Stigma and Substance Use as Barriers to ART Adherence Among Youth Living with HIV in Zambia

Background: Despite progress in Zambia’s HIV response, the disease still poses a significant health burden on the country. In 2021, Zambia had the 7th highest adult HIV prevalence worldwide at 10.8%, with over 15,000 new infections occurring among youth aged 15-24. The progression of HIV to AIDS has devastating consequences, especially among young people. Between 2005 and 2015, there was a 45% increase in AIDS-related deaths among youth aged 15-19, and AIDS ranks as the second leading cause of death among young women in Africa. Anti-retroviral therapy (ART) is an effective treatment that suppresses HIV viral load by interfering with the viral replication cycle; however, youth living with HIV (YLHIV) in Zambia face significant barriers to antiretroviral therapy (ART) adherence, including stigma and substance use. In 2019, an estimated 65,000 adolescents in Zambia were living with HIV, with only about 60% on ART. Furthermore, 46% of YLHIV in Zambia reported missing a recent clinic appointment. This care deficit leaves most YLHIV virally non-suppressed, making them vulnerable to opportunistic infections and life-threatening complications. Methods: This study utilized qualitative analysis of focus group discussions (FGDs) among YLHIV (ages 18–24) receiving care at Kanyama First Level Hospital (KFLH) and Matero Urban Health Centre (MUHC) in Lusaka, Zambia. FGDs assessed participants’ experiences of ART adherence, substance use, and HIV self-management. There were six FGDs conducted, three among female participants and three among males. Participants were eligible based on <80% medication adherence in the previous month, combined with substance use during the same period. Results: FGDs revealed stigma and substance use as major barriers to ART adherence among YLHIV. Participants faced stigma from healthcare providers, family, and friends. Fear of disclosure led adolescents to hide their status, avoid taking medication in public, or disengage from care. Additionally, substance use with alcohol, cannabis, and amphetamines was found to worsen mental health and disrupt medication routines, leading to increased viral replication. Conclusion: Non-adherence to ART can be attributed to several intersectional factors, most notably stigma and substance use. To address these barriers, the next phase of the project will utilize FGD findings to design a culturally sensitive mobile health (mHealth) motivational text messaging (MTM) intervention. The intervention aims to improve ART adherence and health outcomes while reducing stigma, addressing substance use, and protecting privacy. Participants will receive motivational text messages reminding them to take their medications, attend clinic appointments, and reduce their substance use.