A quantitative analysis of food insecurity and other barriers associated with ART nonadherence among women in rural communities of Eswatini

Background: Eswatini has the highest global prevalence of HIV despite decades of universal access to free antiretroviral therapy (ART). We conducted a mixed methods study to investigate barriers to ART adherence among women living with HIV (WLHIV) in rural communities of Eswatini. Qualitative findings were reported in our previous publication. This subsequent paper expands on our qualitative analysis to examine the magnitude to which identified barriers impacted ART adherence among WLHIV in the same communities. Methods: We used an exploratory sequential design to collect data from WLHIV (n = 166) in rural Eswatini. Quantitative data were collected using interviewer-administered survey questionnaires between October and November 2017. ART adherence was measured using the CASE Adherence Index, with scores less than 10 indicating nonadherence. Log-binomial regression models were used to examine the extent to which critical barriers affected ART adherence among study participants. Results: A majority of the women in our study (56%) were nonadherent to ART. Of the barriers identified in our prior qualitative analysis, only eight were found to be significantly associated with ART nonadherence in our quantitative analysis. These include, with adjusted risk ratios (ARR) and 95% confidence intervals (95% CI): household food insecurity (ARR: 3.16, 95% CI: 1.33–7.52), maltreatment by clinic staff (ARR: 2.67, 95% CI: 1.94–3.66), forgetfulness (ARR: 1.80, 95% CI: 1.41–2.31), stress (ARR: 1.47, 95% CI: 1.14–1.88), gossip (ARR: 1.57, 95% CI: 1.21–2.04), mode of transport (ARR: 0.59, 95% CI: 0.44–0.79), age (ARR: 0.98, 95% CI: 0.97–0.99), and lack of community support (ARR: 0.55, 95% CI: 0.35–0.85). Conclusions: Among numerous barriers identified in our study, food insecurity was found to be a significant contributor toward ART nonadherence among women living with HIV in rural Eswatini. Future strategies aimed at improving ART adherence in Eswatini should include programs which provide food and nutrition support for people living with HIV, particularly rural women living in poverty.