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Participants who did not interrupt ART mainly reported implement new ART regimens and programmes. Lastly,
using an alarm as a reminder for taking their medication. treatment support interventions recommended in this study
This finding suggests the need to explore external reminder need to be tested in practice to determine their efficacy for
mechanisms for improving adherence in this setting, large-scale implementation.
considering that about 15% of VLF participants reported not
using any external reminders. Various studies have also Acknowledgements
found a trend towards better adherence amongst patients
who used external reminders. 37,38,39 In addition, our study The authors would like to thank all the facilities and relevant
showed that participants who used their handbags to store health and research authorities from the City of Johannesburg
their medication were more likely to adhere to treatment. for allowing the research team to engage in a partnership to
This finding is in line with other studies that have reported strengthen health service delivery through technical assistance
having a handbag to have pills all the time as the preferred and research. They also thank the participants for sharing their
ART storage by patients. 40,41,42 experiences, views and recommendations, and Jean Claude
Nkembi for his assistance with data collection and capture.
Side effects are an important predictor of poor adherence,
and cumulative toxicity associated with ART, especially in Competing interests
second-line regimens. 43,44,45 We found that participants with The authors declare that they have no competing interests.
VLF were more likely to have treatment-related side effects.
Furthermore, those participants with side effects were more
likely to be unemployed. Although this was not explored Authors’ contributions
further in our study, various studies have reported that S.B.G. and S.T.L.-E. designed the study and supervised the
employed patients can manage their health and side effects data extraction at the facilities. S.B.G. analysed the
better than their unemployed counterparts. 46,47,48 quantitative data and S.T.L.-E. analysed the qualitative data.
S.B.G. interpreted the data and prepared the first draft of the
Participants had ideas regarding drug formulation that manuscript, which was revised by S.T.L.-E. and W.D.F.V. All
may improve adherence. These included a fixed-dose authors read and approved the final manuscript.
combination, a dosage taken once a day and reducing the
pill size. Furthermore, the participants suggested that
education on the benefits of taking ART could improve Funding information
adherence, whilst a few participants also suggested the This study was funded through the OPTIMIZE project.
implementation of injectable ART. Various studies have OPTIMIZE (AID-OAA-A-15-00069) is funded by the United
recommended similar strategies, 49,50,51 with the effectiveness States Agency for International Development (USAID) under
of some of these strategies being previously reported for the US President’s Emergency Plan for AIDS Relief (PEPFAR).
first-line regimens. 51,52 S.B.G. was supported by the Consortium for Advanced
Research Training in Africa (CARTA). It is jointly led by
Study limitations and strengths the African Population and Health Research Center and
the University of the Witwatersrand and funded by the Carnegie
This study had several limitations. Firstly, the study relied on Corporation of New York (Grant No. B 8606.R02), Swedish
participants’ self-reports, prompting a likelihood that socially International Development Cooperation Agency (SIDA) (Grant
desirable answers may have been provided. However, to No. 54100113), the Developing Excellence in Leadership,
control for this, information such as viral load, side effects Training and Science (DELTAS) Africa Initiative
and comorbidity was verified by checking participants’ (Grant No. 107768/Z/15/Z) and Deutscher Akademischer
medical records as part of data quality checks for the study. Austauschdienst (DAAD). The DELTAS Africa Initiative is an
Secondly, the clinical measure for adherence considered viral independent funding scheme of the African Academy of
load only. Finally, the sample might be small for the results Sciences’ (AAS) Alliance for Accelerating Excellence in Science
to be generalised to all patients receiving second-line ART. in Africa (AESA) and supported by the New Partnership for
However, the direction and size of effect were generally Africa’s Development Planning and Coordinating Agency
consistent, suggesting that the study findings may be robust (NEPAD Agency) with funding from the Wellcome Trust (the
despite these limitations. United Kingdom [UK]) and the UK government.

Conclusion Data availability statement
Participants on a second-line antiretroviral regimen had firm The data sets used or analysed in this study are available
recommendations regarding improving adherence, largely from the corresponding author upon reasonable request.
focused on administration, reduced dosing and pill burden.
The study results suggest the importance of improving
patients’ knowledge about treatment and adherence and Disclaimer
motivation to continue ART use despite the persistence of The views and opinions expressed in this article are those of
side effects. Drug manufacturers and health programmers the authors and do not necessarily reflect the official policy or
must consider such recommendations as they modify and position of any affiliated agency of the authors.

http://www.sajhivmed.org.za 290 Open Access