{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,10]],"date-time":"2026-09-10T08:23:10Z","timestamp":1789028590359,"version":"build-2803163510"},"reference-count":55,"publisher":"Public Library of Science (PLoS)","issue":"7","license":[{"start":{"date-parts":[[2024,7,11]],"date-time":"2024-07-11T00:00:00Z","timestamp":1720656000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Even though quantitative studies have described barriers to anti-retroviral therapy (ART), a more exploratory approach will provide in-depth information on these issues, and potential suggestions to address these issues at individual as well as structural level. We designed this qualitative study to examine the barriers and facilitators for antiretroviral therapy adherence in key population (KP) in Mumbai, India. We also wanted to understand the strategies adopted by these groups and get suggestions to improve adherence to ART.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>This is a qualitative analysis of seven focus group discussions (FGDs) conducted with four KP subgroups in Mumbai. We conducted two FGDs each with female sex workers (FSW), men who have sex with men (MSM), male-to-female transgendered people\/<jats:italic>Hijras<\/jats:italic> (TGH) each, and one FGD with people who inject drugs (IDU). We transcribed the audio-recorded electronic records of these FGDs. We also added the notes of the observers on the group dynamics to the transcribed data. We used the Framework Approach to analyse these data.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Some experiences\u2013such as side effects to ART medicines\u2013were common across groups. However, incarceration as a reason for stopping ART was reported by FSWs but not by other KPs. Friends and family (including <jats:italic>Guru<\/jats:italic>) are important support systems for HIV infected individuals and adherence to ART. Stigma and discrimination by community members and general community prevent regular access of ART centres and other health care facilities. Additional factors which led to missed doses were mental health issues, alcohol use, and misplacing the ART tablets during police raids or during robbery attempts at the cruising sites. Since a common source of discrimination among peers and the community was the presence of \u2018Green book\u2019 (or their treatment book); the key population wanted the AIDS program to change it to digital cards so that labelling one as \u2018HIV positive\u2019 for being seen with the book can be avoided.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>The qualitative study helped us explore the barriers to ART among key population and the community provided specific suggestions to address them. In addition to Key Population centric enhanced adherence counselling, some administrative guidelines and procedures may need to be altered to improve adherence to ART in these populations.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0305390","type":"journal-article","created":{"date-parts":[[2024,7,11]],"date-time":"2024-07-11T17:39:26Z","timestamp":1720719566000},"page":"e0305390","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":5,"title":["Barriers and facilitators for adherence to antiretroviral therapy, and strategies to address the barriers in key populations, Mumbai\u2013A qualitative study"],"prefix":"10.1371","volume":"19","author":[{"given":"Shrikala","family":"Acharya","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mugundu Ramien","family":"Parthasarathy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vijaykumar","family":"Karanjkar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sachendra","family":"Katkar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1291-9033","authenticated-orcid":true,"given":"Maninder Singh","family":"Setia","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2024,7,11]]},"reference":[{"key":"pone.0305390.ref001","volume-title":"National AIDS Control Organisation: National AIDS Control Programme Response to the HIV epidemic in India. 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Shah","year":"2007","journal-title":"Clin Infect Dis"},{"key":"pone.0305390.ref031","volume-title":"Analysing qualitative data","author":"C Pope","year":"2006","edition":"3"},{"issue":"1","key":"pone.0305390.ref032","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1016\/j.annepidem.2017.11.009","article-title":"Stigma as a barrier to health care utilization among female sex workers and men who have sex with men in Burkina Faso.","volume":"28","author":"HY Kim","year":"2018","journal-title":"Ann Epidemiol"},{"issue":"1","key":"pone.0305390.ref033","doi-asserted-by":"crossref","first-page":"7511","DOI":"10.1038\/s41598-022-11647-1","article-title":"Patterns of sexual and HIV-related stigma among men who have sex with men and women living with HIV in Haiti.","volume":"12","author":"JG Devieux","year":"2022","journal-title":"Sci Rep"},{"key":"pone.0305390.ref034","volume-title":"Impact of Stigma on Utilization of Health Services among Sex Workers in Kenya.","author":"L Nyblade","year":"2015"},{"issue":"3","key":"pone.0305390.ref035","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1097\/JNC.0000000000000059","article-title":"Perceived Social Support Among Adults Struggling With Adherence to HIV Care and Treatment.","volume":"30","author":"M Enriquez","year":"2019","journal-title":"J Assoc Nurses AIDS Care"},{"issue":"9","key":"pone.0305390.ref036","doi-asserted-by":"crossref","first-page":"1178","DOI":"10.1080\/09540121.2020.1853660","article-title":"Impact and correlates of sub-optimal social support among patients in HIV care","volume":"33","author":"RJ Fredericksen","year":"2021","journal-title":"AIDS Care"},{"issue":"2","key":"pone.0305390.ref037","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1007\/s10865-020-00186-7","article-title":"Examining stigma, social support, and gender differences in unsuppressed HIV viral load among participants in HPTN 065.","volume":"44","author":"AC Maragh-Bass","year":"2021","journal-title":"J Behav Med"},{"key":"pone.0305390.ref038","doi-asserted-by":"crossref","first-page":"e20190290","DOI":"10.1590\/1983-1447.2020.20190290","article-title":"Association between social support and adherence to anti-retroviral treatment in people living with HIV.","volume":"41","author":"RDS Oliveira","year":"2020","journal-title":"Rev Gaucha Enferm"},{"issue":"4","key":"pone.0305390.ref039","doi-asserted-by":"crossref","first-page":"e0001362","DOI":"10.1371\/journal.pgph.0001362","article-title":"A scoping review of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people\u2019s health in India.","volume":"3","author":"V Chakrapani","year":"2023","journal-title":"PLOS Glob Public Health"},{"issue":"6","key":"pone.0305390.ref040","doi-asserted-by":"crossref","first-page":"703","DOI":"10.1016\/j.jana.2015.07.005","article-title":"Re-thinking HIV-Related Stigma in Health Care Settings: A Qualitative Study.","volume":"26","author":"M Gagnon","year":"2015","journal-title":"J 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