For the roughly 1.7 million adolescents living with HIV globally, poor adherence to daily oral antiretroviral therapy remains one of the most persistent gaps in HIV care — and one of the most consequential. A shift toward long-acting injectable formulations could fundamentally change that equation, but only if young patients, their families, and frontline healthcare workers are willing to embrace it.
This formative qualitative study, conducted across four clinics in KwaZulu-Natal as groundwork for the ATTUNE cluster-randomized stepped-wedge trial, engaged 213 participants — 64 adolescents aged 12–19 living with HIV, 69 caregivers, and 80 healthcare workers — through 23 focus group discussions. Using the Technology Acceptance Model as an analytical framework, researchers identified consistent barriers to current oral ART: unpleasant taste, social stigma tied to visible pill-taking, and unreliable support networks. Long-acting injectable ART was broadly perceived as beneficial across all stakeholder groups, with anticipated gains including reduced daily treatment burden, greater privacy, and improved adherence. Primary concerns were injection-related pain, potential side effects, and logistical questions around clinic-based administration.
This study matters beyond its regional scope for several reasons. South Africa carries the world's largest HIV burden, and KwaZulu-Natal is among its hardest-hit provinces, making adolescent engagement there a bellwether for sub-Saharan Africa broadly. Qualitatively, the convergence of positive attitudes across adolescents, caregivers, and healthcare workers is a meaningful signal — stakeholder alignment at all levels is typically a prerequisite for successful implementation of any novel therapeutic modality. That said, qualitative acceptability data have historically outpaced real-world uptake; perceived willingness and actual behavior often diverge, particularly when logistical barriers like injection scheduling and cold-chain delivery enter the picture. This work is explicitly formative, meaning its primary value lies in shaping the design of the forthcoming ATTUNE trial rather than establishing efficacy or population-level impact. The findings are nonetheless a constructive foundation, suggesting that community education on injection safety and accessible delivery models will be the pivotal implementation challenges to solve.