Table 3.

Findings from Qualitative Studies of General and Alcohol-specific Barriers to ART Adherence Among PLWH.

First author (Year)	Study Design	Mechanism+	Participant Characteristics	General Study Results	Alcohol & ART-Adherence Mechanism Results
Adeniyi et al., (2018)	Semi-structured interviews	Forgetting	100% female; 48.6% between age 21–30; PLWH (N = 177) from maternity facilities in South Africa	Barriers to ART adherence included: side-effects, travel away from primary clinic, forgetfulness, stigma and health systems factors.	Some participants reported that alcohol use, especially over weekends or festive periods, made them forget to take their HIV medications.
Axelsson et al., (2015)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs	61% female; M age = 39.8; PLWH (N = 28) from HIV clinics in Lesotho	Barriers to ART adherence included: interruptions of daily routines or leaving the house without medicine, while facilitators of ART adherence included use of alarms and social support.	Alcohol was identified as a barrier to ART adherence by 4/28 participants. Reasons included skipping medication due to concerns about interactions with alcohol and forgetfulness caused by alcohol.
Balcha et al., (2011)	FGDs & semi-structured interviews	Interactive toxicity beliefs	64% female; Age 26–37; PLWH (N = 14) and healthcare providers (N = 3) from hospitals in Ethiopia	Barriers to ART adherence included: financial constraints, stigma, and sociocultural factors, while disclosure, community support, and universal access to ART facilitated ART adherence.	Providers were described as recommending against alcohol use while on ART. Some participants reported a preference for missing doses of ART rather than abstaining from alcohol.
Barnett et al., (2013)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs	90% female; PLWH (N = 10) and healthcare providers (N = 11) from an HIV clinic in South Africa	Barriers to ART adherence included: side-effects, not using condoms, a lack of understanding around medication timing, time delay between medication and food intake, and large pill sizes.	Drinking was identified as a reason for ART failure by one participant, however, alcohol use was the most common reason for ART failure cited by providers. Patients were reported to often forget to take medication while drinking or actively avoid mixing alcohol with medications.
Bukenya et al., (2019)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs	60% female; M age = 41.7; PLWH (N = 30) from Uganda	Barriers to ART adherence included: travel for work or social activities, stigma, receiving little or no continuous ART adherence education, alcohol consumption, use of alternative ‘HIV cure’ medicines, ART side effects, treatment fatigue, belief that long-term ART or God can ‘cure HIV’, and food insecurity.	Two participants reported forgetting their ART due to alcohol use. No female participants reported using alcohol, reporting total cessation due to toxicity beliefs.
Conroy et al., (2017)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs	50% female; M age = 35.5; PLWH from HIV clinics in South Africa (N = 24 couples with at least one HIV-positive partner)	Several patterns of partner influence on alcohol use and ART emerged: Partners discouraged their significant other from mixing ART and alcohol, partners helped manage alcohol and ART use, and partners encouraged adherence to ART no matter what.	PLWH and their partners acknowledged that drinking alcohol can cause unintentional nonadherence. Some (16.7%) participants also endorsed interactive toxicity beliefs.
Conroy et al., (2019)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs; Social support	50% female; M age = 38; PLWH from HIV clinics in Malawi (N = 25 couples with at least one HIV-positive partner)	Relationship factors such as food insecurity, intimate partner violence, and extramarital relationships worsened the negative consequences of alcohol use on ART adherence. Women encouraged their partners to reduce alcohol use and offered adherence support when men were drinking. Men’s alcohol use was a barrier to supporting wives’ ART adherence.	Participants reported that alcohol use by men weakens the relationship and social support systems necessary for ART adherence. Women reported being more likely to experience IPV when men are drinking, which causes missed ART doses. Couples reported men forget to take medication while drinking.
Conroy et al., (2020)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs; Partner support	50% female; PLWH from HIV clinics in Malawi (N = 23 couples with at least one HIV-positive partner)	Alcohol use was described as a major barrier to ART adherence and was also viewed as the cause of couple and family violence, extramarital partnerships, food insecurity, and poverty.	Wives identified alcohol use as a barrier to ART adherence and endorsed interactive toxicity beliefs as a reason that was given by HIV counselors.
Dahab et al., (2008)	Semi-structured interviews	Forgetting	100% male; PLWH (N = 6) and healthcare providers (N = 5) from an HIV clinic in South Africa	Barriers to ART adherence included: alcohol use, being away from home, stigma, use of traditional medicines, and lack of belief in the existence of HIV and/or one’s own status.	Alcohol use was identified as a primary barrier to ART adherence by causing people to forget to take the medication.
Dickson-Gomez et al., (2015)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs	PLWH (N = 29) and healthcare providers (N = 13) from HIV clinics in El Salvador	PLWH who use substances experience barriers to accessing medical care including: a lack of knowledge of HIV and effective treatments, inconsistent linkage to care, and stigma within health care settings.	Participants described stopping ART when drinking alcohol. Many providers believed and told patients that alcohol in combination with ART was contraindicated and could cause severe side effects (including death). Some patients reported forgetting associated with long-term cognitive impairment from alcohol use.
Fitzgerald et al., (2010)	Semi-structured interviews	Interactive toxicity beliefs	100% male; PLWH (N = 8) from an HIV clinic in South Africa	Alcohol was reported to influence disclosure, uptake, and adherence to ART. Participants reported self-imposed delays to enroll in HIV treatment while attempting to reduce alcohol use.	Some participants expressed interactive toxicity beliefs and were concerned whether they could initiate ART based on their alcohol consumption.
Hershow et al., (2018)	Semi-structured interviews	Forgetting; Timing	40% female; Median age = 38; PLWH (N = 30) with alcohol use disorder from an HIV clinic in Vietnam	Barriers to reducing alcohol use included: availability/affordability of alcohol, social norms, lack of treatment, using alcohol to cope with HIV-related problems. Participants who reduced alcohol use and maintained high ART adherence reported social support as a buffer against social pressure to drink and drinking to cope.	Common reasons for missing ART doses included forgetfulness while under the influence of alcohol and perceived inability to take the medication when at a social event during their typical dosing time.
Laws et al., (2015)	Semi-structured interviews	Interactive toxicity beliefs	31.3% female; PLWH (N = 32) from the US	Participants generally reported limited and inaccurate biomedical understanding of HIV and ART. Participants expressed that strict adherence to ART regimens was important, with some endorsing periodic treatment interruption as beneficial.	Participants reported that ART medications should not be taken while drinking or using illicit drugs because they can “block” the medication. Some participants reported that they received these instructions from their doctor.
Lyimo et al., (2012)	Semi-structured interviews	Interactive toxicity beliefs	59.1% female; M age = 34; PLWH (N = 61) from HIV clinics in Tanzania	Facilitators of adherence included: social-support and assistance of home-based care providers. Barriers to ART adherence included: alcohol use, food insecurity, stigma and disclosure concerns, and the clinics dispensing too few pills.	Participants reported alcohol use was strictly prohibited to patients on ART, or that ART cannot be taken after alcohol had been consumed. Alcohol use was also reported as contributing to inconsistent adherence behaviors.
Madhombiro et al., (2018)	Focus group discussions	Forgetting; Interactive toxicity beliefs; Disinhibition	41% female; M age = 40; PLWH (N = 39) from HIV clinics in Zimbabwe	Major themes included: alcohol has negative effects on HIV treatment, PLWH who drink should be understood and take responsibility for reducing alcohol use, stigma interferes with HIV disclosure and disclosure of drinking to providers, and there is support available to those who wish to reduce alcohol use.	Participants reported awareness of both the direct and indirect effects of alcohol use on ART non-adherence Participants endorsed beliefs that alcohol and ART medications should not be mixed due to negative side-effects. Additionally, they perceived alcohol to negatively influence ART adherence by causing one to forget to take medications.
Moucheraud et al., (2019)	Semi-structured interviews	Forgetting	63.5% female; M age = 41.5; PLWH (N = 148) and healthcare providers (N = 49) from HIV clinics in Tanzania and Uganda	Barriers to adherence identified by PLWH included: distance from pill supply, food insecurity, pill burden/side effects, access to care. Barriers identified by providers included alcohol/alcoholism, stigma, and adherence education.	Although < 5% of participants identified alcohol as a barrier to ART adherence, most providers identified alcohol as a barrier to adherence based on patients forgetting healthcare appointments when intoxicated.
Mukumbang et al., (2017)	Semi-structured interviews and focus group discussions	Forgetting	56% female; PLWH (N = 45) and healthcare providers (N = 20) from HIV clinics in Zambia	Barriers to retention in HIV care included: individual (e.g., alcohol, side effects), interpersonal (e.g., stigma), institutional (e.g., drug shortages), and community (e.g., food insecurity) factors.	Heavy drinking was reported to affect ART adherence by causing participants to forget to take medications.
Nkosi et al., (2016)	Focus group discussions	Forgetting; Interactive toxicity beliefs	100% male; PLWH (N = 27) from HIV clinics in South Africa	Major themes regarding masculinity, alcohol use, and ART adherence included: construction of a health-oriented masculinity that challenged masculine norms, masculinity and HIV-related stigma, and power dynamics in patient-provider relationships that left men feeling powerless.	Participants reported that providers discouraged them from drinking alcohol due to interactive toxicity beliefs, and that healthcare professionals advised against consuming alcohol while on ART because it can cause patients to forget to take ART medications. Participants were resistant to following provider advice to abstain from alcohol while on ART.
Oliveira Serra et al., (2017)	Focus group discussions	Interactive toxicity beliefs; Stigma	44% female; Age range 28–70; PLWH (N = 25) from an HIV clinic in Brazil	Participants were not aware of the effects of using alcohol and other drugs on the reduction of immunity, did not endorse interactive toxicity beliefs, nor beliefs about alcohol and immune functioning.	Participants reported that there are no problems with mixing alcohol with ART, despite hearing otherwise from healthcare providers.
Pengpid et al., (2014)	Semi-structured interviews	Interactive toxicity beliefs	42% female; M age = 37; PLWH (N = 26) from HIV clinics in South Africa	Participants reported developing routines to drink alcohol around the times they took ART to reduce negative consequences, and reducing alcohol use when initiating ART or following education by health care staff.	Participants reported engaging in interactive toxicity avoidance behaviors (e.g., avoiding taking ART while drinking).
Sankar et al., (2007)	Semi-structured interviews	Interactive toxicity beliefs	25% female; M age = 43.3; PLWH (N = 82) and healthcare providers (N = 17) from HIV clinics in the US.	Almost the entire sample (85–90%) endorsed interactive toxicity beliefs, and 51% reported not taking ART while drinking. Participants who were categorized as heavy drinkers were less likely to endorse toxicity beliefs.	Four potential explanatory models of the alcohol/ART interaction were identified: (a) Alcohol reduces the effectiveness of ART; (b) Alcohol is toxic and should never be mixed with medication; (c) Alcohol can worsen HIV by impairing the immune system; and (d) Alcohol has no impact on HIV or ART.
Schensul et al., (2017)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs	100% male; PLWH (N = 50) from HIV clinics in India	Barriers and facilitators to adherence identified by PLWH included: alcohol use, social support (e.g., transportation to the HIV clinic, emotional support), and psychological factors.	The association between alcohol and ART adherence was explained by: forgetting to take ART when drinking and skipping ART due to interactive toxicity beliefs.
Sileo et al., (2019)	Semi-structured interviews	Forgetting; Interactive toxicity beliefs	100% male; M age = 34; PLWH (N = 30) from fishing communities in Uganda	Alcohol was identified, unsolicited, as the primary barrier to ART adherence. Men reported that alcohol use occurs in social and occupational settings, is heavily influenced by peers, is normative in fishing communities, and is used to relieve stress. All men reported that PLWH should reduce or abstain from alcohol use.	Alcohol use was identified as a barrier to ART adherence via cognitive impairment and intentionally skipping doses while drinking. Participants described reducing alcohol consumption after HIV-diagnosis based on recommendations from care providers.
Sorsdahl et al., (2019)	Focus group discussions	Forgetting; Interactive toxicity beliefs	57% female; PLWH (N = 23) from hospitals in South Africa	General barriers to adherence included: wait-times at HIV clinics, ability to attend clinic appointments, stigma, and ART side effects.	Participants reported that alcohol consumption was related to unintentional missed doses related to forgetting and/or failing to prioritize ART during drinking events and/or feeling too hungover to take their ART. Other participants reported intentional nonadherence due to the belief that mixing alcohol with ART was harmful.

Note.

⁺All studies described potential mechanisms in the introduction, results, and/or discussion sections. Sample demographic information reported at follow-up is presented when possible, otherwise baseline sample information is presented. PLWH = people living with HIV; ART = Antiretroviral Therapy; US = United States; IPV = intimate partner violence