The Acceptability of a Real-Time Medication Monitoring-Based Digital Adherence Tool Among Young People Living with HIV in Malawi

Adherence to antiretroviral therapy (ART) is required for young people living with HIV (YPLHIV, 15-24 years) to achieve viral suppression, prevent transmission, and reduce HIV-related morbidity and mortality. Real time medication monitoring based digital adherence tools (RTMM-DATs) - a combination of RTMMs (smart pillboxes), customised adherence feedback, SMS reminders, and optional alarms - may be used to provide promising interventions to improve ART adherence and viral suppression in YPLHIV. In this study, we sought to investigate the concurrent acceptability of a RTMM-DAT intervention which included RTMMs, customised adherence feedback, SMS reminders, and optional alarms, in non-adherent YPLHIV on ART in Malawi enrolled in a randomised controlled trial (RCT) to investigate the effect of the intervention on ART adherence and viral suppression. As a secondary objective, we explored barriers to ART adherence in YPLHIV using the intervention. We conducted a phenomenological study in fourteen YPLHIV enrolled in the intervention arm of the RCT for at least six months using semi-structured interviews between June and July 2024. The interview guide was structured around the constructs of the Theoretical Framework of Acceptability (TFA). Inductive and deductive thematic analysis were performed to achieve the objectives. Overall, the participants expressed positive attitudes toward the intervention and appreciated the portable and discreet design of the RTMM. They appreciated the intervention's usefulness in addressing forgetfulness and promoting routine medication use. Neutral SMS reminders and tailored adherence feedback were appreciated for promoting adherence while safeguarding privacy. Challenges included device recharging in settings with limited electricity, reliance on mobile phones for SMS reminders, lack of remote user access to adherence reports, potential unintended disclosure from audible alarms, and users' underlying social insecurities due to stigma. Furthermore, participants continued to face multiple and complex challenges to ART adherence, such as food insecurity, drug side effects, forgetfulness, and social stigma before and after engaging with the intervention. In conclusion, the intervention was generally acceptable among YPLHIV in Malawi. Addressing barriers such as electricity access, stigma, and enhancing user customisability and access to adherence reports could improve the intervention's acceptability. Additionally, tailoring the intervention to the socio-cultural context of YPLHIV is essential to improve acceptability.