-morbidities such as hypertension, diabetes, and cancer. This dual burden strains the healthcare system and highlights the need for integrated, patient-centered models that streamline service delivery, reduce provider workload, address socioeconomic barriers, ensure care continuity, and regularly assess care quality. Automated Medication Dispensing System (AMDS), originally introduced in the 1970s as tablet counters to improve accuracy and efficiency in hospital settings 14 , are increasingly recognized for their potential in chronic disease management. A recent study showed that AMDS can significantly reduce dispensing errors from 3.87 to 0 per 100,000 dispensations and improve inventory control, particularly when integrated across prescribing, dispensing, and administration processes 15 . In a randomized control study, in-home AMDS have also demonstrated improved medication adherence among 50 years and above patients with chronic conditions, addressing physical and cognitive limitations through reminders and precise dosing 16 . While inpatient use has been associated with reduced medication administration and disposing errors 17 , there remains limited evidence on AMDS effectiveness in public health settings in Eswatini, especially HIV care. Eswatini has integrated technology into chronic disease management through the introduction of Automated Medication Dispensing Systems (AMDS), using HIV care and treatment medicines as an entry point with plans to scale this to other diseases. The country’s adoption of AMDS is driven by perceived benefits it offers to patients, providers and the health system. The AMDS perceived features include: enhanced security due to its electronically controlled medication distribution system; potential for increased accessibility; and promise of convenience. The AMDS introduced in Eswatini consists of a closed system unit with a touch-screen interface linked to secure storage compartments where prescribed pre-packaged medication parcels are stored. Patients enrolled in the system receive a one-time PIN code that allows them to access their medication from the system at their convenience. While the AMDS present a promising solution for improving ART adherence, client perspectives on this innovation remain underexplored. Understanding client experiences is crucial to refining and scaling up AMDS implementation to ensure it remains client-centered, acceptable, and cost-effective. This study sought to assess client satisfaction, improved experience, acceptability, and convenience in using AMDS, to inform future programming and system improvements. By integrating user feedback into implementation strategies, Eswatini can optimize the impact of AMDS, to enhance long term patient retention in care and improve overall healthcare delivery efficiency. Methods Study design and setting The study was conducted at five health facilities in Manzini – one of the regions of the country located in the west-center part of the country. The AMDS, referred to as dispensing lockers in the 2022 Eswatini Integrated HIV Management Guidelines 18 , and locally known as “ Lula Meds ” ( Lula meaning “easy”), was introduced as part of differentiated care delivery models adopted by the country to improve access to antiretroviral therapy for people living with HIV/AIDS. Study facilities included the AIDS Healthcare Foundation Lamvelase Clinic; the Raleigh Fitkin Memorial Hospital; Luyengo Clinic; Chakaza Clinic; and Good Shepherd Hospital. A detailed description of the set up and implementation processes of the AMDS at these sites has been previously published 19 . Study participants consisted of ART clients who received HIV care through the AMDS model at these facilities. This study employed a mixed methods study using an explanatory sequential design to collect data from participants at the five health facilities that implemented the initial phase of the AMDS. Data collection The study took place from November 1, 2023, to March 31, 2024. Clients receiving ART at these facilities who had earlier accepted to receive their medications through the AMDS were invited to participate in the study. Prior to data collection, participant consent was received through a self-administered electronic form issued via a hand-held tablet, available in English and Siswati – the local language. Respondent data was also collected using the same electronic tablet platform. After collecting their medication, clients were prompted to provide consent and complete the survey on the tablet. At the end of the surveys, participants who indicated willingness to participate in a follow-up interview were asked to provide their phone contact. A total of 100 participants consented to take part in the exploratory in-depth interviews. Two trained research assistants contacted these individuals by phone, providing further study information and scheduling interviews at the participant’s convenience. During the follow-up interview, verbal informed consent was obtained, which included consent to participate in the study and to record the interview. Participants were informed that they could withdraw from the study at any time during the interview process and there would be no repercussions. Interviews were conducted using a structured guide ( Supplementary File 1 ). Depending on their preference, participants were interviewed in either English or Siswati, and each session lasted approximately 20 minutes. Interviews were recorded using a tape recorder, and research assistants documented additional observations in the accompanying interview note. Data analysis Descriptive statistics were used to analyze quantitative data related to participants’ demographic characteristics, AMDS use, and their perception of the system. Results were summarized using frequency and percentage tables. For qualitative data, trained research assistants transcribed and translated audio recordings from Siswati into English immediately following each interview. Two team members (TM, JD) reviewed the transcripts to ensure fidelity to the original recordings and accuracy of meaning in translation. Thematic analysis, following the multi-step approach described by Braun and Clarke (2006) 20 , was used to interpret qualitative data. A shared digital platform facilitated collaborative coding and data reduction. The analysis was both inductive (data driven) and deductive (theory driven) 20 , guided by a broader theoretical framework and incorporating constant comparison 21 and iterative refinement of codes. Team discussion began during data collection, allowing early identification of emerging patterns. Draft codes were developed and revised over time, culminating in the organization of related codes into overarching themes. In addition to thematic analysis, a word frequency analysis was conducted on the qualitative interview data to further visualize participants' positive perceptions of the AMDS compared to traditional pharmacy services. Frequently mentioned terms were grouped into thematic categories to reflect broader concepts. For example, words such as “quickly”, “fast”, and “no queue” were categorized under “quicker”, while phrases like “pick-up after working hours” and “come at any time” were grouped as "Convenient." The results were visually presented in a word cloud to highlight the most expressed sentiments. Missing data was managed using the listwise deletion method. Participants who declined consent to participate in this study were considered missing data, accounting for 1.78% (13 individuals out of 730 participants). Given the low missing data rate (< 10%), these individuals were excluded, and descriptive data analysis was conducted using participants with complete data. Results Demographic profile of study population Most participants (81%) were from Manzini region, and 66% were females (see Table 1 below). All participants were aged 21 years or older, with a mean age of 42.8 years (± 9.8). Most individuals (90%) were on an optimized dolutegravir (DTG) containing regimen. Variability in duration of amount of ARVs dispensed to patients was observed, with 23.6% receiving less than 3 months, 47.9% receiving 3–5 months, and 28.5% receiving at least 6 months of their drugs dispensed to take home during their visit to the clinic. The majority (99.9%) had been on ART for at least one year, and 98.2% of patients had either undetectable or suppressed viral loads. Our descriptive statistical analysis further examined participants’ use of the AMDS (summarized in Table 2 ). The majority of participants (94.4%) reported a preference for using Lulameds, while 2.1% favored the traditional pharmacy pick-up approach. The remaining participants (3.5%) expressed no specific preference regarding the medication collection approach. Overall, participants found the AMDS easy to use (91.9%). Additionally, 94% reported the shortest clinic visit time of less than ten minutes. The most frequently cited advantages of the AMDS included convenience (31.2%), rapid processing (67.4%), reduced queuing time (59.7%), and immediate access to medication (55.9%). Only a small portion of participants (11.2%) reported any dissatisfaction with the AMDS. The concerns raised included limited support during an emergency (4%), lack of direct interaction with healthcare providers (2.4%), and failure to login due to expired PIN (4.9%). In Diagram 1 , we present a visual summary of the user experience and uptake of the AMDS, illustrating the overall flow from participant enrollment to user feedback on the system use. Table 1 Descriptive Analysis of Participants’ Demographic Characteristics 1 Demographics N (%) Demographics N (%) Region Sex Manzini 581 (81.0) Female 473 (66.0) Lubombo 136 (19.0) Male 244 (34.0) Age (years) Duration on ART (years) Mean (SD): 42.8 (± 9.8) | Median: 43.0 Mean (SD): 9.2 (± 0.34) | Median: 9.2 21–30 76 (10.6) 60 33 (4.6) >15 79 (11.0) Viral load status MMD 2 Undetectable (< 50c/ µl ) 649 (90.5) 1000c/ µl ) 13 (1.8) >= 6 months 204 (28.5) Current ART Regimen 3 TDF + 3TC + DTG 640 (90.0) ABC + 3TC + DTG 20 (2.8) AZT + 3TC + DTG 39 (5.5) TDF + 3TC + EFV 12 (1.7) Note : 1 The sample size for this analysis is 717 individuals. 2 MMD denotes Multi-Month Dispensing, refers to the practice of providing antiretroviral therapy (ART) clients with a supply of antiretroviral medications (ARVs) for more than one month at a time, reducing the need for monthly clinic visits and prescription renewals. 3 TDF denotes tenofovir; 3TC denotes lamivudine; DTG denotes dolutegravir; AZT denotes zidovudine; EFV denotes efavirenz; ABC denotes abacavir. Table 2 Descriptive Analysis of Automated Medication Dispensing Systems (AMDS) Usage 1 Total Female Male Manzini 2 Lubombo 3 N (%) n (%) n (%) n (%) n (%) Medication pickup preference Smart locker (AMDS) 677 (94.4) 453 (95.8) 224 (91.8) 545 (93.8) 132 (97.1) Pharmacy (traditional) 15 (2.1) 9 (1.9) 6 (2.5) 15 (2.6) 0 (0.0) No preference 25 (3.5) 11 (2.3) 14 (5.7) 21 (3.6) 4 (2.9) How easy is using the AMDS Easy 659 (91.9) 440 (93.0) 219 (89.8) 524 (90.2) 135 (99.3) Fair 31 (4.3) 18 (3.8) 13 (5.3) 30 (5.2) 1 (0.7) Difficult 27 (3.8) 15 (3.2) 12 (4.9) 27 (4.6) 0 (0.0) Length of time waited prior to receiving medication 20 mins 18 (2.6) 13 (2.8) 5 (2.0) 18 (3.0) 0 (0.0) Aspect of the AMDS the patient liked most Can pick up at any time (convenience ) Yes 224 (31.2) 148 (31.3) 76 (31.2) 176 (30.3) 48 (35.3) No 493 (68.8) 325 (68.7) 168 (68.9) 405 (69.7) 88 (64.7) Process is fast and efficient Yes 483 (67.4) 316 (66.8) 167 (68.4) 411 (70.7) 72 (52.9) No 234 (32.6) 157 (33.2) 77 (31.6) 170 (29.3) 64 (47.1) No long waiting in line Yes 428 (59.7) 287 (60.7) 141 (57.8) 364 (62.7) 64 (47.1) No 289 (40.3) 186 (39.3) 103 (42.2) 217 (37.3) 72 (52.9) Immediate access to medication Yes 401 (55.9) 202 (42.7) 114 (46.7) 301 (51.8) 15 (11.0) No 316 (44.1) 271 (57.3) 130 (53.3) 280 (48.2) 121 (89.0) Aspects of the AMDS the patient disliked Dissatisfaction with AMDS No 637 (88.8) 422 (89.2) 215 (88.1) 508 (87.4) 129 (94.9) Yes 80 (11.2) 51 (10.8) 29 (11.9) 73 (12.6) 7 (5.1) Limited support available during emergencies Yes 29 (4.0) 15 (3.2) 14 (5.7) 27 (4.6) 2 (1.5) No 688 (96.0) 458 (96.8) 230 (94.3) 554 (95.4) 134 (98.5) Lack of interaction with a healthcare provider Yes 17 (2.4) 13 (2.8) 4 (1.6) 17 (2.9) 0 (0.0) No 700 (97.6) 460 (97.3) 240 (98.4) 564 (97.1) 136 (100.0) Not being examined by a clinician Yes 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) No 717 (100.0) 473 (100.0) 244 (100.0) 581 (100.0) 136 (100.0) Expired PIN Yes 35 (4.9) 23 (4.9) 12 (4.9) 31 (5.3) 4 (2.9) No 682 (95.1) 450 (95.1) 232 (95.1) 550 (94.7) 132 (97.1) Note : 1 The sample size for this analysis is 717 individuals. 2 Manzini is the economic and industrial hub region in central Eswatini. 3 Lubombo is a mountainous region situated in eastern Eswatini. Diagram 1. User Experience and Uptake of Automated Medication Dispensing System (AMDS) Thematic Analysis Findings A total of 100 participants took part in the qualitative exploration interviews. Analysis of their responses revealed interrelated themes that captured how the AMDS met their needs (Table 3 ): (1) AMDS is a convenient method of receiving ART; (2) Positive perceptions of AMDS motivate clients to adhere to treatment; (3) AMDS has the potential to benefit more clients if expanded; and (4) Challenges associated with the AMDS are less burdensome than those experienced within traditional facility-based medication pickup. These themes suggest that AMDS support clients by enhancing convenience, fostering a sense of being valued and trusted by the health care providers so that they can manage their health care needs, reducing barriers to ART access, and offering scalable benefits for broader implementation. Table 3 Themes Emerging from Participant Experiences with the Automated Medicine Dispensing System (AMDS) Themes Description 1. AMDS is a convenient method of receiving ART Convenience encompassed the ability to collect ART at any time, reduced waiting times, avoidance of queues at the pharmacy or clinic, and increased privacy during medication pickup. 2. Positive perceptions of AMDS motivate clients to adhere to treatment Participants expressed that trust from health workers, prior experiences with pharmacy services, and concerns about being removed from the AMDS influenced their motivation to adhere to treatment. 3. AMDS has the potential to benefit more clients if expanded Participants viewed AMDS expansion as including additional medications (e.g., painkillers), decentralizing AMDS to other health facilities or towns, and extending access to 24-hour availability in some sites. 4. Challenges associated with the AMDS are less burdensome than those experienced within traditional facility-based medication pickup Challenges included personal issues such as lost or expired PINs or phone malfunctions, as well as facility-level concerns like appointment scheduling conflicts, queues, and occasional disagreements with staff. The AMDS barriers were seen as less burdensome than traditional service models. Theme 1. AMDS is a convenient method of receiving ART We broadly define convenience as the various mechanisms that facilitate easier access to ART for participants. Many reported the ability to collect medication at any time, including after hours or when healthcare workers were unavailable or the facility was closed. This flexibility, without being limited by clinic operating hours or staff schedules, was a key advantage. As stated by some participants, “I like the machine [AMDS] because you can come at any time and get my medication. I live at a quite distant place from the clinic, so the fact that I can come at any time, even if it’s late.” (KI25) “I prefer the machine [AMDS]. It is very convenient. I just go straight there and collect my medication.” (KI75) “The machine [AMDS] has been working well for me. You can use it at any time, even when I am not able to go to the clinic during the week, I can now go on Saturday, unlike with the nurses who do not work on weekends.” (KI79) “I prefer the machine [AMDS] because it operates for longer hours, and as a textile worker, I am not able to request time at work to go to the clinic so I can pass by after work.” (KI93) “... the delays while queuing to see a nurse so you'd spend the whole day in the clinic.” (KI74) Convenience was also reflected in the faster process of accessing ART through AMDS. Participants were able to integrate medication pickup into their daily routines, such as during work breaks or while commuting, without disrupting other responsibilities. The time-saving aspect was especially important for employed clients, who could collect medication discreetly and efficiently. “I prefer the machine [AMDS] because most of the time when I go to the clinic, it's during my work hours, so I need something that will be quick for me, like this machine [AMDS].” (KI41) “The machine [AMDS] is quick, and even if you have limited time, you can still access your medication.” (KI56) “I used to find long queues and spend a lot of time at the clinic, yet I'm a very busy person. Since I started using the machine, I haven't experienced such issues. Now I just get there and collect.” (KI18) “The machine [AMDS] works better for me as I can take my lunch break at work and quickly get my medication instead of having to request some time at work.” (KI68) “I love that I can just take 15 minutes of my lunch break and quickly rush to the clinic to get my medication.” (KI77) “As long as I got the message, even if I don’t have transport money, I can still make a plan as we are given an allowance of days to collect our medication, and also you can go there at any convenient time for you. You can also ask someone who's in town to get your parcel from the machine.” (KI30) “It's the time, especially because I'm a truck driver, so now I can just park it at the garage in 5 minutes, and I'll be done. You don’t even talk to anyone, as everything is well documented on the envelope. This machine even relieves the workload on the nurses.” (KI92) “I think that has made things easier for us, even when I’m at work no matter what time I knock off I can still access my medication and now I don’t have to ask for time out at work to go to the clinic so it also saves us from a lot of explanation that we need to do when asking to go to the clinic. So this just remains a personal issue.” (KI27) Participants also found the AMDS easy to use. After an initial orientation from a healthcare worker, most could operate the machine independently. If challenges arose, assistance was accessible either from healthcare staff during the day or from security officers after hours, further supporting seamless use. Some clients shared: “It's simple and all you need is your PIN.” (KI93) “I loved that you just punch your pin and collect your medication, there's nothing complicated about it.” (KI92) “. .. they shouldn’t be afraid as they get taught how to use the machine, so it becomes easy.” (KI60) “No, everything was properly explained to me, and even if I'd encounter a challenge, there are security officers at the gate who can assist me.” (KI29) Additional convenience was noted in the process of completing routine blood tests. Participants indicated that blood tests were quicker for those enrolled in AMDS, which reduced their overall time spent at the facility. , “It usually takes less than 2 minutes as you just enter your pin and collect your medication from the lockers. If you must do blood tests, quickly you do that and leave.” (KI6) Importantly, enrollment in AMDS did not restrict access to healthcare providers. Participants appreciated that they could still request a consultation when needed, which reinforced their sense of continued care and support. Some clients shared: “No, it doesn’t [affect me] because it’s not like I am no longer allowed to consult with nurses.” (KI77) “I love the machine as you are also reminded of your laboratory appointments, so there is no issue at all with it. I am happy with the machine as I don’t have to talk to anyone now.” (KI65) “I was told that I can still consult with a nurse if I'm having a problem. I think that is okay, as it would happen that you would queue with people who needed to see the nurse, yet you are okay.” (KI56) The absence of queues in the AMDS was frequently mentioned as a major benefit. Unlike traditional medication pickup at the pharmacy or consultation rooms, the AMDS allowed clients to avoid long waits, making the process less stressful and more efficient. Some participants excitedly praised AMDS’ absence of queues, “The machine is fast. In this hospital, there are long queues, so I'm happy since I no longer get delayed now.” (KI54) “I have talked to some people who visit other clinics that don’t have the machine, and I told them that here we no longer have this thing of queuing and staying the whole day in the clinic.” KI84 “This side there are no queues, so it avoids the delay, which makes things easier for us, rather than moving from bench to bench.” (KI30) “I am working, and I usually don’t have the time to go to the clinic, so now that there is the machine, I can just take 5 minutes and go to the clinic.” (KI99) “I think the machine was a bold initiative. It helps us to take our medication properly and honor our appointment dates. There is no need to get stressed out about the queues and wasting time in the clinic.” (KI45) “I love that it saves me a lot of time, and it helps me avoid the queue, such that now I feel excited when I have to come to the clinic.” (KI96) Several participants valued the privacy offered by the AMDS. Fewer people around during pickup reduced the risk of accidental disclosures of their HIV status, enhancing their overall comfort with the process: “I would encourage those who are still not comfortable with disclosing to move to the machine as there is privacy, and no one will notice because quickly you'll be in and out of the clinic.” (KI93) “The machine is very fast and there's privacy. At the pharmacy, we queue in an open area so people can see you.” (KI55) “. . .What I love the most is privacy. This side, you are alone, you don’t have to mingle with people.” (KI30) “I love the privacy provided by this machine. No one will notice that you were also in the clinic.” (KI53) “What I love the most is that it saves time and the privacy it offers. Some of us are still not comfortable with people knowing about our HIV status, so inside the clinic, you come across a lot of people, even those you know, so people will end up knowing about your health status.” (KI64). Theme 2. Positive perceptions of AMDS motivate clients to adhere to treatment Participants’ perceptions of the AMDS reflected a combination of attitudes, beliefs, and motivations tied to their experience with the system. These perceptions were shaped by feelings of trust from healthcare workers, prior experiences with traditional ART delivery, and concerns about maintaining eligibility for AMDS use. Many participants recognized that access to AMDS was not automatic, it required meeting specific eligibility criteria set by healthcare workers, such as consistent adherence to treatment. This awareness served as a motivator for participants to take their medication as prescribed and to encourage others to do the same to gain or maintain access to AMDS. : “Yes, because now I know that not everyone is eligible for the machine, so I'd advise people to take their medication properly for good adherence.” KI19 “Yes, I once asked the nurse why it wasn’t everyone getting their medication from the machine, and I was told that it depends on one's adherence to treatment. So, I would also advise people to take their medication properly so they can be eligible for this service.” KI31 “I would encourage them to take their medication properly so they can also qualify for this machine, and on this side, you only need a PIN, so everything is fast, you don’t get delayed.” KI35. For some, being selected for AMDS was interpreted as a sign of trust from healthcare workers. This sense of recognition fostered a desire not to disappoint providers and, in turn, reinforced their commitment to treatment adherence. “I believe the reason I'm using this machine is because the nurses knew that I was taking my medication properly. . .” KI71 The convenience and benefits of AMDS were themselves a source of motivation. Participants felt that maintaining good adherence was a way of showing appreciation for a system that respects their time and privacy. One participant noted that, “It's just that as men we don't take good care of our health, but this machine favors us as we don't even queue, quickly you are done, then you can go back to work. There is no excuse now not to take your medication, everything has been made simpler for us.”KI92 Previous negative experiences with traditional ART pickup such as long queues, lack of privacy, or strained interactions with healthcare staff also shaped participants’ appreciation of the AMDS. Some participants explained: “I was once mistreated at Zombodze Clinic, which can sometimes make you go back home without even getting your medication.” (KI41) “Inside the clinic, there are long queues, and you have to move from the reception to the counseling office, to the nurse and sometimes to the doctor, then to the pharmacy, which is time-consuming. So now I love that you only go directly to the machine.” (KI44) “There was too much delay; you'd get to the clinic in the morning and wait for the nurses to start working, then they'd attend to us one by one, which was too much of a waste of time; you had to start with the adherence officers.” (KI73) “Yes, there were several issues. You would get to the clinic at 9 am and leave at 3 pm, yet you don’t even have money to get something to eat, as you only have bus fare. Some of us reside in distant places, so we need to travel to access our medication. Also, you'd find that we were made to wait for a long time, so they call your file number first, then you go to other departments, which took a long time, but now in 5 minutes’ time you board a bus back home. So, this machine has really made things easier for us.” (KI32) Some participants expressed frustration with unnecessary or prior unpleasant interactions with healthcare workers, particularly when they were otherwise well and did not feel the need for clinical consultation. AMDS allowed them to avoid these encounters, which they viewed as time-consuming or emotionally draining: “Before, I would have to interact with nurses even if I’m not in a good mood, now I just go to the machine and get what I came for.” KI97 “In the past, you'd face problems. Let's say you're still new, and when you get there, you find the nurse in a grumpy mood. But now you just get there, collect your medication, and then you're done. This won't discourage you, cause you to discontinue taking your medication, as compared to when you would get annoyed by a nurse to the point that you feel like throwing away the medication.” KI27 “Sometimes you'd find that the nurses are on tea break, so you're made to wait, yet now I just go directly to the machine on my own, collect my medication and leave.” KI29 “In the clinic, you'd find that the staff sometimes ignore us, and the machine just saves me from a lot of trouble which includes being provoked by the healthcare workers.” KI10 There was a recurring perception that poor adherence or clinical outcomes could lead to removal from the AMDS. This potential consequence created a strong incentive to remain adherent and retain access to the system. Participants’ fear of losing AMDS benefits contributed to sustained motivation to stay on treatment: “Yes, I would love to [continue receiving ART in the AMDS], the only reason I'd stop using the machine is if I'd stop taking my medication properly, then I'd be disqualified from this machine.” KI70 “.. . the only problem would be if we don’t take our medication properly. Otherwise, if I adhere well, it doesn’t affect me in any way.” KI62 Theme 3. AMDS has the potential to benefit more clients if expanded Participants expressed strong interest in the expansion of AMDS in terms of both functionality and geographic reach. Expansion was described across three dimensions: diversify the range of services available through the AMDS, decentralize its presence to more health facilities and communities, and extend access to 24-hour availability. Participants noted that being able to collect other prescribed medications such as painkillers after clinician consultation would enhance the overall convenience. Some participants said: “If maybe we could get other medication like painkillers whenever you made a complaint to the doctor about pain, rather than then having to go to the pharmacy for the painkillers as this is time consuming.” KI2 “I'm not sure but if it could also dispense more medication instead of ART as there are long queues in all departments.” KI64 Some highlighted that expanding the range of medications dispensed could help reduce stigma associated with AMDS, which is currently viewed primarily as an HIV-specific service. “If the machine can also load drugs for NCD [non-communicable diseases] patients because the machine is now stigmatized. So, if we can include other medications.” KI99 Participants also suggested incorporating other routine health services into the AMDS, such as blood tests, weight and blood pressure measurements. The goal was to streamline care by minimizing unnecessary interactions with healthcare workers and avoiding the long waits typically associated with receiving these services inside the clinic. “If there could be another machine there which we could use to check for our BP and weight and if we could access our laboratory results from the machine too, to avoid interacting with people.” KI39 “I'm not sure what they can do to make things simpler for us on days when we go to the laboratory. If we could get immediate assistance there, and if the results could be issued through the machine, then we could go to see a nurse after.” KI68 “If instead of having to go back and queue in the clinic for blood tests, if the machine could function in such a way that it can perform the blood tests.” KI73 Several participants expressed the need for improved communication features within the AMDS. They wanted the option to send health-related messages to healthcare workers, particularly outside of normal operating hours. Even if immediate assistance was not available, the ability to communicate concerns was viewed as valuable. Additionally, some participants suggested incorporating audio instructions alongside written prompts to improve accessibility for elderly or illiterate users: “Sometimes I may need to see a nurse but if its after-hours then I can't so if there could be a section somewhere where we could comment with our concerns and issues.” KI62 “I think what would work best especially for the late hours would be if there could be a call center so we can get assistance over the phone at any time.” KI44 “Maybe if it could have a sound for those who cannot read.” KI75 “If the machine could be made in such a way that even the elderly can be able to use it without having to seek assistance.” KI32 Participants advocated for the decentralization of AMDS units to more health facilities, towns, and even community settings. They believe this would improve access and ensure that a greater number of clients would benefit from the service, particularly those living farther from major health centers: “I'm not sure but for now I would just suggest that the machine be decentralized because some of the people on treatment are unemployed and will not have transport money or some do not even have the time, so if we could access the machine in nearby places to where we reside.” KI39 “If the government could decentralize this machine to more sites to make it easily accessible to all people, like if it could be placed in shops and nearby clinics as well.” KI30 “I think with time we need to have more machines or decentralize them to communities to make the medication easily accessible to clients, it doesn’t need to be in health facilities, we can also utilize other facilities found in communities.” KI37 While some sites offered around-the-clock access, others restricted use due to security or facility closure after hours. Thus, participants emphasized the need for 24-hour access to AMDS in all facilities. Participants found these limitations inconvenient and expressed a desire for consistent 24/7 access to ensure flexibility in medication pickup regardless of time constraints. “I think it would be very convenient to have a 24-hour service, but still the clinic closes at 8 pm, so I am able to access my medication even after my classes.” KI9 “I think it would be best if the machine could operate 24 hours to allow us to access our medication at our convenient time, otherwise now the fact that they close at 8pm affects us. They can get a security officer too.” KI93 “.. . I wish in my facility it could be a 24-hour service.” KI82 “As I had suggested earlier, this service needs to be a 24-hour service.” KI82 Theme 4. Challenges associated with the AMDS are less burdensome than those experienced within traditional facility-based medication pickup While participants widely acknowledged the benefits of the AMDS, several challenges were also reported. Common issues included difficulties with PINs, such as forgotten or expired PINs, failure to receive SMS notifications, or mobile phone malfunctions that limited timely access to medication. Internet connectivity problems also disrupted access to AMDS. In cases like these, participants had to contact healthcare workers for support. “There is nothing except for the fact that the last time I went there my pin had expired but there was a lady assisting me and she directed me to go get another pin without so much waste of time I got a new pin and was able to get my medication.” KI3 “Just a concern I have about what would happen if I were to lose the pin.” KI5 “No, just that I missed the message but then they called me.” KI21 “Well, it becomes a challenge when you’ve lost your pin so maybe there could be a way to go to get assistance independently after we've lost the pins.” KI16 “My concern would be with the network on days when it is down, then I'd have to go to see a doctor.” KI32 Another challenge cited was the scheduling of separate appointments for ART pickup and routine blood tests. This arrangement was considered inconvenient, as it requires multiple visits to the facility. Participants noted that some clinics had begun to address this issue by integrating services or synchronizing appointment dates. “The machine is better, but you should schedule us for one appointment if we are supposed to do blood tests and pick up medication from the machine. What happens now is I get an SMS to pick up my medication then later I receive an SMS notifying me that I am due for blood tests.” KI29 “So far there's nothing as we only expect to get medication from the machine, but what I’ve noted is an improvement is that in the past you would go collect your medication from the machine then if you are due for blood tests then you'd go inside but now if it's your date to do tests you just find a paper which allows you to spend less time.” KI15 Despite these limitations, participants overwhelmingly preferred the AMDS over traditional pharmacy-based ART pickup. They emphasized that the challenges associated with AMDS were more manageable compared to those experienced in the pharmacy, such as long queues and lack of privacy. Several participants recounted instances where they left the facility without medication due to these challenges, which was not the case in the AMDS. “ [Referring to before getting ART in the AMDS]. .. when it is during my working hours [visiting the facility during work hours], you'd find a queue and stay in the hospital until you decide to leave without getting assistance because you have to go back to work.” (KI78) “Some people would miss their appointments because they don’t have enough time for waiting in queues at the clinic, so this [AMDS] has become advantageous for all of us.” KI39 “It helps save my time and I love the fact that there is a lot of privacy in the machine. You just go directly to the machine, and you'll be alone, unlike queuing at the pharmacy.” KI1 “It is very fast this side, you don’t find many people, so you have your privacy. Unlike when you are queuing, which makes you uncomfortable. This side you get to be relaxed, and you don’t interact with people.” (KI39) Word Frequency Analysis To visualize the interview data by word cloud, we identified six major categories: convenient, quicker, innovative, accurate, easier, and private, as shown in Fig. 1 . The word size in the figure represents the frequency of mentions by participants, with “Quicker” and “Convenient” emerging as the most frequently cited reasons for preferring the AMDS. Additionally, some participants valued the machine for its accuracy and privacy, highlighting key aspects that contribute to user preference. Discussion This study offers important insights into how people living with HIV in Eswatini experience and perceive the use of Automated Medication Dispensing Systems as a differentiated model of antiretroviral therapy delivery. The use of a mixed-methods explanatory sequential design strengthened the study, allowing for a nuanced understanding that combined the breadth of survey data with the depth of qualitative narratives. We included clients from five diverse health facilities across two of four regions in Eswatini, which improved the representativeness of our findings within similar public health settings. Additionally, providing the survey in both English and Siswati likely enhanced participation and response accuracy. The high level of engagement as evidenced by both the survey completion rates and the number of participants who agreed to follow-up interviews reflects the relevance of our study, and the acceptability of the AMDS model among users. The importance of offering patients more flexible and accessible ways to collect their medications with the ultimate outcomes of improving their satisfaction and adherence to treatment have been demonstrated by several studies. A randomized controlled trial exploring the effectiveness of in-home electronic medication dispensing systems among patients on chronic medications reported improved adherence with clients accessing these innovative models of service delivery 15 . Study conducted by HSRC (2024) 22 in South Africa reported that by allowing patients to pick up their ART at times that are most convenient for them, minimizing disruptions to their daily routines, addresses these unique needs. This innovative approach does not only enhance access to treatment but also supports ART adherence by allowing flexibility for clients particularly in resource limited settings 22 . Moreover, the system’s ability to reduce waiting times and provide privacy for medication collection significantly improves the patient’s experiences enhancing access without worrying about crowded waiting areas and long queues 23 . This study authenticates prior findings which suggest that innovative DSD models such as AMDS play a vital role in improving ART access and adherence especially in resource-limited settings 6 , 24 . A significant majority of study participants (94.4%) preferred using the AMDS over the traditional pharmacy medicines pick-up model. The strong user satisfaction is consistently reported from prior studies done in Kenya and South Africa that reported a high acceptability of pharmacy automation and ART lockers among stable ART clients 25 , 26 . Participants opined that ADMS greatly enhances convenience in access to medicine refills and a significant plurality (94%) stated that this model greatly reduces the time it takes to refill prescriptions. In South Africa, a study reported similar findings where a significant reduction in waiting times was noted 27 . Furthermore, our study findings revealed that 90.5% of participants had undetectable viral loads, while only 1.8% had a suppressed viral load. While this study did not specifically seek to establish the effect of ADMS on virologic suppression outcome, these results are suggestive of high adherence observed among participants who used ADMS as a contributing factor to the observed high virologic suppression rates. In 2020, Medecins Sans Frontieres reported that approaches such as fast-track pharmacy refills and decentralized drug distribution are linked to improved retention in care 28 . These services have been invaluable in overcoming the barriers to ART adherence and retention, such as stigma, the digital divide and privacy concerns and limited healthcare access 29 . Our study adds more evidence to the existing body of knowledge about factors contributing to observed high adherence and retention in care for patients receiving chronic care for their illnesses. The study participants expressed their satisfaction with the AMDS' ability to effectively address common challenges associated with facility-based ART collection, such as lengthy waiting times, restrictive clinic operation hours and worries about stigma. These findings are consistent with reports from population studies in Zimbabwe and Malawi where interventions such as community ART refill groups and medication lockers reduced the need for frequent clinical visit while enhancing high levels of adherence and viral load suppression 30 , 31 . In Tanzania, Okonji et al., (2022) 32 demonstrated that stigma remains a significant barrier to ART retention and service delivery models that enhance confidentiality can substantially improve adherence and treatment outcomes. Our study findings further render credence that adoption of AMDS on a wider scale would have positive implications for improved efficiency in care delivery through reduction in heavy workload for health care workers associated with prescriptions refills at the pharmacy. Despite these strengths, our study had several limitations that should be considered when interpreting the results. About 11.2% of the participants reported challenges with the AMDS utilization. Commonly cited concerns include expired PINs (4.9%), lack of human interaction to trouble shoot unanticipated challenges (2.4%) and related limited emergency support services (4.0%). This suggests that while AMDS enhances efficiency, integration of additional support mechanisms such as emergency helplines or periodic clinical check-ins could further optimize the model. Innovations should be tailored to patients' unique needs, addressing stigma, and providing personalized support to enhance user operability of innovative health solutions 24 . Similarly, such concerns were reported in a study in Zambia on digital interventions in the education sector where users expressed a desire for a balance between automation and occasional human interaction for reassurance 33 . Moreover, participants were drawn from clients already enrolled in the AMDS service delivery model; we may have excluded the views of those who declined to use the system or were not eligible for enrollment, potentially introducing selection bias. Second, data collection occurred immediately after medication pickup within the health facility, which may have influenced participants to provide more socially desirable responses. While our qualitative component added valuable context, we did not apply visual analysis such as the word cloud plot for negative responses, which could have helped systematically capture the frequency and nature of concerns raised. Additionally, the study focused solely on client perspectives; insights from healthcare workers or facility managers were not explored, which may have limited our understanding of operational challenges and system-level barriers. Finally, this study captured client experiences during the early implementation phase of AMDS. As such, it does not assess long-term outcomes, including sustained retention in care, medication adherence over time, or clinical outcomes such as viral suppression. These collectively warrant further exploration through longitudinal research as Eswatini considers expanding the AMDS model across more health facilities. Conclusion Our study underscores the strong user acceptance and perceived value of the AMDS in supporting medication delivery among people living with HIV. Participants, who were stable ART clients receiving chronic care, described the AMDS as convenient, easy to use, and timesaving. Beyond improving access, the AMDS also supports medication adherence and empowers clients by offering greater autonomy in treatment management. These findings suggest that AMDS holds significant potential to transform medication access in Eswatini. While a few concerns such as limited support in emergencies and the absence of face-to-face interaction with health providers were raised, future studies are encouraged to explore how the system can be refined to enhance long-term impact and feasibility in a wider range. As AMDS roll out continues, it is beneficial to establish a structured process to continuously assess patient’s changing needs and perspectives to ensure they are integrated into efforts to enhance patient satisfaction. Declarations Ethics approval and consent to participate For ethical review, the Eswatini Health and Human Research Review Board (EHHRRB – 146/2023) and Georgetown University Institutional Review Board (STUDY 00005423) reviewed and approved the implementation of the study. Study participants provided both a formal written informed consent for the feedback and follow-up phone interview, and verbal consent was also sought at the beginning of the follow-up phone interview. All study procedures were conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable Availability of data and materials The data used in this study is available and will be shared by the corresponding author upon request. Competing interest The authors declare no conflict of interest, and the funders had no role in the design, writing, or publication of this manuscript. Funding The implementation of this study was supported by the U.S. President’s Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention (Co-operative Agreement No.: NU2GGH002294), implemented by Georgetown University in collaboration with the Government of the Kingdom of Eswatini Authors’ Contributions Deus Bazira*: Conceptualization, Funding Acquisition, Supervision, Writing-Review & Editing, Validation, Project Administration. Deus Bazira accepts full responsibility for the finished work and the conduct of the study, has access to the data, and controls the decision to publish. Thokozani Maseko: Investigation, Data Curation, Formal Analysis, Writing-Original Draft Preparation, Methodology, Software, Visualization Weijun Yu*: Supervision, Writing-Original Draft Preparation, Writing-Review & Editing, Project Administration, Visualization Liyandza Mamba: Investigation, Writing-Original Draft Preparation Samson Haumba: Conceptualization, Writing-Original Draft Preparation, Supervision, Writing-Review & Editing, Project Administration Victor Williams: Conceptualization, Investigation, Methodology, Supervising data collection Jiaqin Wu: Formal Analysis, Writing-Original Draft Preparation, Methodology, Software Fezokuhle Khumalo: Writing-Original Draft Preparation Buhle Mkhonta: Writing-Original Draft Preparation Hugben Byarugaba: Writing-Original Draft Preparation Normusa Musarapasi: Writing-Original Draft Preparation, visualization Jaskeerat Thakral: Writing-Original Draft Preparation Thembisile Chili: Writing-introduction, study implementation supervision Pido Bongomin: Conceptualization, Study implementation oversight, Project Administration, Review of the first draft Arnold Mafukidze: Conceptualization, Study implementation oversight, Review of the first draft Sharon Kibwana: Conceptualization, Study implementation oversight, Project Administration, Review of the first draft Clara Nyakopota: Conceptualization, Study implementation oversight Sylvia Ojoo: Conceptualization, Study implementation oversight, Review manuscript final draft Acknowledgement We would like to thank Ms. Shannon Mulligan from Georgetown University Center for Global Health Practice and Impact for her valuable administrative support and coordination throughout the course of this project. 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Supplementary Files Supplementaryfile1PatientInterviewGuideandquestions.docx Diagram1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 11 Dec, 2025 Editor invited by journal 19 Nov, 2025 Editor assigned by journal 19 Nov, 2025 Submission checks completed at journal 19 Nov, 2025 First submitted to journal 18 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":72044,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eWord Cloud: Reasons for Preferring the AMDS\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8145607/v1/7a4db874415edaf6cb94d4ed.png"},{"id":99306901,"identity":"8625c9b1-05d8-451a-9a57-d9d5d46479de","added_by":"auto","created_at":"2025-12-31 16:03:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1278509,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8145607/v1/2ad0c80d-739b-4afe-be6a-1ee26f156db2.pdf"},{"id":98747552,"identity":"2d5b9f0f-1598-47b6-9697-29bae81ca873","added_by":"auto","created_at":"2025-12-22 08:52:55","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":30182,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile1PatientInterviewGuideandquestions.docx","url":"https://assets-eu.researchsquare.com/files/rs-8145607/v1/14f5a726361f7159402d19cf.docx"},{"id":98777742,"identity":"f0cb3422-90d7-43cd-87d5-d7876150e884","added_by":"auto","created_at":"2025-12-22 12:28:24","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":353358,"visible":true,"origin":"","legend":"","description":"","filename":"Diagram1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8145607/v1/67671ce97b28c5c0a8de7aaa.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Automated Medication Dispensing System: Are We Meeting Patient Needs? Insights from People Living with HIV’s Perspectives in Eswatini","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDrug dispensing is a critical step in therapeutic intervention continuum in health care delivery. Medicine dispensing function remains a purview of pharmaceutical staff led by a trained pharmacist in developed and resource rich settings. In resource-limited settings, however, the dispensing role has been task-shifted to other health care professional cadres including nurses\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. With advances in technology the labor-intensive function is getting further task-shifted to automated dispensing systems\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In chronic disease management process such as HIV/AIDS care, long term treatment adherence remains a concern \u0026ndash; considering more than 39.9 people million live with HIV\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGlobally, HIV/AIDS remains a major public health challenge, with 39.9\u0026nbsp;million people living with HIV (PLHIV) in 2023 and over 30\u0026nbsp;million accessing antiretroviral therapy (ART)\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Community-based delivery models, including decentralized clinics and peer support systems, have expanded ART access in remote regions\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. However, persistent challenges such as fragile health infrastructure, medication supply interruption, workforce shortages, and sociopolitical instability continue to undermine the progress\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Stigma, discrimination, and rising HIV drug resistance further threaten gains, particularly in low-resource and high-burden settings\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eInterruptions in ART delivery pose serious public health risks by increasing viral replication, accelerating disease progression, and heightening transmission rates\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Inconsistent adherence also drives the emergence of drug-resistant HIV strains, undermining treatment efficacy and narrowing future therapeutic options\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. HIV/AIDS life-long care and treatment nature presents strain on the health system and demands more patient commitment. AMDS seeks to alleviate the onerous time demands on patients seeking their medication re-fills and enhances their experience to strengthen long term treatment adherence to HIV anti-retroviral therapy and retention in care.\u003c/p\u003e \u003cp\u003eEswatini, a developing country in Southern Africa carries a huge HIV epidemic burden leading to sustain chronic shock to the country\u0026rsquo;s resource constrained health system. In addition, the country faces a growing need for chronic care, driven by a high burden of both non-communicable diseases (NCD) and HIV. In 2019, NCD accounted for 46% of all deaths\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Meanwhile, advances in antiretroviral therapy (ART) have transformed HIV into a chronic condition, leading to an aging population of people living with HIV (PLHIV) increasingly facing NCDs co-morbidities such as hypertension, diabetes, and cancer. This dual burden strains the healthcare system and highlights the need for integrated, patient-centered models that streamline service delivery, reduce provider workload, address socioeconomic barriers, ensure care continuity, and regularly assess care quality.\u003c/p\u003e \u003cp\u003eAutomated Medication Dispensing System (AMDS), originally introduced in the 1970s as tablet counters to improve accuracy and efficiency in hospital settings\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e, are increasingly recognized for their potential in chronic disease management. A recent study showed that AMDS can significantly reduce dispensing errors from 3.87 to 0 per 100,000 dispensations and improve inventory control, particularly when integrated across prescribing, dispensing, and administration processes\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. In a randomized control study, in-home AMDS have also demonstrated improved medication adherence among 50 years and above patients with chronic conditions, addressing physical and cognitive limitations through reminders and precise dosing \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. While inpatient use has been associated with reduced medication administration and disposing errors\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, there remains limited evidence on AMDS effectiveness in public health settings in Eswatini, especially HIV care.\u003c/p\u003e \u003cp\u003eEswatini has integrated technology into chronic disease management through the introduction of Automated Medication Dispensing Systems (AMDS), using HIV care and treatment medicines as an entry point with plans to scale this to other diseases. The country\u0026rsquo;s adoption of AMDS is driven by perceived benefits it offers to patients, providers and the health system. The AMDS perceived features include: enhanced security due to its electronically controlled medication distribution system; potential for increased accessibility; and promise of convenience. The AMDS introduced in Eswatini consists of a closed system unit with a touch-screen interface linked to secure storage compartments where prescribed pre-packaged medication parcels are stored. Patients enrolled in the system receive a one-time PIN code that allows them to access their medication from the system at their convenience.\u003c/p\u003e \u003cp\u003eWhile the AMDS present a promising solution for improving ART adherence, client perspectives on this innovation remain underexplored. Understanding client experiences is crucial to refining and scaling up AMDS implementation to ensure it remains client-centered, acceptable, and cost-effective. This study sought to assess client satisfaction, improved experience, acceptability, and convenience in using AMDS, to inform future programming and system improvements. By integrating user feedback into implementation strategies, Eswatini can optimize the impact of AMDS, to enhance long term patient retention in care and improve overall healthcare delivery efficiency.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design and setting\u003c/p\u003e \u003cp\u003eThe study was conducted at five health facilities in Manzini \u0026ndash; one of the regions of the country located in the west-center part of the country. The AMDS, referred to as dispensing lockers in the 2022 Eswatini Integrated HIV Management Guidelines\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e, and locally known as \u0026ldquo;\u003cem\u003eLula Meds\u003c/em\u003e\u0026rdquo; (\u003cem\u003eLula\u003c/em\u003e meaning \u0026ldquo;easy\u0026rdquo;), was introduced as part of differentiated care delivery models adopted by the country to improve access to antiretroviral therapy for people living with HIV/AIDS.\u003c/p\u003e \u003cp\u003eStudy facilities included the AIDS Healthcare Foundation Lamvelase Clinic; the Raleigh Fitkin Memorial Hospital; Luyengo Clinic; Chakaza Clinic; and Good Shepherd Hospital. A detailed description of the set up and implementation processes of the AMDS at these sites has been previously published\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Study participants consisted of ART clients who received HIV care through the AMDS model at these facilities.\u003c/p\u003e \u003cp\u003e This study employed a mixed methods study using an explanatory sequential design to collect data from participants at the five health facilities that implemented the initial phase of the AMDS.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe study took place from November 1, 2023, to March 31, 2024. Clients receiving ART at these facilities who had earlier accepted to receive their medications through the AMDS were invited to participate in the study. Prior to data collection, participant consent was received through a self-administered electronic form issued via a hand-held tablet, available in English and Siswati \u0026ndash; the local language. Respondent data was also collected using the same electronic tablet platform. After collecting their medication, clients were prompted to provide consent and complete the survey on the tablet. At the end of the surveys, participants who indicated willingness to participate in a follow-up interview were asked to provide their phone contact. A total of 100 participants consented to take part in the exploratory in-depth interviews. Two trained research assistants contacted these individuals by phone, providing further study information and scheduling interviews at the participant\u0026rsquo;s convenience. During the follow-up interview, verbal informed consent was obtained, which included consent to participate in the study and to record the interview. Participants were informed that they could withdraw from the study at any time during the interview process and there would be no repercussions. Interviews were conducted using a structured guide (\u003cb\u003eSupplementary File 1\u003c/b\u003e). Depending on their preference, participants were interviewed in either English or Siswati, and each session lasted approximately 20 minutes. Interviews were recorded using a tape recorder, and research assistants documented additional observations in the accompanying interview note.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003e Descriptive statistics were used to analyze quantitative data related to participants\u0026rsquo; demographic characteristics, AMDS use, and their perception of the system. Results were summarized using frequency and percentage tables. For qualitative data, trained research assistants transcribed and translated audio recordings from Siswati into English immediately following each interview. Two team members (TM, JD) reviewed the transcripts to ensure fidelity to the original recordings and accuracy of meaning in translation.\u003c/p\u003e \u003cp\u003eThematic analysis, following the multi-step approach described by Braun and Clarke (2006)\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, was used to interpret qualitative data. A shared digital platform facilitated collaborative coding and data reduction. The analysis was both inductive (data driven) and deductive (theory driven)\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, guided by a broader theoretical framework and incorporating constant comparison\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e and iterative refinement of codes. Team discussion began during data collection, allowing early identification of emerging patterns. Draft codes were developed and revised over time, culminating in the organization of related codes into overarching themes.\u003c/p\u003e \u003cp\u003e In addition to thematic analysis, a word frequency analysis was conducted on the qualitative interview data to further visualize participants' positive perceptions of the AMDS compared to traditional pharmacy services. Frequently mentioned terms were grouped into thematic categories to reflect broader concepts. For example, words such as \u0026ldquo;quickly\u0026rdquo;, \u0026ldquo;fast\u0026rdquo;, and \u0026ldquo;no queue\u0026rdquo; were categorized under \u0026ldquo;quicker\u0026rdquo;, while phrases like \u0026ldquo;pick-up after working hours\u0026rdquo; and \u0026ldquo;come at any time\u0026rdquo; were grouped as \"Convenient.\" The results were visually presented in a word cloud to highlight the most expressed sentiments.\u003c/p\u003e \u003cp\u003eMissing data was managed using the listwise deletion method. Participants who declined consent to participate in this study were considered missing data, accounting for 1.78% (13 individuals out of 730 participants). Given the low missing data rate (\u0026lt;\u0026thinsp;10%), these individuals were excluded, and descriptive data analysis was conducted using participants with complete data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eDemographic profile of study population\u003c/h2\u003e \u003cp\u003eMost participants (81%) were from Manzini region, and 66% were females (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below). All participants were aged 21 years or older, with a mean age of 42.8 years (\u0026plusmn;\u0026thinsp;9.8). Most individuals (90%) were on an optimized dolutegravir (DTG) containing regimen. Variability in duration of amount of ARVs dispensed to patients was observed, with 23.6% receiving less than 3 months, 47.9% receiving 3\u0026ndash;5 months, and 28.5% receiving at least 6 months of their drugs dispensed to take home during their visit to the clinic. The majority (99.9%) had been on ART for at least one year, and 98.2% of patients had either undetectable or suppressed viral loads.\u003c/p\u003e \u003cp\u003eOur descriptive statistical analysis further examined participants\u0026rsquo; use of the AMDS (summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The majority of participants (94.4%) reported a preference for using Lulameds, while 2.1% favored the traditional pharmacy pick-up approach. The remaining participants (3.5%) expressed no specific preference regarding the medication collection approach. Overall, participants found the AMDS easy to use (91.9%). Additionally, 94% reported the shortest clinic visit time of less than ten minutes.\u003c/p\u003e \u003cp\u003eThe most frequently cited advantages of the AMDS included convenience (31.2%), rapid processing (67.4%), reduced queuing time (59.7%), and immediate access to medication (55.9%). Only a small portion of participants (11.2%) reported any dissatisfaction with the AMDS. The concerns raised included limited support during an emergency (4%), lack of direct interaction with healthcare providers (2.4%), and failure to login due to expired PIN (4.9%). In \u003cb\u003eDiagram 1\u003c/b\u003e, we present a visual summary of the user experience and uptake of the AMDS, illustrating the overall flow from participant enrollment to user feedback on the system use.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Analysis of Participants\u0026rsquo; Demographic Characteristics\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDemographics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManzini\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e581 (81.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e473 (66.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLubombo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e136 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e244 (34.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eDuration on ART (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMean (SD): 42.8 (\u0026plusmn;\u0026thinsp;9.8) | Median: 43.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eMean (SD): 9.2 (\u0026plusmn;\u0026thinsp;0.34) | Median: 9.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76 (10.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (0.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e230 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e199 (27.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e41\u0026ndash;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e263 (36.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e260 (36.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51\u0026ndash;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e178 (24.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e79 (11.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eViral load status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cb\u003eMMD\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndetectable (\u0026lt;\u0026thinsp;50c/\u003cem\u003e\u0026micro;l\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e649 (90.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt; 3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e169 (23.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuppressed (50-1000c/\u003cem\u003e\u0026micro;l\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u0026ndash;5 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e344 (47.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnsuppressed (\u0026gt;\u0026thinsp;1000c/\u003cem\u003e\u0026micro;l\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026gt;= 6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e204 (28.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent ART Regimen\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTDF\u0026thinsp;+\u0026thinsp;3TC\u0026thinsp;+\u0026thinsp;DTG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e640 (90.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eABC\u0026thinsp;+\u0026thinsp;3TC\u0026thinsp;+\u0026thinsp;DTG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAZT\u0026thinsp;+\u0026thinsp;3TC\u0026thinsp;+\u0026thinsp;DTG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTDF\u0026thinsp;+\u0026thinsp;3TC\u0026thinsp;+\u0026thinsp;EFV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (1.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cem\u003eNote\u003c/em\u003e: \u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eThe sample size for this analysis is 717 individuals.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003e2\u003c/em\u003e \u003c/sup\u003e \u003cem\u003eMMD denotes Multi-Month Dispensing, refers to the practice of providing antiretroviral therapy (ART) clients with a supply of antiretroviral medications (ARVs) for more than one month at a time, reducing the need for monthly clinic visits and prescription renewals.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003e3\u003c/em\u003e \u003c/sup\u003e \u003cem\u003eTDF denotes tenofovir; 3TC denotes lamivudine; DTG denotes dolutegravir; AZT denotes zidovudine; EFV denotes efavirenz; ABC denotes abacavir.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Analysis of Automated Medication Dispensing Systems (AMDS) Usage\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eManzini\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLubombo\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedication pickup preference\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmart locker (AMDS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e677 (94.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e453 (95.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e224 (91.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e545 (93.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e132 (97.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePharmacy (traditional)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo preference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (3.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (2.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHow easy is using the AMDS\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEasy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e659 (91.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e440 (93.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e219 (89.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e524 (90.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e135 (99.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (0.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLength of time waited prior to receiving medication\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;10 mins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e674 (94.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e442 (93.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e232 (95.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e538 (92.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e136 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u0026ndash;20 mins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;20 mins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18 (3.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAspect of the AMDS the patient liked most\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCan pick up at any time (convenience\u003c/em\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e224 (31.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e148 (31.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e76 (31.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e176 (30.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48 (35.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e493 (68.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e325 (68.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e168 (68.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e405 (69.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88 (64.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eProcess is fast and efficient\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e483 (67.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e316 (66.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e167 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e411 (70.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72 (52.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e234 (32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e157 (33.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e77 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e170 (29.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64 (47.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNo long waiting in line\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e428 (59.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e287 (60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e141 (57.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e364 (62.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64 (47.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e289 (40.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e186 (39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e103 (42.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e217 (37.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e72 (52.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eImmediate access to medication\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e401 (55.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e202 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e114 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e301 (51.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15 (11.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e316 (44.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e271 (57.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130 (53.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e280 (48.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e121 (89.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAspects of the AMDS the patient disliked\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDissatisfaction with AMDS\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e637 (88.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e422 (89.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e215 (88.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e508 (87.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e129 (94.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (11.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (10.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29 (11.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73 (12.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (5.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLimited support available during emergencies\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (4.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 (4.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e688 (96.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e458 (96.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e230 (94.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e554 (95.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e134 (98.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eLack of interaction with a healthcare provider\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (2.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17 (2.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e700 (97.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e460 (97.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e240 (98.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e564 (97.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e136 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNot being examined by a clinician\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e717 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e473 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e244 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e581 (100.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e136 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eExpired PIN\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (2.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e682 (95.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e450 (95.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e232 (95.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e550 (94.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e132 (97.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote\u003c/em\u003e: \u003csup\u003e\u003cem\u003e1\u003c/em\u003e\u003c/sup\u003e\u003cem\u003eThe sample size for this analysis is 717 individuals.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003e2\u003c/em\u003e \u003c/sup\u003e \u003cem\u003eManzini is the economic and industrial hub region in central Eswatini.\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003csup\u003e \u003cem\u003e3\u003c/em\u003e \u003c/sup\u003e \u003cem\u003eLubombo is a mountainous region situated in eastern Eswatini.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDiagram 1. User Experience and Uptake of Automated Medication Dispensing System (AMDS)\u003c/h3\u003e\n\u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eThematic Analysis Findings\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of 100 participants took part in the qualitative exploration interviews. Analysis of their responses revealed interrelated themes that captured how the AMDS met their needs (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e): (1) AMDS is a convenient method of receiving ART; (2) Positive perceptions of AMDS motivate clients to adhere to treatment; (3) AMDS has the potential to benefit more clients if expanded; and (4) Challenges associated with the AMDS are less burdensome than those experienced within traditional facility-based medication pickup. These themes suggest that AMDS support clients by enhancing convenience, fostering a sense of being valued and trusted by the health care providers so that they can manage their health care needs, reducing barriers to ART access, and offering scalable benefits for broader implementation.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes Emerging from Participant Experiences with the Automated Medicine Dispensing System (AMDS)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. AMDS is a convenient method of receiving ART\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConvenience encompassed the ability to collect ART at any time, reduced waiting times, avoidance of queues at the pharmacy or clinic, and increased privacy during medication pickup.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Positive perceptions of AMDS motivate clients to adhere to treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants expressed that trust from health workers, prior experiences with pharmacy services, and concerns about being removed from the AMDS influenced their motivation to adhere to treatment.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. AMDS has the potential to benefit more clients if expanded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipants viewed AMDS expansion as including additional medications (e.g., painkillers), decentralizing AMDS to other health facilities or towns, and extending access to 24-hour availability in some sites.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Challenges associated with the AMDS are less burdensome than those experienced within traditional facility-based medication pickup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChallenges included personal issues such as lost or expired PINs or phone malfunctions, as well as facility-level concerns like appointment scheduling conflicts, queues, and occasional disagreements with staff. The AMDS barriers were seen as less burdensome than traditional service models.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTheme 1. AMDS is a convenient method of receiving ART\u003c/h2\u003e \u003cp\u003eWe broadly define convenience as the various mechanisms that facilitate easier access to ART for participants. Many reported the ability to collect medication at any time, including after hours or when healthcare workers were unavailable or the facility was closed. This flexibility, without being limited by clinic operating hours or staff schedules, was a key advantage. As stated by some participants,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I like the machine [AMDS] because you can come at any time and get my medication. I live at a quite distant place from the clinic, so the fact that I can come at any time, even if it\u0026rsquo;s late.\u0026rdquo; (KI25)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I prefer the machine [AMDS]. It is very convenient. I just go straight there and collect my medication.\u0026rdquo; (KI75)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The machine [AMDS] has been working well for me. You can use it at any time, even when I am not able to go to the clinic during the week, I can now go on Saturday, unlike with the nurses who do not work on weekends.\u0026rdquo; (KI79)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I prefer the machine [AMDS] because it operates for longer hours, and as a textile worker, I am not able to request time at work to go to the clinic so I can pass by after work.\u0026rdquo; (KI93)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;... the delays while queuing to see a nurse so you'd spend the whole day in the clinic.\u0026rdquo; (KI74)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eConvenience was also reflected in the faster process of accessing ART through AMDS. Participants were able to integrate medication pickup into their daily routines, such as during work breaks or while commuting, without disrupting other responsibilities. The time-saving aspect was especially important for employed clients, who could collect medication discreetly and efficiently.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I prefer the machine [AMDS] because most of the time when I go to the clinic, it's during my work hours, so I need something that will be quick for me, like this machine [AMDS].\u0026rdquo; (KI41)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The machine [AMDS] is quick, and even if you have limited time, you can still access your medication.\u0026rdquo; (KI56)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I used to find long queues and spend a lot of time at the clinic, yet I'm a very busy person. Since I started using the machine, I haven't experienced such issues. Now I just get there and collect.\u0026rdquo; (KI18)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The machine [AMDS] works better for me as I can take my lunch break at work and quickly get my medication instead of having to request some time at work.\u0026rdquo; (KI68)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I love that I can just take 15 minutes of my lunch break and quickly rush to the clinic to get my medication.\u0026rdquo; (KI77)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;As long as I got the message, even if I don\u0026rsquo;t have transport money, I can still make a plan as we are given an allowance of days to collect our medication, and also you can go there at any convenient time for you. You can also ask someone who's in town to get your parcel from the machine.\u0026rdquo; (KI30)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It's the time, especially because I'm a truck driver, so now I can just park it at the garage in 5 minutes, and I'll be done. You don\u0026rsquo;t even talk to anyone, as everything is well documented on the envelope. This machine even relieves the workload on the nurses.\u0026rdquo; (KI92)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that has made things easier for us, even when I\u0026rsquo;m at work no matter what time I knock off I can still access my medication and now I don\u0026rsquo;t have to ask for time out at work to go to the clinic so it also saves us from a lot of explanation that we need to do when asking to go to the clinic. So this just remains a personal issue.\u0026rdquo; (KI27)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also found the AMDS easy to use. After an initial orientation from a healthcare worker, most could operate the machine independently. If challenges arose, assistance was accessible either from healthcare staff during the day or from security officers after hours, further supporting seamless use. Some clients shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It's simple and all you need is your PIN.\u0026rdquo; (KI93)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I loved that you just punch your pin and collect your medication, there's nothing complicated about it.\u0026rdquo; (KI92)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;. .. they shouldn\u0026rsquo;t be afraid as they get taught how to use the machine, so it becomes easy.\u0026rdquo; (KI60)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;No, everything was properly explained to me, and even if I'd encounter a challenge, there are security officers at the gate who can assist me.\u0026rdquo; (KI29)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAdditional convenience was noted in the process of completing routine blood tests. Participants indicated that blood tests were quicker for those enrolled in AMDS, which reduced their overall time spent at the facility. ,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It usually takes less than 2 minutes as you just enter your pin and collect your medication from the lockers. If you must do blood tests, quickly you do that and leave.\u0026rdquo; (KI6)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eImportantly, enrollment in AMDS did not restrict access to healthcare providers. Participants appreciated that they could still request a consultation when needed, which reinforced their sense of continued care and support. Some clients shared:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;No, it doesn\u0026rsquo;t [affect me] because it\u0026rsquo;s not like I am no longer allowed to consult with nurses.\u0026rdquo; (KI77)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I love the machine as you are also reminded of your laboratory appointments, so there is no issue at all with it. I am happy with the machine as I don\u0026rsquo;t have to talk to anyone now.\u0026rdquo; (KI65)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was told that I can still consult with a nurse if I'm having a problem. I think that is okay, as it would happen that you would queue with people who needed to see the nurse, yet you are okay.\u0026rdquo; (KI56)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe absence of queues in the AMDS was frequently mentioned as a major benefit. Unlike traditional medication pickup at the pharmacy or consultation rooms, the AMDS allowed clients to avoid long waits, making the process less stressful and more efficient. Some participants excitedly praised AMDS\u0026rsquo; absence of queues,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The machine is fast. In this hospital, there are long queues, so I'm happy since I no longer get delayed now.\u0026rdquo; (KI54)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I have talked to some people who visit other clinics that don\u0026rsquo;t have the machine, and I told them that here we no longer have this thing of queuing and staying the whole day in the clinic.\u0026rdquo; KI84\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;This side there are no queues, so it avoids the delay, which makes things easier for us, rather than moving from bench to bench.\u0026rdquo; (KI30)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I am working, and I usually don\u0026rsquo;t have the time to go to the clinic, so now that there is the machine, I can just take 5 minutes and go to the clinic.\u0026rdquo; (KI99)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think the machine was a bold initiative. It helps us to take our medication properly and honor our appointment dates. There is no need to get stressed out about the queues and wasting time in the clinic.\u0026rdquo; (KI45)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I love that it saves me a lot of time, and it helps me avoid the queue, such that now I feel excited when I have to come to the clinic.\u0026rdquo; (KI96)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral participants valued the privacy offered by the AMDS. Fewer people around during pickup reduced the risk of accidental disclosures of their HIV status, enhancing their overall comfort with the process:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I would encourage those who are still not comfortable with disclosing to move to the machine as there is privacy, and no one will notice because quickly you'll be in and out of the clinic.\u0026rdquo; (KI93)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The machine is very fast and there's privacy. At the pharmacy, we queue in an open area so people can see you.\u0026rdquo; (KI55)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;. . .What I love the most is privacy. This side, you are alone, you don\u0026rsquo;t have to mingle with people.\u0026rdquo; (KI30)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I love the privacy provided by this machine. No one will notice that you were also in the clinic.\u0026rdquo; (KI53)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;What I love the most is that it saves time and the privacy it offers. Some of us are still not comfortable with people knowing about our HIV status, so inside the clinic, you come across a lot of people, even those you know, so people will end up knowing about your health status.\u0026rdquo; (KI64).\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eTheme 2. Positive perceptions of AMDS motivate clients to adhere to treatment\u003c/h3\u003e\n\u003cp\u003e Participants\u0026rsquo; perceptions of the AMDS reflected a combination of attitudes, beliefs, and motivations tied to their experience with the system. These perceptions were shaped by feelings of trust from healthcare workers, prior experiences with traditional ART delivery, and concerns about maintaining eligibility for AMDS use. Many participants recognized that access to AMDS was not automatic, it required meeting specific eligibility criteria set by healthcare workers, such as consistent adherence to treatment. This awareness served as a motivator for participants to take their medication as prescribed and to encourage others to do the same to gain or maintain access to AMDS. :\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, because now I know that not everyone is eligible for the machine, so I'd advise people to take their medication properly for good adherence.\u0026rdquo; KI19\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Yes, I once asked the nurse why it wasn\u0026rsquo;t everyone getting their medication from the machine, and I was told that it depends on one's adherence to treatment. So, I would also advise people to take their medication properly so they can be eligible for this service.\u0026rdquo; KI31\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I would encourage them to take their medication properly so they can also qualify for this machine, and on this side, you only need a PIN, so everything is fast, you don\u0026rsquo;t get delayed.\u0026rdquo; KI35.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor some, being selected for AMDS was interpreted as a sign of trust from healthcare workers. This sense of recognition fostered a desire not to disappoint providers and, in turn, reinforced their commitment to treatment adherence.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I believe the reason I'm using this machine is because the nurses knew that I was taking my medication properly. . .\u0026rdquo; KI71\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe convenience and benefits of AMDS were themselves a source of motivation. Participants felt that maintaining good adherence was a way of showing appreciation for a system that respects their time and privacy. One participant noted that,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It's just that as men we don't take good care of our health, but this machine favors us as we don't even queue, quickly you are done, then you can go back to work. There is no excuse now not to take your medication, everything has been made simpler for us.\u0026rdquo;KI92\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePrevious negative experiences with traditional ART pickup such as long queues, lack of privacy, or strained interactions with healthcare staff also shaped participants\u0026rsquo; appreciation of the AMDS. Some participants explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I was once mistreated at Zombodze Clinic, which can sometimes make you go back home without even getting your medication.\u0026rdquo; (KI41)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Inside the clinic, there are long queues, and you have to move from the reception to the counseling office, to the nurse and sometimes to the doctor, then to the pharmacy, which is time-consuming. So now I love that you only go directly to the machine.\u0026rdquo; (KI44)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There was too much delay; you'd get to the clinic in the morning and wait for the nurses to start working, then they'd attend to us one by one, which was too much of a waste of time; you had to start with the adherence officers.\u0026rdquo; (KI73)\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, there were several issues. You would get to the clinic at 9 am and leave at 3 pm, yet you don\u0026rsquo;t even have money to get something to eat, as you only have bus fare. Some of us reside in distant places, so we need to travel to access our medication. Also, you'd find that we were made to wait for a long time, so they call your file number first, then you go to other departments, which took a long time, but now in 5 minutes\u0026rsquo; time you board a bus back home. So, this machine has really made things easier for us.\u0026rdquo; (KI32)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Some participants expressed frustration with unnecessary or prior unpleasant interactions with healthcare workers, particularly when they were otherwise well and did not feel the need for clinical consultation. AMDS allowed them to avoid these encounters, which they viewed as time-consuming or emotionally draining:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Before, I would have to interact with nurses even if I\u0026rsquo;m not in a good mood, now I just go to the machine and get what I came for.\u0026rdquo; KI97\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In the past, you'd face problems. Let's say you're still new, and when you get there, you find the nurse in a grumpy mood. But now you just get there, collect your medication, and then you're done. This won't discourage you, cause you to discontinue taking your medication, as compared to when you would get annoyed by a nurse to the point that you feel like throwing away the medication.\u0026rdquo; KI27\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Sometimes you'd find that the nurses are on tea break, so you're made to wait, yet now I just go directly to the machine on my own, collect my medication and leave.\u0026rdquo; KI29\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;In the clinic, you'd find that the staff sometimes ignore us, and the machine just saves me from a lot of trouble which includes being provoked by the healthcare workers.\u0026rdquo; KI10\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThere was a recurring perception that poor adherence or clinical outcomes could lead to removal from the AMDS. This potential consequence created a strong incentive to remain adherent and retain access to the system. Participants\u0026rsquo; fear of losing AMDS benefits contributed to sustained motivation to stay on treatment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, I would love to [continue receiving ART in the AMDS], the only reason I'd stop using the machine is if I'd stop taking my medication properly, then I'd be disqualified from this machine.\u0026rdquo; KI70\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;.. . the only problem would be if we don\u0026rsquo;t take our medication properly. Otherwise, if I adhere well, it doesn\u0026rsquo;t affect me in any way.\u0026rdquo; KI62\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 3. AMDS has the potential to benefit more clients if expanded\u003c/h3\u003e\n\u003cp\u003eParticipants expressed strong interest in the expansion of AMDS in terms of both functionality and geographic reach. Expansion was described across three dimensions: diversify the range of services available through the AMDS, decentralize its presence to more health facilities and communities, and extend access to 24-hour availability. Participants noted that being able to collect other prescribed medications such as painkillers after clinician consultation would enhance the overall convenience. Some participants said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If maybe we could get other medication like painkillers whenever you made a complaint to the doctor about pain, rather than then having to go to the pharmacy for the painkillers as this is time consuming.\u0026rdquo; KI2\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I'm not sure but if it could also dispense more medication instead of ART as there are long queues in all departments.\u0026rdquo; KI64\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome highlighted that expanding the range of medications dispensed could help reduce stigma associated with AMDS, which is currently viewed primarily as an HIV-specific service.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If the machine can also load drugs for NCD [non-communicable diseases] patients because the machine is now stigmatized. So, if we can include other medications.\u0026rdquo; KI99\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants also suggested incorporating other routine health services into the AMDS, such as blood tests, weight and blood pressure measurements. The goal was to streamline care by minimizing unnecessary interactions with healthcare workers and avoiding the long waits typically associated with receiving these services inside the clinic.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If there could be another machine there which we could use to check for our BP and weight and if we could access our laboratory results from the machine too, to avoid interacting with people.\u0026rdquo; KI39\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I'm not sure what they can do to make things simpler for us on days when we go to the laboratory. If we could get immediate assistance there, and if the results could be issued through the machine, then we could go to see a nurse after.\u0026rdquo; KI68\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If instead of having to go back and queue in the clinic for blood tests, if the machine could function in such a way that it can perform the blood tests.\u0026rdquo; KI73\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSeveral participants expressed the need for improved communication features within the AMDS. They wanted the option to send health-related messages to healthcare workers, particularly outside of normal operating hours. Even if immediate assistance was not available, the ability to communicate concerns was viewed as valuable. Additionally, some participants suggested incorporating audio instructions alongside written prompts to improve accessibility for elderly or illiterate users:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes I may need to see a nurse but if its after-hours then I can't so if there could be a section somewhere where we could comment with our concerns and issues.\u0026rdquo; KI62\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think what would work best especially for the late hours would be if there could be a call center so we can get assistance over the phone at any time.\u0026rdquo; KI44\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Maybe if it could have a sound for those who cannot read.\u0026rdquo; KI75\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;If the machine could be made in such a way that even the elderly can be able to use it without having to seek assistance.\u0026rdquo; KI32\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Participants advocated for the decentralization of AMDS units to more health facilities, towns, and even community settings. They believe this would improve access and ensure that a greater number of clients would benefit from the service, particularly those living farther from major health centers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I'm not sure but for now I would just suggest that the machine be decentralized because some of the people on treatment are unemployed and will not have transport money or some do not even have the time, so if we could access the machine in nearby places to where we reside.\u0026rdquo; KI39\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If the government could decentralize this machine to more sites to make it easily accessible to all people, like if it could be placed in shops and nearby clinics as well.\u0026rdquo; KI30\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think with time we need to have more machines or decentralize them to communities to make the medication easily accessible to clients, it doesn\u0026rsquo;t need to be in health facilities, we can also utilize other facilities found in communities.\u0026rdquo; KI37\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhile some sites offered around-the-clock access, others restricted use due to security or facility closure after hours. Thus, participants emphasized the need for 24-hour access to AMDS in all facilities. Participants found these limitations inconvenient and expressed a desire for consistent 24/7 access to ensure flexibility in medication pickup regardless of time constraints.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think it would be very convenient to have a 24-hour service, but still the clinic closes at 8 pm, so I am able to access my medication even after my classes.\u0026rdquo; KI9\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I think it would be best if the machine could operate 24 hours to allow us to access our medication at our convenient time, otherwise now the fact that they close at 8pm affects us. They can get a security officer too.\u0026rdquo; KI93\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;.. . I wish in my facility it could be a 24-hour service.\u0026rdquo; KI82\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;As I had suggested earlier, this service needs to be a 24-hour service.\u0026rdquo; KI82\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 4. Challenges associated with the AMDS are less burdensome than those experienced within traditional facility-based medication pickup\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWhile participants widely acknowledged the benefits of the AMDS, several challenges were also reported. Common issues included difficulties with PINs, such as forgotten or expired PINs, failure to receive SMS notifications, or mobile phone malfunctions that limited timely access to medication. Internet connectivity problems also disrupted access to AMDS. In cases like these, participants had to contact healthcare workers for support.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There is nothing except for the fact that the last time I went there my pin had expired but there was a lady assisting me and she directed me to go get another pin without so much waste of time I got a new pin and was able to get my medication.\u0026rdquo; KI3\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Just a concern I have about what would happen if I were to lose the pin.\u0026rdquo; KI5\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;No, just that I missed the message but then they called me.\u0026rdquo; KI21\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Well, it becomes a challenge when you\u0026rsquo;ve lost your pin so maybe there could be a way to go to get assistance independently after we've lost the pins.\u0026rdquo; KI16\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;My concern would be with the network on days when it is down, then I'd have to go to see a doctor.\u0026rdquo; KI32\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother challenge cited was the scheduling of separate appointments for ART pickup and routine blood tests. This arrangement was considered inconvenient, as it requires multiple visits to the facility. Participants noted that some clinics had begun to address this issue by integrating services or synchronizing appointment dates.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The machine is better, but you should schedule us for one appointment if we are supposed to do blood tests and pick up medication from the machine. What happens now is I get an SMS to pick up my medication then later I receive an SMS notifying me that I am due for blood tests.\u0026rdquo; KI29\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So far there's nothing as we only expect to get medication from the machine, but what I\u0026rsquo;ve noted is an improvement is that in the past you would go collect your medication from the machine then if you are due for blood tests then you'd go inside but now if it's your date to do tests you just find a paper which allows you to spend less time.\u0026rdquo; KI15\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDespite these limitations, participants overwhelmingly preferred the AMDS over traditional pharmacy-based ART pickup. They emphasized that the challenges associated with AMDS were more manageable compared to those experienced in the pharmacy, such as long queues and lack of privacy. Several participants recounted instances where they left the facility without medication due to these challenges, which was not the case in the AMDS.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;\u003c/em\u003e[Referring to before getting ART in the AMDS]. .. \u003cem\u003ewhen it is during my working hours\u003c/em\u003e [visiting the facility during work hours], \u003cem\u003eyou'd find a queue and stay in the hospital until you decide to leave without getting assistance because you have to go back to work.\u0026rdquo; (KI78)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Some people would miss their appointments because they don\u0026rsquo;t have enough time for waiting in queues at the clinic, so this [AMDS] has become advantageous for all of us.\u0026rdquo; KI39\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It helps save my time and I love the fact that there is a lot of privacy in the machine. You just go directly to the machine, and you'll be alone, unlike queuing at the pharmacy.\u0026rdquo; KI1\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;It is very fast this side, you don\u0026rsquo;t find many people, so you have your privacy. Unlike when you are queuing, which makes you uncomfortable. This side you get to be relaxed, and you don\u0026rsquo;t interact with people.\u0026rdquo; (KI39)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eWord Frequency Analysis\u003c/h2\u003e \u003cp\u003eTo visualize the interview data by word cloud, we identified six major categories: convenient, quicker, innovative, accurate, easier, and private, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The word size in the figure represents the frequency of mentions by participants, with \u0026ldquo;Quicker\u0026rdquo; and \u0026ldquo;Convenient\u0026rdquo; emerging as the most frequently cited reasons for preferring the AMDS. Additionally, some participants valued the machine for its accuracy and privacy, highlighting key aspects that contribute to user preference.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study offers important insights into how people living with HIV in Eswatini experience and perceive the use of Automated Medication Dispensing Systems as a differentiated model of antiretroviral therapy delivery. The use of a mixed-methods explanatory sequential design strengthened the study, allowing for a nuanced understanding that combined the breadth of survey data with the depth of qualitative narratives. We included clients from five diverse health facilities across two of four regions in Eswatini, which improved the representativeness of our findings within similar public health settings. Additionally, providing the survey in both English and Siswati likely enhanced participation and response accuracy. The high level of engagement as evidenced by both the survey completion rates and the number of participants who agreed to follow-up interviews reflects the relevance of our study, and the acceptability of the AMDS model among users.\u003c/p\u003e \u003cp\u003eThe importance of offering patients more flexible and accessible ways to collect their medications with the ultimate outcomes of improving their satisfaction and adherence to treatment have been demonstrated by several studies. A randomized controlled trial exploring the effectiveness of in-home electronic medication dispensing systems among patients on chronic medications reported improved adherence with clients accessing these innovative models of service delivery\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Study conducted by HSRC (2024)\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e in South Africa reported that by allowing patients to pick up their ART at times that are most convenient for them, minimizing disruptions to their daily routines, addresses these unique needs. This innovative approach does not only enhance access to treatment but also supports ART adherence by allowing flexibility for clients particularly in resource limited settings\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Moreover, the system\u0026rsquo;s ability to reduce waiting times and provide privacy for medication collection significantly improves the patient\u0026rsquo;s experiences enhancing access without worrying about crowded waiting areas and long queues\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. This study authenticates prior findings which suggest that innovative DSD models such as AMDS play a vital role in improving ART access and adherence especially in resource-limited settings\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA significant majority of study participants (94.4%) preferred using the AMDS over the traditional pharmacy medicines pick-up model. The strong user satisfaction is consistently reported from prior studies done in Kenya and South Africa that reported a high acceptability of pharmacy automation and ART lockers among stable ART clients\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Participants opined that ADMS greatly enhances convenience in access to medicine refills and a significant plurality (94%) stated that this model greatly reduces the time it takes to refill prescriptions. In South Africa, a study reported similar findings where a significant reduction in waiting times was noted\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFurthermore, our study findings revealed that 90.5% of participants had undetectable viral loads, while only 1.8% had a suppressed viral load. While this study did not specifically seek to establish the effect of ADMS on virologic suppression outcome, these results are suggestive of high adherence observed among participants who used ADMS as a contributing factor to the observed high virologic suppression rates. In 2020, Medecins Sans Frontieres reported that approaches such as fast-track pharmacy refills and decentralized drug distribution are linked to improved retention in care\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. These services have been invaluable in overcoming the barriers to ART adherence and retention, such as stigma, the digital divide and privacy concerns and limited healthcare access\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Our study adds more evidence to the existing body of knowledge about factors contributing to observed high adherence and retention in care for patients receiving chronic care for their illnesses.\u003c/p\u003e \u003cp\u003eThe study participants expressed their satisfaction with the AMDS' ability to effectively address common challenges associated with facility-based ART collection, such as lengthy waiting times, restrictive clinic operation hours and worries about stigma. These findings are consistent with reports from population studies in Zimbabwe and Malawi where interventions such as community ART refill groups and medication lockers reduced the need for frequent clinical visit while enhancing high levels of adherence and viral load suppression\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. In Tanzania, Okonji et al., (2022)\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e demonstrated that stigma remains a significant barrier to ART retention and service delivery models that enhance confidentiality can substantially improve adherence and treatment outcomes. Our study findings further render credence that adoption of AMDS on a wider scale would have positive implications for improved efficiency in care delivery through reduction in heavy workload for health care workers associated with prescriptions refills at the pharmacy.\u003c/p\u003e \u003cp\u003eDespite these strengths, our study had several limitations that should be considered when interpreting the results. About 11.2% of the participants reported challenges with the AMDS utilization. Commonly cited concerns include expired PINs (4.9%), lack of human interaction to trouble shoot unanticipated challenges (2.4%) and related limited emergency support services (4.0%). This suggests that while AMDS enhances efficiency, integration of additional support mechanisms such as emergency helplines or periodic clinical check-ins could further optimize the model. Innovations should be tailored to patients' unique needs, addressing stigma, and providing personalized support to enhance user operability of innovative health solutions\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Similarly, such concerns were reported in a study in Zambia on digital interventions in the education sector where users expressed a desire for a balance between automation and occasional human interaction for reassurance\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMoreover, participants were drawn from clients already enrolled in the AMDS service delivery model; we may have excluded the views of those who declined to use the system or were not eligible for enrollment, potentially introducing selection bias. Second, data collection occurred immediately after medication pickup within the health facility, which may have influenced participants to provide more socially desirable responses. While our qualitative component added valuable context, we did not apply visual analysis such as the word cloud plot for negative responses, which could have helped systematically capture the frequency and nature of concerns raised. Additionally, the study focused solely on client perspectives; insights from healthcare workers or facility managers were not explored, which may have limited our understanding of operational challenges and system-level barriers.\u003c/p\u003e \u003cp\u003eFinally, this study captured client experiences during the early implementation phase of AMDS. As such, it does not assess long-term outcomes, including sustained retention in care, medication adherence over time, or clinical outcomes such as viral suppression. These collectively warrant further exploration through longitudinal research as Eswatini considers expanding the AMDS model across more health facilities.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study underscores the strong user acceptance and perceived value of the AMDS in supporting medication delivery among people living with HIV. Participants, who were stable ART clients receiving chronic care, described the AMDS as convenient, easy to use, and timesaving. Beyond improving access, the AMDS also supports medication adherence and empowers clients by offering greater autonomy in treatment management. These findings suggest that AMDS holds significant potential to transform medication access in Eswatini. While a few concerns such as limited support in emergencies and the absence of face-to-face interaction with health providers were raised, future studies are encouraged to explore how the system can be refined to enhance long-term impact and feasibility in a wider range. As AMDS roll out continues, it is beneficial to establish a structured process to continuously assess patient\u0026rsquo;s changing needs and perspectives to ensure they are integrated into efforts to enhance patient satisfaction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor ethical review, the Eswatini Health and Human Research Review Board (EHHRRB \u0026ndash; 146/2023) and Georgetown University Institutional Review Board (STUDY 00005423) reviewed and approved the implementation of the study. Study participants provided both a formal written informed consent for the feedback and follow-up phone interview, and verbal consent was also sought at the beginning of the follow-up phone interview. All study procedures were conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used in this study is available and will be shared by the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interest\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflict of interest, and the funders had no role in the design, writing, or publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe implementation of this study was supported by the U.S. President\u0026rsquo;s Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention (Co-operative Agreement No.: NU2GGH002294), implemented by Georgetown University in collaboration with the Government of the Kingdom of Eswatini\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDeus Bazira*: Conceptualization, Funding Acquisition, Supervision, Writing-Review \u0026amp; Editing, Validation, Project Administration. Deus Bazira accepts full responsibility for the finished work and the conduct of the study, has access to the data, and controls the decision to publish.\u003c/p\u003e\n\u003cp\u003eThokozani Maseko: Investigation, Data Curation, Formal Analysis, Writing-Original Draft Preparation, Methodology, Software, Visualization\u003c/p\u003e\n\u003cp\u003eWeijun Yu*: Supervision, Writing-Original Draft Preparation, Writing-Review \u0026amp; Editing, Project Administration, Visualization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLiyandza Mamba: Investigation, Writing-Original Draft Preparation\u003c/p\u003e\n\u003cp\u003eSamson Haumba: Conceptualization, Writing-Original Draft Preparation, Supervision, Writing-Review \u0026amp; Editing, Project Administration\u003c/p\u003e\n\u003cp\u003eVictor Williams: Conceptualization, Investigation, Methodology, Supervising data collection\u003c/p\u003e\n\u003cp\u003eJiaqin Wu: Formal Analysis, Writing-Original Draft Preparation, Methodology, Software\u003c/p\u003e\n\u003cp\u003eFezokuhle Khumalo: Writing-Original Draft Preparation\u003c/p\u003e\n\u003cp\u003eBuhle Mkhonta: Writing-Original Draft Preparation\u003c/p\u003e\n\u003cp\u003eHugben Byarugaba: Writing-Original Draft Preparation\u003c/p\u003e\n\u003cp\u003eNormusa Musarapasi: Writing-Original Draft Preparation, visualization\u003c/p\u003e\n\u003cp\u003eJaskeerat Thakral: Writing-Original Draft Preparation\u003c/p\u003e\n\u003cp\u003eThembisile Chili: Writing-introduction, study implementation supervision\u003c/p\u003e\n\u003cp\u003ePido Bongomin: Conceptualization, Study implementation oversight, Project Administration, Review of the first draft\u003c/p\u003e\n\u003cp\u003eArnold Mafukidze: Conceptualization, Study implementation oversight, Review of the first draft\u003c/p\u003e\n\u003cp\u003eSharon Kibwana: Conceptualization, Study implementation oversight, Project Administration, Review of the first draft\u003c/p\u003e\n\u003cp\u003eClara Nyakopota: Conceptualization, Study implementation oversight\u003c/p\u003e\n\u003cp\u003eSylvia Ojoo: Conceptualization, Study implementation oversight, Review manuscript final draft \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Ms. Shannon Mulligan from Georgetown University Center for Global Health Practice and Impact for her valuable administrative support and coordination throughout the course of this project.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor\u0026rsquo;s information (optional)\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWiedenmayer KA, Kapologwe N, Charles J, Chilunda F, Mapunjo S. 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The impact of remote learning on educational outcomes: A case of selected higher learning institutions in Lusaka District, Zambia. Int J Res Publication Reviews. 2024;5(7):587\u0026ndash;96. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.55248/gengpi.2024.31274\u003c/span\u003e\u003cspan address=\"10.55248/gengpi.2024.31274\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Diagram 1","content":"\u003cp\u003eDiagram 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Automated Medication Dispensing System (AMDS), People living with HIV (PLHIV), Medication adherence, Noncommunicable diseases (NCD), Mixed methods study","lastPublishedDoi":"10.21203/rs.3.rs-8145607/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8145607/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile automated medication dispensing systems (ADMS) have been implemented in developed countries for some time to improve efficiency and enhance provider and patient experience, they are relatively a new phenomenon in Sub-Sahara Africa. There is limited evidence to date about how AMDS implementation has improved patient satisfaction in resource limited settings. This study aimed to generate evidence on patient experience by assessing satisfaction of patients living with HIV who adopted the ADMS to access medication for chronic disease care management in Eswatini.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA mixed methods study was conducted using an explanatory sequential design to collect data from 717 outpatients aged 18 and above accessing HIV care at five health facilities that implemented the AMDS in Manzini and Lubombo regions of Eswatini. Data was collected between November 1, 2023, through March 31, 2024. In-depth survey data was collected from 100 participants through 20-minute exploratory phone interviews. Descriptive statistics described participants’ demographic characteristics and their use of the AMDS. Thematic analysis was used to examine qualitative interview data, and word frequency analysis was conducted for visualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participants (81%) were from the Manzini region, and 99.9% had been on antiretroviral therapy (ART) for at least one year. Most participants found the AMDS easy to use (91.9%), and 94% reported experiencing the shortest waiting times (\u0026lt; 10 minutes). Key advantages cited for using the AMDS included convenience (31.2%), rapid processing (67.4%), reduced queuing time (59.7%), and immediate access to medication (55.9%). Only a small portion of participants (11.2%) expressed dissatisfaction with the AMDS. Thematic analysis revealed AMDS enhanced patient experience through: convenience in accessing ART; optimized adherence to treatment; held potential to benefit more clients if scaled up; and was perceived as less burdensome compared to conventional pharmacy window drug pick up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients expressed strong user acceptance of the AMDS for medication delivery among people living with HIV receiving chronic care. Participants found the system convenient, easy to use, and supportive of adherence through increased autonomy. While some limitations were raised, the AMDS shows great potential to improve medication access in Eswatini and should be further evaluated for broader implementation.\u003c/p\u003e","manuscriptTitle":"Automated Medication Dispensing System: Are We Meeting Patient Needs? Insights from People Living with HIV’s Perspectives in Eswatini","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 08:52:50","doi":"10.21203/rs.3.rs-8145607/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-12-12T02:50:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-19T14:35:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-19T10:09:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-19T10:09:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-11-18T12:37:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"25fa4ea0-800e-4969-a077-7b4a8dca77fa","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T08:52:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 08:52:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8145607","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8145607","identity":"rs-8145607","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}