Pill-count Antiretroviral Therapy Adherence and its Contextual Determinants in a Semi-rural Ghanaian Municipality: A Mixed-methods Cross-sectional Study

Abstract

Background: Antiretroviral therapy (ART) adherence estimates in Ghana differ by setting and measurement method, and evidence from semi-rural municipal services using pill-count data remains limited. Objective: To estimate ART adherence and examine individual, psychosocial, treatment-related and health-system factors among adults receiving HIV care at Ahafo-Ano North Municipal Hospital, Ghana, while contextualising quantitative findings with ART staff perspectives. Methods: A facility-based mixed-methods cross-sectional study included 227 adults receiving ART. Adherence was assessed primarily by pill count, complemented by self-report and checked against pharmacy dispensing records, and classified at a ≥95% threshold. Chi-square tests and multivariable logistic regression assessed associated factors. Semi-structured interviews with three purposively selected ART staff provided complementary service-level context. Results: Thirty-eight participants (16.7%) achieved ≥95% pill-count adherence. Most measured variables were not significantly associated with adherence; the manuscript separately reports an association between reasons for skipping doses and adherence (p < 0.001). In the multivariable model, reported social support from family or friends was associated with lower odds of adherence (AOR 0.28, 95% CI 0.09–0.90). Given the broad support measure and cross-sectional design, this result should not be interpreted causally. Staff described denial following diagnosis, transport and financial constraints, early adverse effects, stigma and limited follow-up capacity. Conclusion: Fewer than one in five participants met the strict pill-count adherence threshold. Findings support context-sensitive adherence counselling, improved follow-up and transport-responsive service delivery, alongside longitudinal multisite research using standardised adherence and virological outcomes.