This study was conducted to explore the psychosocial factors that hindered adherence ART among HIV positive young adults. Non-adherence to ART was perceived to result from stigma and discrimination, mental health problems, work-related problems and low socio-economic status, religious beliefs and poor knowledge, healthcare system factors and poor family support. Addressing these psychosocial factors hindering adherence to ART would promote increased compliance to treatment and hence reduced morbidity and mortality form HIV/AIDS. Stigma and discrimination were described to affect all young adults on care and it was among the most common reasons of failure to swallow the pills while at school, work places, and homes. Stigma is due to perceived unbearable burden for taking medication for life which lessens the self-confidence of the clients leading to non-adherence [11, 15]. Stigma in the healthcare facilities manifests in form of internalized fear of being seen in ART clinic, impatience to wait, and rush in picking the drugs [15]. A study done in Northern Uganda among young adults also reported stigma as the main cause of non-adherence to ART [11]. Similar findings have been reported in Myanmar, where enacted stigma and internalized stigma were associated with worse ART adherence [13]. Stigma and discrimination restrict the freedom of HIV positive in taking their ART pills in the presence of other people resulting in delaying, poor timing and non-adherence to ART. Stigma remains a stumbling block to good adherence and its impact is not only reflected on the recipients of care but also on their care takers, communities, and the entire health care system [15]. The consequent poor counselling and inadequate holistic health assessment of the client worsens adherence practices but may also contribute to ART failure [15].

Disclosure of HIV status has remarkable benefits in promoting drug adherence among other social benefits[22, 23]. In our study, clients who had not disclosed their HIV status found it difficult to ask permission from their superiors to allow them to go and pick their medication from the health facility. Missed appointments, poor timing and skipping to take their medication was noted among students who had not disclosed their HIV status as they were unable to seek permission, special consideration in terms of meals, and receiving adequate social support from the school manned clinic. Similar findings were cited in Ghana where non-disclosure led to low adherence on ART [12]. Non-adherence was significantly more common among clients who had not disclosed their HIV status to their partners, a finding which was consistent with study findings [12]. Therefore, clients who have not disclosed their HIV status should be counselled on the role of disclosure in improve adherence to ART.

Consistent with previous studies [14, 16, 24], failure to adhere to ART was attributed to mental health problems including stress, depression, feelings of self-harm, poor coping mechanisms and use of illicit drugs. In Malawi, young adults who had depressive symptoms were significantly more likely to default on their ART medication [25]. Like in previous studies [14, 24], newly diagnosed HIV positive clients were more likely to resort to the use of alcohol and other illicit drugs to cope with the associated psychosocial stress. Alcohol and substance intake affects social cognition and lowers social inhibition of the clients leading to forgetfulness, irrational behaviors and decisions which consequently comprise the ability of HIV positive clients to adhere to their medications [14]. Promoting adherence requires strong psychosocial counselling services to screen, identify, and appropriately manage clients who are likely to start using drugs and as well clients who are already abusing drugs.

Previous studies have indicated that long waiting time in ART clinics was significantly associated with poor ART drug adherence [26, 27]. A study revealed non-adherence to ART was attributed to long waiting time in 24% of clients [27]. Consistent with previous studies [28], long waiting times and high volume of clients in ART clinics meant that some clients did not honor their appointments, while some clients spent so much time in the clinic, and chose to leave the clinic without receiving their drugs. The high volume of patients relative to the few healthcare workers compromises on the quality of client-healthcare worker interaction, privacy, poor quality of care, and failure of the healthcare workers to identify issues of ART adherence among clients [28]. Measures should be developed to reduce long waiting times in ART clinics so as to reduce issues of non-adherence to medications and consequent treatment failure

Consistent with findings from previous studies[28, 29], poverty, and low-socio economic status contributed to the ART non adherence among HIV young adults. In a scoping review of the factors contributing to ART adherence, logistical and financial support to HIV positive clients were found to facilitate adherence to ART medication [30], which also supports our findings. Non-adherence from lack of money was attributed to failure of the clients to afford basic needs such as food and transport fares to cater for additional demands of taking ART medications. COVID-19 restrictions were attributed to cause poor ART drug adherence related to financial insecurity from closure of business, non-paid leave, laying off workers, and doubling of transport fares. Financial hardships together with poor quality of meals at schools meant that while in school students were not able to buy additional food to supplement their feeding and consequently cope with the demands of taking ART medications. This underscores a need for schools to provide special support to HIV positive clients in school through provision of special meals in order to promote drug adherence.

Some religious beliefs were perceived to be associated with poor adherence to ART medication. Some Muslim clients were implored to stop taking their medication during Ramadan, while some pastors gave false hope to their followers that God would heal them even when they do not take medication. The findings of our study were in agreement with a study findings [31, 32] which cited poor ART adherence was related beliefs in faith healing, alternative traditional medication, and perceptions that HIV was caused by witchcraft. However, this was contrary to the findings in Ghana, where religious beliefs empowered the clients to ignore stigma, become resilient and motivated to take their medications because of their beliefs that God approved the use of ART thus promoting good adherence [33].