The 2025 estimates show that of the estimated 40.8 million people living with HIV worldwide in 2024, 2.42 million were children aged 0 - 19. Each day in 2024, approximately 712 children became infected with HIV and approximately 250 children died from AIDS-related causes, mostly due to inadequate access to HIV prevention, care and treatment services.

The burden remains heaviest in sub-Saharan Africa, which accounted for 61 per cent of the 630,000 AIDS-related deaths globally in 2024. And adolescent girls and young women continue to be disproportionately affected. Over 210,000 adolescent girls and young women aged 15 - 24 acquired HIV last year, an average of 570 new infections every day [1][2].

These figures help in the understanding of the HIV epidemic and the reflection on the urgent need for targeted investment and equity-focused strategies especially for those being left behind. This approach helps governments and communities to eliminate vertical transmission of HIV, and thrive for triple elimination of HIV, syphilis and hepatitis B, close the treatment gap for children and adolescents living with HIV by integrating early diagnosis and optimising new paediatric regimens which prevent new HIV infections among adolescent girls and improve access to quality sexual and reproductive health services [1]-[3]. UNAIDS and UNICEF are collaborating on a new analysis using the 2025 estimates and updated modelling to understand the future impacts of the current funding landscape. Preliminary scenarios show how increased child mortality and rising HIV infections among children and adolescents if the current trajectory continues [1][3].

Antiretroviral therapy (ART) has transformed HIV from a fatal disease to a manageable chronic condition, but optimal adherence defined as taking ≥95% of prescribed doses is essential for viral suppression, prevention of transmission, and averting HIV drug resistance or (HIVDR) [2]. The standard definition of adherence is taking 95% - 100% of the right drug, in the right way, at the right time and in the right dose. Adherence requires an informed choice, a relationship of trust between patient/family/care provider and the implementation of evaluation procedures for better monitoring of patients on ART [4]. Despite progress, SSA lags behind the UNAIDS 95-95-95 targets which means 95% of people living with HIV (PLHIV) knowing their status, 95% of those who have a positive status should be on their ART, and 95% those who are on ART should virally suppressed.

In Cameroon, national estimates indicate only 46.9% of PLHIV know their status, 91.3% of the 46.9% of the general population are on ART or are ART adherent, and 80% of those who are on ART are virally suppressed, with paediatric rates even lower at 35% coverage; meaning only 35% of estimated paediatric PLHIV in Cameroon are on ART—far below the adult rate (~42.8% of all PLHIV on ART) and the 95% UNAIDS target [5][6].

Adolescents pose unique challenges to ART adherence, including developmental transitions, stigma, mental health issues, and high-risk behaviours [7][8]. In conflict-affected regions like Cameroon’s Northwest, sociopolitical instability exacerbates barriers such as clinic access and supply chain disruptions [9]. Recent studies highlight multifaceted individual determinants of suboptimal ART adherence and retention in care such as forgetfulness, lack of family support, stigma, and food insecurity [10]-[12]. However, some studies combine insights from different groups, like patients, families, and healthcare workers, to create tailored solutions for HIV care in places with limited resources [13].

By integrating mixed-methods data, it proposes an adaptable multistage model to optimize adherence, aligning with WHO’s 2025 [2]. guidelines on differentiated service delivery (DSD) and long-acting injectables (LAI-ART). This study proposing a tailored, multistage model to improve adherence, incorporating WHO’s 2025 strategies like DSD a customized care delivery and LAI-ART; injectables to simplify treatment is highly relevant to ART adherence, aiming to close the gap between diagnosis and sustained viral suppression for adolescents, a population with long standing low adherence rates in Cameroon.

Non-adherence to ART among CALHIV in SSA contributes to high morbidity, mortality, and onward transmission of HIV [14]. In Cameroon, the Northwest Region’s ongoing Anglophone crisis has displaced populations, disrupted healthcare, and increased loss-to-follow-up (LTFU) rates to 58% in the paediatric populations [15][16]. HIV care system issues like suboptimal regimens for example use of non-nucleoside reverse-transcriptase inhibitors (NNRTIs) or NNRTI-based treatments, or HIV treatment plan which involves a combination of drugs which are not fully effective, possibly due to issues like drug resistance, inappropriate drug choices, side effects, or limited access to better medications, as seen in resource-limited settings like Cameroon may not work well for everyone especially in adolescents. Over time, the virus can become resistant to these drugs, meaning they stop working for many Cameroonian adolescents, leading to treatment failure in about 35% of cases. Also, if people do not get treatment or if they skip doses, this speeds up HIV drug resistance (HIVDR), when the virus learns to fight back against the medications, making them useless. This puts huge pressure on health systems, as switching to stronger “second-line” drugs can cost up to $10,000 (5,650,000 FCFA) per person [2][17]. This issue also affects fairness in healthcare, as women and girls face unique challenges. About 85% of caregivers for HIV-positive kids are single women, who often bear heavy responsibilities alone. However, studies show that teenage girls with HIV are better at sticking to their treatment, with 1.8 times higher success rates compared to boys in some cases. These differences highlight how gender and other social factors create unequal experiences in managing HIV [8][18].

Current interventions, like Zimbabwe’s Zvandiri peer model, show promise of 25% adherence boost, but lack adaptation to conflict zones [11]. Two-thirds (64.7%) of the global population of adolescents living with HIV, ages 10 - 19, reside in ESA2. Challenges related to pregnancy and parenthood can threaten ART adherence among adolescents living with HIV, whose ART adherence rates are already lower than those of all other age groups. These disadvantages are predicted to extend to the children of adolescent mothers, with the next generation showing lower educational achievement, higher poverty, and increased risk of becoming adolescent parents themselves [19].

In Cameroon, there is limited data on the adherence to ART by ALHIV and the factors associated with adherence to ART amongst these adolescents. Understanding the factors associated with adherence ALHIV population provides vital information to guide targeted interventions and thus better outcomes for the clients. This study therefore sets out to assess the adherence level of ALHIV and to evaluate the factors associated with ART adherence in the Bamenda Health Districts.

In this study, ART adherence among 196 adolescents living with HIV (ALHIV) was 81.6%, below the UNAIDS 95% target for optimal viral suppression [27]. Higher education was significantly associated with better adherence P = 0.001), while stigma—experienced by 40.7% of participants—negatively influenced outcomes. Other key predictors included duration on ART (OR 3.4, P < 0.05), caregiver type, satisfaction with health care providers, and absence of discrimination. Qualitative findings reinforced these patterns, identifying stigma, forgetfulness, and logistical barriers, alongside protective factors such as family support, peer networks, and self-motivation. These results point to the need for a multistage adherence model integrating supportive policies, community engagement, and task-shifting to strengthen adolescent HIV care.

The 81.6% adherence rate is not good enough, meaning too many adolescents are skipping their medication. This raises serious health concerns, as it increases the risk of virologic failure (VF) by which the treatment stops controlling the virus, HIV drug resistance (HIVDR) in which the medication stops working entirely, and onward transmission or spreading the virus to others. These findings, specifically from the two Bamenda health districts in Cameroon’s Northwest Region, show that adherence problems are complex, especially because the area is affected by sociopolitical conflict.

The study highlights that poor adherence is not just about an individual forgetting their pills. Instead, it is caused by a mixture of structural barriers like systemic issues or disruptions to getting to the clinic. access disruptions and not having enough to eat such as in food insecurity; Also individual challenges like mental strain; psychological distress and getting tired of treatment; treatment fatigue.

The significant role of education shows that when adolescents are informed, they are better able to prioritize their treatment (ART). The fact that 40% of adolescents face stigma is a major problem, as this widespread stigma reduces their self-confidence and social support, leading to feelings of isolation and ultimately, poor adherence. In short, the study confirms its goal which is was also to identify adherence as a complex problem influenced by personal, social, and system-wide factors.

Our study found an ART adherence rate of 81.6% among adolescents living with HIV (ALHIV).

This rate is consistent with what is typically seen in Sub-Saharan Africa (SSA), where adherence rates for ALHIV usually fall between 60% and 85% [28][29]. This is consistent with a larger systematic review that reported pooled adherence rates for ALHIV in SSA around 72% to 80%. Both our study and the review found that factors like stigma and family support are key influences on whether adolescents stick to their treatment. Similarly, a study in Addis Ababa found a high adherence rate of 79.1% among adolescents aged 13 - 19 [30]. The slight difference between their 79.1% and our 81.6% may be due to differences in sample size and the fact that our study included a wider age range (10 - 24 years).

While our overall rate is similar to others, the specific factors that protected against poor adherence in our study were slightly different; we found a significant protective effect of education (P = 0.001) and we also highlighted the importance of caregiver involvement. Other studies often find no significant link between adherence and factors like gender or treatment duration. The reason our study highlighted education and caregiver involvement so strongly might be because we focused on conflict-affected areas. In these unstable settings, socioeconomic vulnerabilities (like lacking education or stable parental support) are intensified, making these factors much more critical to adherence.

In contrast, a 2025 scoping review by Magura et al., 2025 [29] identified barriers such as psychological distress and logistical issues as universal in SSA, but noted higher adherence in stable regions through digital interventions, which were underexplored in our setting. These discrepancies may be attributed to the methodological differences, such as our mixed-methods and geographical location of study sites, sample sizes to mention but these.

These findings contribute to the evidence based on ART adherence in ALHIV by proposing a scalable multistage model that integrates differentiated service delivery (DSD), mHealth reminders, and nutrition support, similar to those in WHO 2025 guidelines [2][31][32]. Practically, they advocated for targeted interventions like peer-led support groups and stigma-reduction campaigns in conflict zones, potentially reducing loss-to-follow-up rates which is currently 58% in Cameroonian paediatrics and advancing UNAIDS 95-95-95 goals [26]. On a broader scale, this study highlights equity issues, such as gendered burdens on female adolescents and adolescent mothers, informing policy reforms for inclusive HIV programming in SSA. Similar issues have been reported in a Nigerian study by Limbada et al., and Vicent CCN et al. [32][33].

This mixed-methods cross-sectional study involving 196 ALHIV aged 10 - 19 years in Bamenda Health Districts, Cameroon, a conflict-affected region, revealed a predominantly younger cohort 74% aged 10 - 14 years), with high Christian affiliation with 88%, secondary education (54%), and long-term ART exposure (21% on ART for 11 - 15 years). Recruitment was urban-centric, with 59% from Bamenda Regional Hospital, highlighting access disparities. Overall, self-reported good ART adherence was high at approximately 82% - 86% across sections, but this was tempered by significant barriers like missed appointments (62%), forgetfulness (44% of non-adherence), stigma, and logistical issues [34][35]. This adherence rate suggests moderate success in ART retention amid challenges, meaning that while many ALHIV maintain regimens through facilitators like family support and reminders, systemic failures risk virological failure (VF) and resistance, potentially undermining UNAIDS 95-95-95 targets in SSA [26]. Such results likely stem from improved pediatric ART access post-PMTCT expansions, yet are eroded by conflict-driven disruptions from example transport barriers and psychosocial stressors [36]. Follow-up could involve longitudinal tracking of viral loads to validate self-reports and assess long-term outcomes.

Linking to similar studies, this adherence rate aligns with [37] who reported 86% adherence among Ethiopian ALHIV via community clubs, similar due to shared SSA emphasis on support networks mechanistically reducing forgetfulness, and why from comparable resource-limited settings with perinatal cohorts. The findings are consistent too with the study by Kayiranga D et al. who reported that despite advances in treatment and prevention efforts, adolescents continue to be disproportionately affected by HIV and are a group with poor adherence to antiretroviral medication [38]. It also mirrors Kamau et al. (2023)’s [39] a 78% pooled adherence in orphaned SSA ALHIV and how through caregiver facilitation ART adherence improved This study finding differs from Hlophe et al., 2025)’s [14] who reported a lower 65 % in broader SSA adolescents, the difference that might have resulted from objective measures like viral suppression (VS) capturing underreported non-adherence unlike this study’s self-report bias. Differences with Villiera J B et al.’s [13] Ugandan findings of adherence barriers like fatigue arise how from qualitative depth highlighting stigma, and why from conflict amplifying logistics in Cameroon.

This study showed that having a younger age, having attained moderate education or secondary level, being a Christian, having accessibility to care and having extended ART durations were associated with ART adherence. These could be that adolescents with knowledge of follow-up will also ensure there is enough ART available to be taken to ensure optimal adherence. It could also be that adolescents who followed- up on their medications receive frequent counselling at the PTCs that helped them to ensure strict adherence.

Compared to similar studies, this aligns with Djiyou et al.’s [28] Cameroonian ALHIV with median age 16, 76% of respondents were of secondary education level, similar how via PMTCT-driven survival enabling adolescence, and from national ART policies favoring urban centers. A Rwandan study by Kayiranga, D., et al. and Kizito et al. [11][38] found comparable results, with a mean adolescent age of 17.4 years and 56% of participants in secondary school. This high retention in Rwanda is likely due to predictable SSA education subsidies, which help reduce dropout rates. The main contrast is Rwanda’s older age profile, which reflects its stable post-conflict system’s success in keeping teens in school, versus Cameroon’s insecurity leading to greater loss to follow-up (LTFU). The findings align with the larger cohort studied by [40] particularly in terms of the early initiation of the program or intervention. However, it differs because the Fokam study lacked caregiver data and had a different programmatic focus than the current study. The meta-analysis by Mengesha M.M. et al. (2023) [8] showed that 63% of participants reached the secondary education level. This finding is similar to ours, likely because both groups face stigma barriers to education. The key difference is that their analysis included fewer rural participants, while the current study has a noticeable bias toward urban populations.

The initial statistical test (bivariate analysis) showed that the only significant factor which was keeping clinic appointment was strongly linked to good adherence to treatment. Specifically, patients who respected their appointments were far more likely to have good adherence, an impressive 80% and only 6% of those who did not (P = 0.009). This suggests that being engaged with the clinic or showing up when you are supposed to, is a good sign of whether someone is actually adhering to their treatment. This finding is similar to results from a Yaoundé study by Ketchaji, et al. [41] also found that patients who frequently missed appointments (defaulters) were over two-and-a-half times more likely to have poor adherence (aOR = 2.56). They specifically cited issues like poor transport and problems within the Cameroonian healthcare system as the cause of poor adherence. The findings also align with a large review of Sub-Saharan Africa by Hlophe etal.’s [14] which identified general healthcare service barriers like long wait times as a key problem.

A notable contrast is that we did not find a link with gender, even though other studies often point out specific risks for males. This is probably because our study focused on a younger age group, where those gender differences might not yet be significant. Our lack of a gender link to adherence matches with the data from Buh et al. [42] likely because stigma impacts everyone similarly. They did, however, find that long-term treatment (over 10 years) improved adherence. This difference is probably due to “survivor bias” in the adult study meaning only those who were already successfully adhering for a long time were studied. Our findings on gender were also similar to the inconsistent results found in Kamu et al.’s [39] review, which may be related to the equality of care provided to young people with perinatally acquired HIV. Where we differed is on education whereby the Kanu review noted education barriers, but these were not present in our group because most of our participants were already successfully attending secondary school.

The study identified several psychosocial factors that optimise or suboptimized adherence to ART by ALHIV. Those factors that improve adherence were high disclosure whereby 77% of participants had openly shared their health status, strong family support where an overwhelming 89% reported receiving support from their families and high care satisfaction whereby nearly everyone (96%) was satisfied with the medical care they received. On the other hand, the negative factors identified in this study were stigma and vulnerabilities despite the strong support to many significant challenges as 40% of ALHIV reported having experienced discrimination, 20% reported feeling isolated and only a minority (32%) regularly attended support groups. Overall, these findings suggest that strong personal and family support are helping to optimise ART adherence in these adolescents, but they are still very vulnerable to stigma and isolation in their daily lives. These factors likely play an important role in how well they are able to adhere to their treatment.

The finding that high disclosure helps adherence is consistent with a Sub-Saharan African (SSA) review by Gudisa and Jun [43] in that they also found that disclosure helps adherence by boosting self-efficacy (a person’s belief in their ability to succeed) and by reducing stigma. This similarity is likely due to both studies operating under shared education policies in the region. Our findings that support helps motivate adherence aligns with the scoping review by Moyo et al. [44]. The consistency is noticed in that both studies show that support works by providing emotional aid.

Our findings differed in that Moyo et al.’s work emphasized stigma more strongly than ours. This difference is probably because our participants were more integrated into schools, which might offer a more supportive and less stigmatizing environment than other settings.

The current study’s finding that an undisclosed status (keeping one’s status secret) acts as a barrier to treatment is supported by Kamote et al.’s [45] in their Tanzanian study.

The difference is that their study found that this barrier was linked to economic factors (which was not a focus here). This difference exists because their study focused heavily on the impact of food insecurity, a factor not central to our current research.

Our results match with those of the review by Hlophe et al. [46] regarding the importance of family literacy as a predictor of good outcomes. This match is likely due to the impact of similar educational interventions. Their review showed different results when it came to the role of non-biological caregivers (like aunts, uncles, or foster parents). This difference probably stems from variations in orphanhood rates and family structures between the study populations.

Overall, adherence to treatment was quite high at 82%. The reasons for non-adherence (missing doses) or when people did not take their medicine correctly, the main reasons were; Forgetfulness which is the biggest reason as it was cited by 44% of ALHIV second by timing issues as taking the medicine at the wrong time was reported by 17% and shame or feelings of embarrassment or stigma, affecting 11% of ALHIV. The reasons for missed appointments (retention gaps) found by the current study to be a larger problem was missing clinic appointments which was reported by 62% of people who missed them, who gave the causes being more related to logistics and daily life and which included transport issues for example difficulty getting to the clinic, mentioned by 33% of ALHIV and forgetfulness for example forgetting the appointment date, reported by 30% of ALHIV.

The study also noted that very few adolescents made lifestyle changes, such as only 2% engaging in regular exercise. These findings show that while most individuals are good at taking their medicine (high adherence), there are significant structural problems like transport and individual barriers like forgetfulness that make it hard for them to stay consistently engaged with the clinic (retention gaps).

The study’s findings on adherence align with several other pieces of research work as our adherence rate of 81.6% is similar to the 65% rate found in the broader Sub-Saharan African (SSA) review by [14] because both studies point to stigma barriers and economic constraints as major challenges affecting adherence. The finding as the role of forgetfulness in poor adherence in our study also aligns with the findings of [14] which also linked non-adherence to fatigue and a feeling of burnout. The findings in our reported rates of forgetfulness are higher than theirs and this difference is likely because our data relied on self-reporting, where people sometimes over-report common issues like forgetting. The current study’s results showing the importance of support match the 78% adherence rate seen in orphans studied by Kamau et al. [39]. In both cases, this success is attributed to the positive influence of caregivers and the presence of structured aid programs.

Our overall high adherence rate is comparable to the 86% adherence rate achieved through support clubs in the study by Fatti G., et al.’s [37] study, however, did not find a focus on lifestyle changes like exercise was important for adherence, whereas our study did. This difference stems from the distinct focus of their intervention (clubs) versus the factors we studied.

The final analysis identified which factors significantly increased or decreased the risk of poor adherence to ART among ALHIV. Two main predictors found by the current study to significantly increase the chance of poor adherence, the first being treatment duration (5 - 10 years on ART) whereby adolescents who had been on ART for 5 to 10 years were 3.4 times more likely to have poor adherence (OR = 3.4). This suggests that the mid-range of long-term treatment is a critical, high-risk period. The second but unexpected predictor was no discrimination whereby adolescents who did not report experiencing discrimination were 4.64 times more likely to have poor adherence (OR = 4.64). This is a surprising finding, which might suggest that those who acknowledge facing discrimination are better supported or more vigilant about their health.

Two factors significantly reduced the chance of poor adherence and were firstly care satisfaction whereby adolescents who reported being satisfied with their care were dramatically less likely to have poor adherence (OR = 0.031) and father caregivers by which having a father as the primary caregiver was protective, making poor adherence less likely (OR = 0.34).

Our study found that several predictors commonly studied were not linked to poor adherence in ALHIV, including age, gender, disclosure of HIV status, and general family/social support.

Our finding that being on ART for 5 - 10 years is a high-risk period for poor adherence is consistent with a study by Ketchaji A et al. [41] which found a similar risk after more than 5 years (aOR = 2.33). This risk is likely due to treatment fatigue (getting tired of taking medicine daily for years). This is especially relevant in groups like ours who have been on treatment for a long time since birth (perinatal longevity). The mid-range duration of 5 - 10 years being risky also matches with that of Kizito et al. [11] review on virological failure (VF) predictors, which links duration and stigma to burnout. Our study found that discrimination was unexpectedly protective (less risk of poor adherence), which differs from Damulak PP, et al.’s [47] work where discrimination is usually a major risk factor. This unusual finding in our study might be due to a unique bias in how the data was collected or reported.

Self-reported data might have underrepresented discrimination in this study due to denial, social desirability, or masked concerns, with ALHIV concealing their status despite underlying fears. Poor adherence could have reduced social exposures for instance avoiding interactions to hide symptoms, thereby limiting opportunities for discrimination, while those facing discrimination might adhere better as a resilience response. Moreover, might be other barriers like the lack of financial, material, and social support from community and health services negatively affected ART adherence. So might be the ALHIV did not experience discrimination which could have been a facilitator to ART adherence but at same time did experience these barriers and that resulted with poor adherence.

This bidirectional link is supported by longitudinal studies and conceptual frameworks showing that stigma initially impairs adherence but can lead to coping mechanisms that improve it among survivors. A United State study noted that participants with low reported stigma still engaged in status concealment, indicating hidden issues.

In high-prevalence regions like sub-Saharan Africa (SSA), normalized stigma may go unlabeled as discrimination, while overt experiences encourage protective adherence. Concealment strategies like hiding medications hinder adherence, but deception like misattributing illness can improve it by securing support without stigma [47].

Adolescents not experiencing discrimination might underreport it due to denial, lack of awareness as subtle microaggressions might go unnoticed or indicate social desirability bias which is wanting to appear “unaffected” in surveys. In contrast, those experiencing discrimination might be more vigilant about ART adherence as a coping mechanism, turning negative experiences into motivation for self-care. This aligns with resilience theories in public health, where adversity can foster adaptive behaviours in some ALHIV.

The absence of experienced discrimination might proxy for other risks, like living in isolated or low-awareness communities where HIV education is poor, leading to complacency and poor adherence. Alternatively, those who might not have been discriminated against could have undisclosed status, though disclosure was not significant here, reducing external stigma and internal motivation for adherence. Socioeconomic confounders like wealthier families facing less overt discrimination but more access to alternatives or mental health issues like depression masking discrimination perception might have also played roles, as bivariate analysis does not adjust for these.

This unexpected finding from our study is consistent with a Ghanian study by Nutor JJ et al. [48] which reported that the majority of the participants who reported low internalized stigma reported non-adherence to the ART compared to those who reported high internalized stigma.

This counterintuitive finding contrasts with findings of semi-structured interviews conducted in Zimbabwe with 24 emerging adults who had a recent history of viral non-suppression and with objective to explore barriers and facilitators of adherence to ART and whereby findings show that interventions to reduce stigma, foster peer support, and therapy for common mental disorders could facilitate emerging adults aged 18 - 29 to adhere to ART [49].

A major contrast comes from Buh A., et al.’s [50] adult data, which found that longer duration was protective (improving adherence). This difference exists because their participants were adults who likely have greater autonomy and control over their health decisions than adolescent. Our finding that satisfaction with care is protective strongly aligns with Magura et al.’s [29] review on healthcare access. Both studies showed that satisfaction leads to better outcomes, primarily because it helps build trust between the patient and the healthcare provider.

Our findings are consistent with several other studies on what helps and what hinders treatment adherence in Sub-Saharan Africa (SSA) [51].

Our results align with the SSA review by Moyo et al. [44] on facilitators that help adherence, such as reminders and support. These facilitators work the same way by providing motivation. This similarity likely stems from shared practices in perinatal education (care provided to mothers and children around the time of birth), which emphasizes these supportive measures early on.

Our results match the barriers identified by Magura et al. [29], which included medication stockouts and stigma. Both sets of findings show that these issues create problems with access to care. Magura et al.’s work placed a greater emphasis on motherhood as a factor, which differs from our study because our research focused more broadly on gender among adolescents.

The findings from our study on the positive role of counseling are supported by Djiyou et al. [28]. This is because effective counseling helps maintain virological suppression (VS), and this consistency is likely due to the quality of urban services available in both study settings.

The barriers faced by mothers highlighted in Akinsolu et al.’s [52] review, specifically related to childcare, also align with our work. This commonality exists because both studies reflect systemic inequities that affect women and caregivers.

This study has some limitations. First, adherence assessment was based on patients’ self-report which might affect the estimation effect. Second, the study considered anyone who have ever missed their dose as non-adherent regardless of number of missed dose and time since missed. Despite attempts taken during data collection, the study may be affected by social desirability and recall biases.

Concluding, qualitative insights advocate integrated adolescent services for barriers. There was also potential selection bias, as the current study was hospital-based sampling might have excluded adolescents not engaged in care and who could have systematically different adherence patterns.

Overall adherence levels (82% - 86%) among adolescents living with HIV in this conflict-affected context mirror the broader progress seen across sub-Saharan Africa. However, these averages conceal important structural and psychosocial barriers, including treatment fatigue, stigma, and logistical challenges, which are compounded by conflict-related inequities. Our findings highlight the protective role of family support, self-motivation, counselling, and NGO involvement, while also underscoring gaps around stigma reduction and maternal childcare burdens. The alignment of facilitators with regional evidence affirms the value of reminder systems, peer support, and counselling, but conflict settings demand tailored responses such as decentralized services, anti-discrimination measures, and mHealth-enabled reminder and support interventions. Long-acting ART formulations and targeted assistance to caregivers emerge as critical strategies to mitigate fatigue and sustain adherence. Addressing these multilevel dynamics is essential to advancing equity and resilience in adolescent HIV care within the fragile health systems. The study’s qualitative findings highlight forgetfulness (44%) and logistical issues (33% transport) as the key barriers to ART by ALHIV. Specifically, forgetfulness, reported by 44% of participants, directly aligns with the potential of mHealth reminders, such as automated SMS or app-based alerts to serve as a proactive, user-friendly tool for prompting timely medication intake and reducing cognitive lapses without requiring additional behavioural changes. Similarly, logistical issues, including transportation challenges cited by 33% of respondents, highlight the value of decentralized services, which could mitigate these burdens by bringing care closer to communities through mobile clinics, home delivery of medications, or telehealth options, thereby improving accessibility and minimizing disruptions to daily routines especially on periods of lockdowns. By explicitly integrating these high-frequency barriers into the design and implementation of such solutions, future programs can enhance adherence rates, reduce health disparities, and ultimately contribute to better long-term HIV management outcomes.

Future research should employ longitudinal designs with objective measures like viral loads to track adherence trajectories and causality. Multicenter RCTs evaluating long-acting ART and mHealth in conflict zones could assess impacts, including rural samples and multivariate analyses to control confounders, with qualitative follow-ups on mothers.

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

This study was funded by the authors.

DEB was responsible for the conception and design of the study, directed data collection and organization, statistical analysis and drafting of the manuscript.

Authors contributions: DEB, LLN and AMBS conceptualized the study. DEB, LLN, AMBS and NNKJ developed the methodology. LLN contributed to the conception and design of the study, participated in data collection as well as interpretation and drafting of the manuscript. NNKJ contributed to the conception and design of the study, participated in data collection, analysis of data and interpretation of data as well as drafting of the manuscript. AMBS contributed to the conception and design of the study, participated in data collection, analysis of data as well as interpretation and drafting of the manuscript. All authors read and approved the final version of the manuscript for submission. Formal analysis was conducted by DEB, LLN and AMBS. The original draft was prepared by DEB, LLN and AMBS. All authors read and approved the final version of the manuscript for submission.