Abstract
BACKGROUND: South Africa has a high prevalence of HIV and substance use, with 13% of the population meeting criteria for lifetime substance use disorder (SUD). Substance disorders are associated with adverse health outcomes, including poor adherence to antiretroviral therapy (ART), reduced health-seeking behaviour and increased risk-taking behaviour. Limited research has explored the perspectives of people with HIV in low- and middle-income countries when accessing substance use treatment. OBJECTIVES: To identify barriers and facilitators influencing engagement in substance use treatment programmes among people with HIV and SUDs, drawing on perspectives from both patients and healthcare providers. METHOD: This qualitative study analysed individual interviews from Project Khanya, a peer-delivered intervention promoting ART adherence among adults living with HIV with at least a moderate SUD. Using criterion sampling, 34 adults with HIV and nine healthcare providers involved in HIV or substance use care were included. Inductive thematic analysis of transcripts from audio recordings identified individual, social, and structural factors influencing treatment engagement. RESULTS: Participants had a mean age of 39.2 years and 48% were female; providers had a mean age of 40.8 years and were predominantly female. Five main subthemes influenced engagement in substance use treatment: social support, substance use, service-related factors, readiness to change, and financial constraints. Facilitators included strong social support, positive healthcare experiences, outreach, psychoeducation, insight, and reduced substance use, while barriers included poor support, stigma, negative healthcare interactions, financial challenges, and ongoing substance use. CONCLUSION: Intersectional stigma, privacy concerns, and ongoing substance use hinder engagement in HIV and SUD treatment, whereas holistic, person-centred approaches can improve programme attendance and health outcomes.