Beyond Pill-Taking: Family Support, Side Effects, and Forgetting as Predictors of ART Non-Adherence in Zimbabwean Adolescents

Beyond Pill-Taking: Family Support, Side Effects, and Forgetting as Predictors of ART Non-Adherence in Zimbabwean Adolescents | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond Pill-Taking: Family Support, Side Effects, and Forgetting as Predictors of ART Non-Adherence in Zimbabwean Adolescents Loice Zinyowera¹, Faith Chiwungwe¹, Miriam Chitura¹ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9455908/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Adolescents living with HIV face disproportionately poor antiretroviral therapy (ART) adherence compared to adults. In Zimbabwe, viral suppression in adolescents on ART remains well below the national average and standard enhanced adherence counselling has yielded limited results. This study examined factors influencing ART adherence, challenges faced, and strategies to improve adherence among adolescents followed up at Sally Mugabe Central Hospital, Harare, Zimbabwe. Methods A cross-sectional quantitative survey was conducted with 120 participants comprising 50 adolescents aged 10–19 years living with HIV and on ART, 50 parents or guardians, and 20 healthcare providers. Structured questionnaires collected data on ART adherence patterns, barriers, and recommended strategies. Data were analysed using descriptive statistics and correlation analysis in SPSS. A pilot study was conducted with three participants per group to establish instrument reliability and validity. Results The response rate was 96.7% (116/120). Most adolescents reported taking ART as prescribed almost always (37.07%) or always (27.59%); however, 71.55% missed 1–3 doses per month. Lack of family support was the most frequently cited adherence factor (23.81%), followed by difficulty accessing ART (17.24%), stigma (16.25%), and forgetfulness (15.89%). Forgetfulness was the dominant challenge overall, reported by 84.48% of participants. Simplified dosing regimens were the most effective improvement strategy endorsed by 55.17% of respondents. Community outreach and regular follow-ups (20.69%) and family or caregiver involvement (18.10%) were the top provider-level strategies recommended. Conclusions ART non-adherence in Zimbabwean adolescents is driven by interacting psychosocial, structural, and treatment-related factors. Simplified dosing, reminder systems, and family-integrated counselling are the highest-priority interventions. Healthcare providers and policymakers must address structural and psychosocial barriers together to achieve sustained viral suppression in this population. antiretroviral therapy medication adherence adolescents HIV Zimbabwe sub-Saharan Africa viral suppression Background Antiretroviral therapy (ART) has transformed HIV infection from a fatal illness to a manageable chronic condition. Sustaining near-perfect adherence of 90–95% or above remains the central clinical challenge for long-term HIV management [ 1 ]. Globally, adolescents consistently demonstrate lower ART adherence rates and poorer virologic outcomes than adults, and long-term treatment outcome analyses across sub-Saharan Africa confirm this group as among the most at risk for suboptimal viral suppression [ 2 ]. Zimbabwe reflects this regional pattern. While national ART coverage stands at 96% and viral suppression at 93%, coverage among children and adolescents reaches only 71% with viral suppression at 85%, significantly below national benchmarks [ 3 ]. From January to June 2024, 104 adolescent patients at Sally Mugabe Central Hospital received enhanced adherence counselling but continued to record viral loads above 10,000 copies/mL [ 4 ], demonstrating that existing counselling interventions are insufficient for this population. The Zimbabwe Demographic Health Survey (2023) reported an overall ART adherence level of 62.3% among adolescents on ART [ 3 ]. Adolescence introduces a distinct vulnerability profile for treatment adherence. This developmental stage involves identity formation, risk-taking behaviour, incomplete cognitive and emotional maturation, limited financial autonomy, and heightened susceptibility to stigma and peer pressure [ 5 ]. These developmental characteristics create barriers to consistent medication-taking that differ fundamentally from those of adults. Studies across sub-Saharan Africa link poor adolescent ART adherence to inadequate family support, stigma, side effects, treatment fatigue, forgetfulness, and structural access barriers including transportation costs and clinic distance [ 6 , 7 , 8 ]. Despite Zimbabwe reporting 95% linkage of children and adolescents to ART as of 2020, adherence and viral suppression rates in this group lag significantly behind adults. Adolescents in Zimbabwe and across sub-Saharan Africa are underrepresented in ART adherence research, particularly in urban tertiary care settings where drug-related challenges and social pressures differ from rural contexts. Understanding the specific predictors of non-adherence in this setting is essential for designing effective, context-appropriate interventions. This study aimed to identify factors influencing ART adherence, explore the challenges faced by adolescents, and generate evidence-based recommendations for improving adherence among adolescents followed up at Sally Mugabe Central Hospital, Harare, Zimbabwe. Methods Study design and setting A cross-sectional descriptive quantitative study was conducted at Sally Mugabe Central Hospital, Harare, Zimbabwe. The hospital is the country's largest public referral hospital and provides ART services to a substantial adolescent HIV population. Data collection took place over a six-month period in 2024. Study population and sampling The total sample comprised 120 participants across three groups: 50 adolescents aged 10–19 years living with HIV and receiving ART, 50 parents or guardians of adolescents on ART, and 20 healthcare providers including doctors, nurses, and pharmacists involved in adolescent ART care. The target population was drawn from adolescents registered in the hospital's ART clinic registry. Adolescents were selected using simple random sampling from the clinic registry until the sample of 50 was reached. Healthcare providers were recruited through purposive sampling based on direct involvement in adolescent ART care at Sally Mugabe Central Hospital. Parents and guardians were recruited through convenience sampling at clinic appointments. Inclusion criteria required that adolescents were aged 10–19 years, living with HIV, and currently receiving ART. Adolescents not on ART or with significant co-morbidities materially affecting adherence were excluded. Data collection instruments Three structured questionnaires were designed for each participant group. The adolescent questionnaire covered demographic information, ART adherence frequency, number of missed doses, medication timing, factors affecting adherence, challenges experienced, coping strategies, healthcare provider interactions, and recommendations for improvement. The parent or guardian questionnaire assessed caregiving involvement, disclosure practices, reminder practices, and support mechanisms. The healthcare provider questionnaire addressed adherence monitoring methods, clinical challenges, and service delivery recommendations. A pilot study was conducted with three participants from each group prior to main data collection to test instrument validity and reliability. Questionnaires were distributed and collected in person by the researcher on the same day to minimise attrition. Data analysis Data were analysed using IBM SPSS Statistics. Descriptive statistics including frequencies, percentages, and measures of central tendency were computed for all variables. Correlation analysis examined relationships between adherence patterns and key explanatory variables. Results are presented as frequencies and percentages supported by tables. Ethical considerations Ethical approval was obtained from the Medical Research Council of Zimbabwe (MRCZ). Institutional clearance was granted by Sally Mugabe Central Hospital. Zimbabwe Open University provided supervisory approval. Written informed consent was obtained from all adult participants. For adolescent participants under 18 years, parental or guardian consent was obtained in addition to the adolescent's own assent. Participation was entirely voluntary and participants could withdraw at any time without consequence. All data were anonymised and used solely for research purposes. Results Participant characteristics The response rate was 96.7% with 116 of 120 questionnaires returned. Of the 50 adolescent participants, 40.52% were aged 17–19 years, 32.76% were 14–16 years, and 26.72% were 10–13 years. Female participants comprised 51.72% and males 48.28%. The majority (73.28%) were enrolled in secondary education and 26.72% had primary-level education. ART adherence patterns When asked how often they took ART as prescribed, 37.07% of adolescents reported almost always and 27.59% reported always. A quarter (25.00%) reported sometimes, 6.90% rarely, and 3.45% never (Table 1 ). Regarding missed doses, 71.55% reported missing 1–3 doses per month, 22.20% missed 4–6 doses, and 6.30% missed 7–9 doses (Table 2 ). Male adolescents constituted the majority of those reporting 1–3 missed doses. Evening was the most common medication-taking time (46.55%), followed by morning (33.62%) and afternoon (19.83%). Table 1 ART adherence frequency among adolescent participants (N = 116) Adherence frequency n % Always 32 27.59 Almost always 43 37.07 Sometimes 29 25.00 Rarely 8 6.90 Never 4 3.45 Participants were asked: How often do you take your ART medication as prescribed? (Scale: 1 = Never, 5 = Always) Table 2 Number of missed ART doses per month by sex (N = 116) Missed doses per month n % 1–3 doses 83 71.55 4–6 doses 26 22.20 7–9 doses 7 6.03 Male adolescents constituted the majority reporting 1–3 missed doses. Factors affecting ART adherence Participants identified several factors influencing their adherence. Lack of family support was the leading factor (23.81%), followed by difficulty accessing ART treatment (17.24%), stigma (16.25%), and forgetfulness (15.89%). Transportation challenges were cited by 10.48%, ART side effects by 9.04%, and cost by 7.29% (Table 3 ). Table 3 Factors affecting ART adherence among adolescent participants (N = 116) Factor n % Lack of family support 27 23.81 Difficulty accessing ART treatment 20 17.24 Stigma 19 16.25 Forgetfulness 18 15.89 Transportation challenges 12 10.48 ART side effects 10 9.04 Cost 8 7.29 Participants selected all applicable factors from a structured list. Adherence challenges and coping strategies Forgetfulness was the dominant adherence challenge, cited by 84.48% of adolescent participants. ART side effects were reported by 10.34%, stigma by 3.45%, and cost and transportation each by 0.86%. To address these challenges, 41.38% of participants used reminders and 37.93% used pillboxes or organisers. Family support was used by 9.48%, integration into daily routines by 5.17%, healthcare provider guidance by 3.45%, and mobile applications by 2.59%. Healthcare provider support Among factors related to healthcare provider interactions, satisfaction with healthcare providers was identified as the most influential by 38.79% of respondents. Frequency of adherence counselling was cited by 31.90%, and quality of the patient-provider relationship by 29.31% (Table 4 ). Table 4 Healthcare provider support factors cited by participants (N = 116) Healthcare provider factor n % Satisfaction with healthcare provider 45 38.79 Frequency of adherence counselling 37 31.90 Quality of patient-provider relationship 34 29.31 Strategies to improve ART adherence Simplified dosing regimens were rated the most effective patient-level improvement strategy by 55.17% of respondents, followed by reminder systems (18.97%), adherence counselling (14.66%), and support groups (11.21%). When asked about provider-level strategies, participants recommended community outreach programmes and regular follow-ups (20.69%), family or caregiver involvement (18.10%), simplified medication regimens (17.24%), improved patient-provider communication (16.38%), mental health support (14.66%), and enhanced patient education (12.93%). Discussion This study demonstrates that ART non-adherence among adolescents at Sally Mugabe Central Hospital arises from an interacting set of psychosocial, structural, and treatment-related factors, with three predictors dominating: lack of family support, difficulty accessing ART, and stigma. These findings are consistent with the existing sub-Saharan African literature while adding context-specific primary data from an urban tertiary care setting in Zimbabwe. Forgetfulness was the most frequently cited adherence challenge (84.48%), which aligns with studies linking missed doses in adolescents to competing demands, underdeveloped executive function, and the absence of structured carer reminders [ 6 ]. Adolescence involves incomplete development of self-regulatory capacity, which affects the sustainability of complex daily medication routines [ 5 ]. The high reported uptake of reminders (41.38%) and pillboxes (37.93%) as coping strategies indicates that patients are already adopting behavioural tools, and health systems should formalise and scale these approaches. Evidence supports that multicomponent behavioural strategies including simplified regimens, reminders, and family-based support are more effective than single-domain interventions [ 8 ]. Lack of family support as the top structural factor (23.81%) is consistent with qualitative findings from Botswana, where young adults living with perinatally acquired HIV described diminishing caregiver involvement as a key challenge as they aged into adolescence [ 9 ]. The biopsychosocial framework applied in this study positions family and social environment as central mediators of health behaviour [ 10 ]. The transition from caregiver-managed to self-managed adherence is a critical period where health systems must provide additional scaffolding. Stigma was cited by 16.25% of participants as an adherence factor. Studies in health facilities across multiple sub-Saharan African countries identify stigma as a structural barrier to treatment-seeking, retention in care, and adherence [ 11 ]. Stigma-driven concealment of HIV status leads directly to non-disclosure of medication-taking, missed doses, and eventual dropout from care [ 12 ]. Community-level and facility-level stigma reduction strategies must be prioritised alongside clinical interventions. ART side effects were cited by 9.04% as a factor and 10.34% as a challenge. Evidence supports that once-daily, single-tablet regimens improve retention in HIV care and reduce side-effect-related non-adherence compared to more complex multi-tablet regimens [ 13 ]. The 55.17% endorsement of simplified dosing as the highest-priority improvement strategy confirms that regimen simplification should be the first-line clinical response to non-adherence where clinically appropriate. Evidence on the safety and effectiveness of current paediatric and adolescent regimens provides a basis for clinicians to consider these options [ 18 ]. Provider satisfaction (38.79%) and counselling frequency (31.90%) were the most cited healthcare system factors. A non-judgmental, trust-based relationship between provider and adolescent patient is consistently associated with improved adherence outcomes [ 8 ]. Youth-friendly services with dedicated consultation spaces or hours would lower psychological barriers to honest communication at the point of care. Access barriers including transportation and distance (17.24% and 10.48%) reflect a structural dimension of non-adherence that clinical interventions alone cannot address. Barriers and facilitators research from other low- and middle-income settings confirms that physical access constraints are among the most consistent predictors of non-adherence and loss to follow-up [ 15 ]. Long-term multicountry cohort data from sub-Saharan Africa similarly identifies disrupted care continuity as a key driver of virologic failure [ 2 ]. Community-based ART refill programmes and mobile clinic approaches offer feasible structural solutions. Limitations This study was conducted at a single urban tertiary hospital, limiting generalisability to rural or community clinic settings. The six-month data collection period does not capture long-term adherence trends or seasonal variation. The quantitative design provides breadth but not depth; qualitative inquiry into lived experiences would enrich understanding of the mechanisms behind reported barriers. Self-reported adherence data are subject to social desirability bias, which may have led to over-reporting of adherence. The study population was restricted to adolescents currently in care, and those lost to follow-up represent an important group whose barriers remain uncaptured. Conclusions ART non-adherence among adolescents at Sally Mugabe Central Hospital is driven by forgetfulness, inadequate family support, stigma, access barriers, and side effects. These factors operate together and require integrated, multi-level responses rather than isolated clinical interventions. Simplified dosing regimens, structured reminder systems, family-integrated counselling, and youth-friendly services are the interventions most strongly supported by both this study's findings and the broader evidence base. Health systems must shift from treating adolescent non-adherence as an individual failing and address it as a systems-level challenge. Investment in nurse-led community outreach, peer support, mental health integration, and structural access improvements will be essential to close the gap between adolescent and adult viral suppression rates in Zimbabwe and comparable settings across sub-Saharan Africa. Abbreviations ART Antiretroviral therapy HIV Human Immunodeficiency Virus AIDS Acquired Immune Deficiency Syndrome MRCZ Medical Research Council of Zimbabwe SPSS Statistical Package for the Social Sciences VLS Viral load suppression PLHIV People living with HIV SSA Sub-Saharan Africa WHO World Health Organisation UNAIDS Joint United Nations Programme on HIV/AIDS Declarations Ethics approval and consent to participate Ethical approval was obtained from the Medical Research Council of Zimbabwe (MRCZ/B/2810). Institutional clearance was granted by Sally Mugabe Central Hospital (SMCHE171024/106), Harare, Zimbabwe. Zimbabwe Open University provided supervisory approval. Written informed consent was obtained from all adult participants. For participants under 18 years, written parental or guardian consent and adolescent assent were obtained. All methods were carried out in accordance with the Declaration of Helsinki. Consent for publication Not applicable. This manuscript does not contain data from any individual persons. Availability of data and materials The datasets supporting the conclusions of this article are included within the article and its tables. The original anonymised questionnaire data are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research received no external funding. It was conducted as part of the undergraduate nursing science degree requirements at Zimbabwe Open University. No funders had any role in study design, data collection, analysis, interpretation, or manuscript preparation. Authors' contributions LZ designed the study, developed the data collection instruments, collected and analysed data, and drafted the manuscript. FC provided primary supervision, guided the conceptual and theoretical framework, and critically revised the manuscript. MC critically reviewed the manuscript. All authors have read and approved the final manuscript. Acknowledgements The authors thank the adolescent participants, parents, guardians, and healthcare providers at Sally Mugabe Central Hospital who gave their time and shared their experiences. The support of the hospital management and the Medical Research Council of Zimbabwe in facilitating this research is gratefully acknowledged. References Darby A, Jones SH, Hope S, Hiv K. World Health Organization guidelines (Option A, B, and B+) for antiretroviral drugs to treat pregnant women and prevent HIV infection in infants. Embryo Proj Encycl. 2021. Inzaule SC, Kroeze S, Kityo CM, Siwale M, Akanmu S, Wellington M, et al. Long-term HIV treatment outcomes and associated factors in sub-Saharan Africa: multicountry longitudinal cohort analysis. AIDS. 2022;36(10):1437–47. Zimbabwe. Vulnerability Assessment Committee (ZimVac). Annual Report 2023. Harare: ZimVac; 2023. Sally Mugabe Central Hospital. Monthly Progress Return Form (MPRF) Annual Report 2023. Harare; 2023. Seiffge-Krenke I. Adolescents' health: a developmental perspective. Psychology; 2019. Peter M. Factors contributing to non-adherence to antiretroviral therapy among HIV clients attending ART clinic at Ndejje Health Centre IV, Kampala District. 2022. Kalichman SC, Katner H, Banas E, Hill M, Kalichman MO. HIV-related stigma and non-adherence to antiretroviral medications among people living with HIV in a rural setting. Soc Sci Med. 2020;258:113092. Casale M, Carlqvist A, Cluver L. Recent interventions to improve retention in HIV care and adherence to antiretroviral treatment among adolescents and youth: a systematic review. AIDS Patient Care STDS. 2019;33(6):237–52. Karugaba G, Thupayagale-Tshweneagae G, Moleki MM, Matshaba M. Challenges and coping strategies among young adults living with perinatally acquired HIV infection in Botswana: a qualitative study. PLoS ONE. 2023;18(4):e0284467. Miles E. Biopsychosocial model. Encyclopedia of behavioral medicine. Springer; 2020. pp. 259–60. Nyblade L, Stockton MA, Giger K, Bond V, Ekstrand ML, Lean RM, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med. 2019;17(1):25. Nhlongolwane N, Shonisani T. Predictors and barriers associated with non-adherence to ART by people living with HIV and AIDS in a selected local municipality of Limpopo Province, South Africa. Open AIDS J. 2023;17(1). Bor J, Kluberg SA, LaValley MP, Evans D, Hirasen K, Maskew M, et al. One pill, once a day: simplified treatment regimens and retention in HIV care. Am J Epidemiol. 2022;191(6):999–1008. Casale M, Carlqvist A, Cluver L. Recent interventions to improve retention in HIV care and adherence to antiretroviral treatment among adolescents and youth: a systematic review. AIDS Patient Care STDS. 2019;33(6):237–52. Gabster A, Socha E, Pascale JM, Cabezas Talavero G, Castrellón A, Quiel Y, et al. Barriers and facilitators to antiretroviral adherence and retention in HIV care among people living with HIV in the Comarca Ngäbe-Buglé, Panama. PLoS ONE. 2022;17(6):e0270044. Dear N, Esber A, Iroezindu M, Bahemana E, Kibuuka H, Maswai J, et al. Routine HIV clinic visit adherence in the African Cohort Study. AIDS Res Ther. 2022;19(1):1. Mavhu W, Willis N, Mufuka J, et al. Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial. Lancet Glob Health. 2020;8(2):e264–75. Saint-Lary L, Dassi Tchoupa Revegue MH, Jesson J, Renaud F, Penazzato M, Townsend CL, et al. Effectiveness and safety of atazanavir use for the treatment of children and adolescents living with HIV: a systematic review. Front Pediatr. 2022;10:913105. Hlophe LD, Tamuzi JL, Shumba C, Nyasulu PS. Barriers to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: a mixed-methods systematic review. PLoS ONE. 2022. Heath K, Levi J, Hill A. The Joint United Nations Programme on HIV/AIDS 95-95-95 targets: worldwide clinical and cost benefits of generic manufacture. AIDS. 2021;35(Suppl 2):S197–203. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 07 May, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers agreed at journal 28 Apr, 2026 Reviewers invited by journal 28 Apr, 2026 Editor assigned by journal 22 Apr, 2026 Submission checks completed at journal 22 Apr, 2026 First submitted to journal 18 Apr, 2026 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. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9455908","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":633959109,"identity":"1e4ae937-74ec-4de9-a21c-d7519adf2e79","order_by":0,"name":"Loice Zinyowera¹","email":"","orcid":"","institution":"Zimbabwe Open University","correspondingAuthor":false,"prefix":"","firstName":"Loice","middleName":"","lastName":"Zinyowera¹","suffix":""},{"id":633959110,"identity":"29d65d32-cfd1-4ae1-b125-ef4baf26a663","order_by":1,"name":"Faith Chiwungwe¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACCcYGCIP58AEQV4YELWxpCSAuDxFaYAy2HAMQRVgL/+zmNmneHbWJ/Ww8n1/dqLHgYWA/fHQDXkvuHARqOXM8cWYb7zbrnGNAh/Gkpd3Ap8VAIrHtNm/bsdwN93u3GeewAbVI8JgRp2X/MZ5nxjn/iNdSk7uBjYf5cW4bEVokbiS2/5zbdqB+xjE2M+bcPgkeNkJ+4Z+R/tjgbVudMX8b8+PPOd/q5PjZDx/DqwUKDoMINnAcsRGhHATqQATzByJVj4JRMApGwQgDAHKSSFZzFfshAAAAAElFTkSuQmCC","orcid":"","institution":"Zimbabwe Open University","correspondingAuthor":true,"prefix":"","firstName":"Faith","middleName":"","lastName":"Chiwungwe¹","suffix":""},{"id":633959111,"identity":"41d373d5-f529-40a5-856c-18521c85724b","order_by":2,"name":"Miriam Chitura¹","email":"","orcid":"","institution":"Zimbabwe Open University","correspondingAuthor":false,"prefix":"","firstName":"Miriam","middleName":"","lastName":"Chitura¹","suffix":""}],"badges":[],"createdAt":"2026-04-18 10:23:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9455908/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9455908/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108647351,"identity":"f5a16d91-e849-4e66-97d7-bc6e9110a289","added_by":"auto","created_at":"2026-05-07 00:21:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":216976,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9455908/v1/c27a1a7a-6b3e-46a5-aacf-1643eebdd1b5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Pill-Taking: Family Support, Side Effects, and Forgetting as Predictors of ART Non-Adherence in Zimbabwean Adolescents","fulltext":[{"header":"Background","content":"\u003cp\u003eAntiretroviral therapy (ART) has transformed HIV infection from a fatal illness to a manageable chronic condition. Sustaining near-perfect adherence of 90\u0026ndash;95% or above remains the central clinical challenge for long-term HIV management [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Globally, adolescents consistently demonstrate lower ART adherence rates and poorer virologic outcomes than adults, and long-term treatment outcome analyses across sub-Saharan Africa confirm this group as among the most at risk for suboptimal viral suppression [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eZimbabwe reflects this regional pattern. While national ART coverage stands at 96% and viral suppression at 93%, coverage among children and adolescents reaches only 71% with viral suppression at 85%, significantly below national benchmarks [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. From January to June 2024, 104 adolescent patients at Sally Mugabe Central Hospital received enhanced adherence counselling but continued to record viral loads above 10,000 copies/mL [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], demonstrating that existing counselling interventions are insufficient for this population. The Zimbabwe Demographic Health Survey (2023) reported an overall ART adherence level of 62.3% among adolescents on ART [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdolescence introduces a distinct vulnerability profile for treatment adherence. This developmental stage involves identity formation, risk-taking behaviour, incomplete cognitive and emotional maturation, limited financial autonomy, and heightened susceptibility to stigma and peer pressure [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These developmental characteristics create barriers to consistent medication-taking that differ fundamentally from those of adults. Studies across sub-Saharan Africa link poor adolescent ART adherence to inadequate family support, stigma, side effects, treatment fatigue, forgetfulness, and structural access barriers including transportation costs and clinic distance [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite Zimbabwe reporting 95% linkage of children and adolescents to ART as of 2020, adherence and viral suppression rates in this group lag significantly behind adults. Adolescents in Zimbabwe and across sub-Saharan Africa are underrepresented in ART adherence research, particularly in urban tertiary care settings where drug-related challenges and social pressures differ from rural contexts. Understanding the specific predictors of non-adherence in this setting is essential for designing effective, context-appropriate interventions.\u003c/p\u003e \u003cp\u003e This study aimed to identify factors influencing ART adherence, explore the challenges faced by adolescents, and generate evidence-based recommendations for improving adherence among adolescents followed up at Sally Mugabe Central Hospital, Harare, Zimbabwe.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eA cross-sectional descriptive quantitative study was conducted at Sally Mugabe Central Hospital, Harare, Zimbabwe. The hospital is the country's largest public referral hospital and provides ART services to a substantial adolescent HIV population. Data collection took place over a six-month period in 2024.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population and sampling\u003c/h3\u003e\n\u003cp\u003e The total sample comprised 120 participants across three groups: 50 adolescents aged 10\u0026ndash;19 years living with HIV and receiving ART, 50 parents or guardians of adolescents on ART, and 20 healthcare providers including doctors, nurses, and pharmacists involved in adolescent ART care. The target population was drawn from adolescents registered in the hospital's ART clinic registry.\u003c/p\u003e \u003cp\u003eAdolescents were selected using simple random sampling from the clinic registry until the sample of 50 was reached. Healthcare providers were recruited through purposive sampling based on direct involvement in adolescent ART care at Sally Mugabe Central Hospital. Parents and guardians were recruited through convenience sampling at clinic appointments. Inclusion criteria required that adolescents were aged 10\u0026ndash;19 years, living with HIV, and currently receiving ART. Adolescents not on ART or with significant co-morbidities materially affecting adherence were excluded.\u003c/p\u003e\n\u003ch3\u003eData collection instruments\u003c/h3\u003e\n\u003cp\u003eThree structured questionnaires were designed for each participant group. The adolescent questionnaire covered demographic information, ART adherence frequency, number of missed doses, medication timing, factors affecting adherence, challenges experienced, coping strategies, healthcare provider interactions, and recommendations for improvement. The parent or guardian questionnaire assessed caregiving involvement, disclosure practices, reminder practices, and support mechanisms. The healthcare provider questionnaire addressed adherence monitoring methods, clinical challenges, and service delivery recommendations.\u003c/p\u003e \u003cp\u003eA pilot study was conducted with three participants from each group prior to main data collection to test instrument validity and reliability. Questionnaires were distributed and collected in person by the researcher on the same day to minimise attrition.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eData were analysed using IBM SPSS Statistics. Descriptive statistics including frequencies, percentages, and measures of central tendency were computed for all variables. Correlation analysis examined relationships between adherence patterns and key explanatory variables. Results are presented as frequencies and percentages supported by tables.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003ewas obtained from the Medical Research Council of Zimbabwe (MRCZ). Institutional clearance was granted by Sally Mugabe Central Hospital. Zimbabwe Open University provided supervisory approval. Written informed consent was obtained from all adult participants. For adolescent participants under 18 years, parental or guardian consent was obtained in addition to the adolescent's own assent. Participation was entirely voluntary and participants could withdraw at any time without consequence. All data were anonymised and used solely for research purposes.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eThe response rate was 96.7% with 116 of 120 questionnaires returned. Of the 50 adolescent participants, 40.52% were aged 17\u0026ndash;19 years, 32.76% were 14\u0026ndash;16 years, and 26.72% were 10\u0026ndash;13 years. Female participants comprised 51.72% and males 48.28%. The majority (73.28%) were enrolled in secondary education and 26.72% had primary-level education.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eART adherence patterns\u003c/h3\u003e\n\u003cp\u003eWhen asked how often they took ART as prescribed, 37.07% of adolescents reported almost always and 27.59% reported always. A quarter (25.00%) reported sometimes, 6.90% rarely, and 3.45% never (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding missed doses, 71.55% reported missing 1\u0026ndash;3 doses per month, 22.20% missed 4\u0026ndash;6 doses, and 6.30% missed 7\u0026ndash;9 doses (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Male adolescents constituted the majority of those reporting 1\u0026ndash;3 missed doses. Evening was the most common medication-taking time (46.55%), followed by morning (33.62%) and afternoon (19.83%).\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\u003eART adherence frequency among adolescent participants (N\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdherence frequency\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\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlmost always\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eParticipants were asked: How often do you take your ART medication as prescribed? (Scale: 1\u0026thinsp;=\u0026thinsp;Never, 5\u0026thinsp;=\u0026thinsp;Always)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\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\u003eNumber of missed ART doses per month by sex (N\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissed doses per month\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\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;3 doses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u0026ndash;6 doses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026ndash;9 doses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eMale adolescents constituted the majority reporting 1\u0026ndash;3 missed doses.\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFactors affecting ART adherence\u003c/h2\u003e \u003cp\u003eParticipants identified several factors influencing their adherence. Lack of family support was the leading factor (23.81%), followed by difficulty accessing ART treatment (17.24%), stigma (16.25%), and forgetfulness (15.89%). Transportation challenges were cited by 10.48%, ART side effects by 9.04%, and cost by 7.29% (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\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\u003eFactors affecting ART adherence among adolescent participants (N\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\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\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLack of family support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.81\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty accessing ART treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForgetfulness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransportation challenges\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eART side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.29\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eParticipants selected all applicable factors from a structured list.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eAdherence challenges and coping strategies\u003c/h2\u003e \u003cp\u003eForgetfulness was the dominant adherence challenge, cited by 84.48% of adolescent participants. ART side effects were reported by 10.34%, stigma by 3.45%, and cost and transportation each by 0.86%.\u003c/p\u003e \u003cp\u003e To address these challenges, 41.38% of participants used reminders and 37.93% used pillboxes or organisers. Family support was used by 9.48%, integration into daily routines by 5.17%, healthcare provider guidance by 3.45%, and mobile applications by 2.59%.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare provider support\u003c/h2\u003e \u003cp\u003eAmong factors related to healthcare provider interactions, satisfaction with healthcare providers was identified as the most influential by 38.79% of respondents. Frequency of adherence counselling was cited by 31.90%, and quality of the patient-provider relationship by 29.31% (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHealthcare provider support factors cited by participants (N\u0026thinsp;=\u0026thinsp;116)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare provider factor\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\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction with healthcare provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.79\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrequency of adherence counselling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.90\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality of patient-provider relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrategies to improve ART adherence\u003c/h2\u003e \u003cp\u003eSimplified dosing regimens were rated the most effective patient-level improvement strategy by 55.17% of respondents, followed by reminder systems (18.97%), adherence counselling (14.66%), and support groups (11.21%). When asked about provider-level strategies, participants recommended community outreach programmes and regular follow-ups (20.69%), family or caregiver involvement (18.10%), simplified medication regimens (17.24%), improved patient-provider communication (16.38%), mental health support (14.66%), and enhanced patient education (12.93%).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that ART non-adherence among adolescents at Sally Mugabe Central Hospital arises from an interacting set of psychosocial, structural, and treatment-related factors, with three predictors dominating: lack of family support, difficulty accessing ART, and stigma. These findings are consistent with the existing sub-Saharan African literature while adding context-specific primary data from an urban tertiary care setting in Zimbabwe.\u003c/p\u003e \u003cp\u003eForgetfulness was the most frequently cited adherence challenge (84.48%), which aligns with studies linking missed doses in adolescents to competing demands, underdeveloped executive function, and the absence of structured carer reminders [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Adolescence involves incomplete development of self-regulatory capacity, which affects the sustainability of complex daily medication routines [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The high reported uptake of reminders (41.38%) and pillboxes (37.93%) as coping strategies indicates that patients are already adopting behavioural tools, and health systems should formalise and scale these approaches. Evidence supports that multicomponent behavioural strategies including simplified regimens, reminders, and family-based support are more effective than single-domain interventions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLack of family support as the top structural factor (23.81%) is consistent with qualitative findings from Botswana, where young adults living with perinatally acquired HIV described diminishing caregiver involvement as a key challenge as they aged into adolescence [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The biopsychosocial framework applied in this study positions family and social environment as central mediators of health behaviour [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The transition from caregiver-managed to self-managed adherence is a critical period where health systems must provide additional scaffolding.\u003c/p\u003e \u003cp\u003eStigma was cited by 16.25% of participants as an adherence factor. Studies in health facilities across multiple sub-Saharan African countries identify stigma as a structural barrier to treatment-seeking, retention in care, and adherence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Stigma-driven concealment of HIV status leads directly to non-disclosure of medication-taking, missed doses, and eventual dropout from care [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Community-level and facility-level stigma reduction strategies must be prioritised alongside clinical interventions.\u003c/p\u003e \u003cp\u003eART side effects were cited by 9.04% as a factor and 10.34% as a challenge. Evidence supports that once-daily, single-tablet regimens improve retention in HIV care and reduce side-effect-related non-adherence compared to more complex multi-tablet regimens [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The 55.17% endorsement of simplified dosing as the highest-priority improvement strategy confirms that regimen simplification should be the first-line clinical response to non-adherence where clinically appropriate. Evidence on the safety and effectiveness of current paediatric and adolescent regimens provides a basis for clinicians to consider these options [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProvider satisfaction (38.79%) and counselling frequency (31.90%) were the most cited healthcare system factors. A non-judgmental, trust-based relationship between provider and adolescent patient is consistently associated with improved adherence outcomes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Youth-friendly services with dedicated consultation spaces or hours would lower psychological barriers to honest communication at the point of care.\u003c/p\u003e \u003cp\u003eAccess barriers including transportation and distance (17.24% and 10.48%) reflect a structural dimension of non-adherence that clinical interventions alone cannot address. Barriers and facilitators research from other low- and middle-income settings confirms that physical access constraints are among the most consistent predictors of non-adherence and loss to follow-up [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Long-term multicountry cohort data from sub-Saharan Africa similarly identifies disrupted care continuity as a key driver of virologic failure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Community-based ART refill programmes and mobile clinic approaches offer feasible structural solutions.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study was conducted at a single urban tertiary hospital, limiting generalisability to rural or community clinic settings. The six-month data collection period does not capture long-term adherence trends or seasonal variation. The quantitative design provides breadth but not depth; qualitative inquiry into lived experiences would enrich understanding of the mechanisms behind reported barriers. Self-reported adherence data are subject to social desirability bias, which may have led to over-reporting of adherence. The study population was restricted to adolescents currently in care, and those lost to follow-up represent an important group whose barriers remain uncaptured.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eART non-adherence among adolescents at Sally Mugabe Central Hospital is driven by forgetfulness, inadequate family support, stigma, access barriers, and side effects. These factors operate together and require integrated, multi-level responses rather than isolated clinical interventions.\u003c/p\u003e \u003cp\u003eSimplified dosing regimens, structured reminder systems, family-integrated counselling, and youth-friendly services are the interventions most strongly supported by both this study's findings and the broader evidence base. Health systems must shift from treating adolescent non-adherence as an individual failing and address it as a systems-level challenge. Investment in nurse-led community outreach, peer support, mental health integration, and structural access improvements will be essential to close the gap between adolescent and adult viral suppression rates in Zimbabwe and comparable settings across sub-Saharan Africa.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eART\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntiretroviral therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eHIV\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eAIDS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcquired Immune Deficiency Syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eMRCZ\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMedical Research Council of Zimbabwe\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSPSS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eVLS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eViral load suppression\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003ePLHIV\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeople living with HIV\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eSSA\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSub-Saharan Africa\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWorld Health Organisation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e\u003cb\u003eUNAIDS\u003c/b\u003e\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJoint United Nations Programme on HIV/AIDS\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthical approval was obtained from the Medical Research Council of Zimbabwe (MRCZ/B/2810). Institutional clearance was granted by Sally Mugabe Central Hospital (SMCHE171024/106), Harare, Zimbabwe. Zimbabwe Open University provided supervisory approval. Written informed consent was obtained from all adult participants. For participants under 18 years, written parental or guardian consent and adolescent assent were obtained. All methods were carried out in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain data from any individual persons.\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets supporting the conclusions of this article are included within the article and its tables. The original anonymised questionnaire data are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no external funding. It was conducted as part of the undergraduate nursing science degree requirements at Zimbabwe Open University. No funders had any role in study design, data collection, analysis, interpretation, or manuscript preparation.\u003c/p\u003e\n\u003ch2\u003eAuthors\u0026apos; contributions\u003c/h2\u003e\n\u003cp\u003eLZ designed the study, developed the data collection instruments, collected and analysed data, and drafted the manuscript. FC provided primary supervision, guided the conceptual and theoretical framework, and critically revised the manuscript. MC critically reviewed the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eThe authors thank the adolescent participants, parents, guardians, and healthcare providers at Sally Mugabe Central Hospital who gave their time and shared their experiences. The support of the hospital management and the Medical Research Council of Zimbabwe in facilitating this research is gratefully acknowledged.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDarby A, Jones SH, Hope S, Hiv K. World Health Organization guidelines (Option A, B, and B+) for antiretroviral drugs to treat pregnant women and prevent HIV infection in infants. Embryo Proj Encycl. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInzaule SC, Kroeze S, Kityo CM, Siwale M, Akanmu S, Wellington M, et al. Long-term HIV treatment outcomes and associated factors in sub-Saharan Africa: multicountry longitudinal cohort analysis. AIDS. 2022;36(10):1437\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimbabwe. Vulnerability Assessment Committee (ZimVac). Annual Report 2023. Harare: ZimVac; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSally Mugabe Central Hospital. Monthly Progress Return Form (MPRF) Annual Report 2023. Harare; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeiffge-Krenke I. Adolescents' health: a developmental perspective. Psychology; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePeter M. Factors contributing to non-adherence to antiretroviral therapy among HIV clients attending ART clinic at Ndejje Health Centre IV, Kampala District. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKalichman SC, Katner H, Banas E, Hill M, Kalichman MO. HIV-related stigma and non-adherence to antiretroviral medications among people living with HIV in a rural setting. Soc Sci Med. 2020;258:113092.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasale M, Carlqvist A, Cluver L. Recent interventions to improve retention in HIV care and adherence to antiretroviral treatment among adolescents and youth: a systematic review. AIDS Patient Care STDS. 2019;33(6):237\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKarugaba G, Thupayagale-Tshweneagae G, Moleki MM, Matshaba M. Challenges and coping strategies among young adults living with perinatally acquired HIV infection in Botswana: a qualitative study. PLoS ONE. 2023;18(4):e0284467.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiles E. Biopsychosocial model. Encyclopedia of behavioral medicine. Springer; 2020. pp. 259\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNyblade L, Stockton MA, Giger K, Bond V, Ekstrand ML, Lean RM, et al. Stigma in health facilities: why it matters and how we can change it. BMC Med. 2019;17(1):25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNhlongolwane N, Shonisani T. Predictors and barriers associated with non-adherence to ART by people living with HIV and AIDS in a selected local municipality of Limpopo Province, South Africa. Open AIDS J. 2023;17(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBor J, Kluberg SA, LaValley MP, Evans D, Hirasen K, Maskew M, et al. One pill, once a day: simplified treatment regimens and retention in HIV care. Am J Epidemiol. 2022;191(6):999\u0026ndash;1008.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCasale M, Carlqvist A, Cluver L. Recent interventions to improve retention in HIV care and adherence to antiretroviral treatment among adolescents and youth: a systematic review. AIDS Patient Care STDS. 2019;33(6):237\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGabster A, Socha E, Pascale JM, Cabezas Talavero G, Castrell\u0026oacute;n A, Quiel Y, et al. Barriers and facilitators to antiretroviral adherence and retention in HIV care among people living with HIV in the Comarca Ng\u0026auml;be-Bugl\u0026eacute;, Panama. PLoS ONE. 2022;17(6):e0270044.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDear N, Esber A, Iroezindu M, Bahemana E, Kibuuka H, Maswai J, et al. Routine HIV clinic visit adherence in the African Cohort Study. AIDS Res Ther. 2022;19(1):1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMavhu W, Willis N, Mufuka J, et al. Effect of a differentiated service delivery model on virological failure in adolescents with HIV in Zimbabwe (Zvandiri): a cluster-randomised controlled trial. Lancet Glob Health. 2020;8(2):e264\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaint-Lary L, Dassi Tchoupa Revegue MH, Jesson J, Renaud F, Penazzato M, Townsend CL, et al. Effectiveness and safety of atazanavir use for the treatment of children and adolescents living with HIV: a systematic review. Front Pediatr. 2022;10:913105.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHlophe LD, Tamuzi JL, Shumba C, Nyasulu PS. Barriers to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: a mixed-methods systematic review. PLoS ONE. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeath K, Levi J, Hill A. The Joint United Nations Programme on HIV/AIDS 95-95-95 targets: worldwide clinical and cost benefits of generic manufacture. AIDS. 2021;35(Suppl 2):S197\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":"aids-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arty","sideBox":"Learn more about [AIDS Research and Therapy](http://aidsrestherapy.biomedcentral.com/)","snPcode":"12981","submissionUrl":"https://submission.nature.com/new-submission/12981/3","title":"AIDS Research and Therapy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"antiretroviral therapy, medication adherence, adolescents, HIV, Zimbabwe, sub-Saharan Africa, viral suppression","lastPublishedDoi":"10.21203/rs.3.rs-9455908/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9455908/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdolescents living with HIV face disproportionately poor antiretroviral therapy (ART) adherence compared to adults. In Zimbabwe, viral suppression in adolescents on ART remains well below the national average and standard enhanced adherence counselling has yielded limited results. This study examined factors influencing ART adherence, challenges faced, and strategies to improve adherence among adolescents followed up at Sally Mugabe Central Hospital, Harare, Zimbabwe.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional quantitative survey was conducted with 120 participants comprising 50 adolescents aged 10\u0026ndash;19 years living with HIV and on ART, 50 parents or guardians, and 20 healthcare providers. Structured questionnaires collected data on ART adherence patterns, barriers, and recommended strategies. Data were analysed using descriptive statistics and correlation analysis in SPSS. A pilot study was conducted with three participants per group to establish instrument reliability and validity.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe response rate was 96.7% (116/120). Most adolescents reported taking ART as prescribed almost always (37.07%) or always (27.59%); however, 71.55% missed 1\u0026ndash;3 doses per month. Lack of family support was the most frequently cited adherence factor (23.81%), followed by difficulty accessing ART (17.24%), stigma (16.25%), and forgetfulness (15.89%). Forgetfulness was the dominant challenge overall, reported by 84.48% of participants. Simplified dosing regimens were the most effective improvement strategy endorsed by 55.17% of respondents. Community outreach and regular follow-ups (20.69%) and family or caregiver involvement (18.10%) were the top provider-level strategies recommended.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eART non-adherence in Zimbabwean adolescents is driven by interacting psychosocial, structural, and treatment-related factors. Simplified dosing, reminder systems, and family-integrated counselling are the highest-priority interventions. Healthcare providers and policymakers must address structural and psychosocial barriers together to achieve sustained viral suppression in this population.\u003c/p\u003e","manuscriptTitle":"Beyond Pill-Taking: Family Support, Side Effects, and Forgetting as Predictors of ART Non-Adherence in Zimbabwean Adolescents","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-07 00:20:50","doi":"10.21203/rs.3.rs-9455908/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-07T22:24:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187986962138571467554026539393467116699","date":"2026-04-28T20:15:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295611447822448050299553546328035027118","date":"2026-04-28T13:00:00+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-28T12:14:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-22T19:33:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-22T11:43:35+00:00","index":"","fulltext":""},{"type":"submitted","content":"AIDS Research and Therapy","date":"2026-04-18T10:18:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"aids-research-and-therapy","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arty","sideBox":"Learn more about [AIDS Research and Therapy](http://aidsrestherapy.biomedcentral.com/)","snPcode":"12981","submissionUrl":"https://submission.nature.com/new-submission/12981/3","title":"AIDS Research and Therapy","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b926f9f8-d423-404e-95a2-a9bc11a3682e","owner":[],"postedDate":"May 7th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-07T22:24:16+00:00","index":16,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T00:20:50+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-07 00:20:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9455908","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9455908","identity":"rs-9455908","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}