Abstract
BACKGROUND: Antiretroviral therapy (ART) has dramatically reduced HIV-related morbidity and mortality worldwide, but adherence remains a critical challenge, particularly in Sub-Saharan Africa. In Somalia, where HIV prevalence is low but health systems are fragile, little is known about the lived experiences of people living with HIV (PLHIV) regarding ART adherence. METHODS: A qualitative study was conducted at ART clinic In Mogadishu Somalia between March-August 2024. A total of 22 adult PLHIV and 12 healthcare providers (8 ART nurses and 4 case managers) participated. Purposive sampling was used to recruit participants; Data were collected through 30 in-depth interviews and 4 focus group discussions using semi-structured guides. Interviews were audio-recorded, transcribed, translated, and thematically analyzed using NVivo software, with emerging themes classified into barriers and facilitators of adherence. RESULTS: Barriers to adherence included stigma and discrimination, religious and cultural beliefs (such as reliance on prayer or holy water), economic hardship (transport costs, food insecurity), health system challenges (stock-outs, long waiting times, confidentiality concerns), and psychological factors (depression, denial). Facilitators included strong family and social support, religious coping that motivated adherence, positive patient-provider relationships, peer support networks, and personal motivation and resilience, particularly among patients committed to living for their children. Illustrative quotes highlighted the daily struggles and strategies patients employed to remain in care. CONCLUSION: ART adherence in Somalia is shaped by complex interactions between socio-cultural, economic, psychological, and health system factors. Interventions that reduce stigma, integrate mental health services, strengthen health systems, provide economic and food support, and leverage religious and peer networks are essential. Collaborating with traditional and religious leaders may further improve acceptance and sustainability of ART programs.