Barriers and facilitators to delivering tobacco cessation interventions at HIV care clinics in Sub-Saharan Africa: Qualitative application of the consolidated framework forimplementation research

Introduction: Tobacco use among people living with HIV (PLWH) in Sub-Saharan Africa (SSA) is prevalent, compounding health risks. Tobacco cessation interventions (TCIs) have shown promise but are not widely tested in HIV care settings. In this study, we applied the Consolidated Framework for Implementation Research (CFIR) to examine barriers and facilitators to implementing the adapted tobacco cessation intervention Quit4life+ for PLWH in Uganda and Zambia. Methods: Guided by the CFIR determinant framework, Quit4life+ trial implementation challenges were evaluated across 16 HIV clinics in Uganda and Zambia between July 2021 and October 2025. Qualitative data were drawn from multiple sources, including 22 quarterly site visit reports, 4 health systems assessments completed by study coordinators and health facility personnel in-charge, key informant interviews with 14 clinic healthcare providers (nurses, nursing officers, and midwives), and focus group discussions with 55 PLWH (aged ≥18 years and receiving HIV care at participating clinics). Qualitative data were mapped to relevant domains and constructs. Results: Within the innovation domain, evidence for TCIs, nicotine replacement therapy (NRT), and culturally adapted message libraries enhanced acceptability, while costs challenged adoption. Outer setting challenges, including seasonal labor demands, civil unrest, poor road access, and restrictive procurement and regulatory processes, influenced delivery. Inner setting barriers included overcrowded clinics, limited counseling space, inconsistent network connectivity, and staff turnover. Providers were motivated to support cessation but reported limited skills and faced intersecting stigma among patients. The implementation process relied on external resources, raising concerns about sustainability. Conclusions: Findings identify multilevel barriers and facilitators to delivering cessation support within HIV care clinics in Uganda and Zambia. Further research is needed to determine how determinants can be effectively addressed and to build the evidence base for the sustainable integration of services into HIV care across SSA.