Online Poster Portal

Background: In sub-Saharan Africa, men experience twice the mortality of women due to delayed initiation of antiretroviral therapy (ART) and poor retention, with interruptions in treatment (IIT) increasing risk of progression, transmission, and death. Healthcare providers commonly withhold critical information regarding the flexibility of ART timing, emergency refills, and treatment-as-prevention (TaSP) from clients, fearing that such knowledge would promote complacency in prevention and treatment adherence efforts. This study challenges that assumption, examining if and how transparent counseling affects medication adherence and prevention strategies among men who experienced IIT in Malawi.

Methods: Men with IIT were randomly selected from the ENGAGE and IDEaL trials (n=1303) to complete in-depth interviews (IDIs), which were stratified by intervention arm and region of residence. Interviews were conducted 4 months post-intervention by trained research assistants, coded in Atlas.ti, and thematically analyzed.

Results: In total, 61 men completed IDIs between November 2022-February 2023 [median age 39 (IQR:32,46), 4 years since diagnosis (IQR:2,10), many married (63.9%), all re-initiated ART, 4.9% with repeat IIT during study period]. Men who received education around timing flexibility (e.g., taking medication a few hours late is preferable to skipping), emergency refill options, and TaSP demonstrated improved— rather than worsened— adherence. Understanding that missed ART doses does not mean failure helped reduce anxiety-driven dose-skipping, particularly among men prone to thinking ART engagement was "all or nothing." Furthermore, educating men about emergency refills gave them agency to maintain ART adherence while travelling, instead of expecting them to return to the same facility despite unpredictable life circumstances. TasP counseling drew on culturally-sensitive values to motivate adherence and fostered protective behaviors towards sexual partners. Critically, men demonstrated a clear distinction between “flexibility as contingency planning” and “permission for carelessness,” maintaining improved ART adherence standards after comprehensive education while feeling equipped to navigate real-world challenges.

Conclusions: Comprehensive HIV counseling— including ART flexibility, TaSP, and emergency refills—empowered clients by replacing fear with agency. Transparent communication equipped clients with realistic tools to navigate daily realities, dismantling barriers to retention. Moving beyond rigid compliance to a model of informed partnership not only safeguards individual health but offers a vital pathway to resilient, lifelong adherence.