Discussion
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We reported qualitative data from the HPTN 071 (PopART) trial on the interaction between managing income and ART adherence in the Western Cape, South Africa. We found that PLHIV used their limited resources to buy substances such as drugs and alcohol to numb the emotional challenges of living with HIV. Other household pooled their income to support access and adherence to ART for PLHIV by sharing expenses among members. A third group prioritized other competing expenses in households, such as covering food over ART related costs, which disrupted the ability of PLHIV to access or adhere to ART.Researchers in low-income settings identified various socio-economic factors, including challenges surrounding household income, as a barrier to ART adherence [Qualitative data in low-income settings have shown that when a household is supporting treatment adherence of an individual, there are also additional financial strains experienced by these households [Our study suggests that achieving optimal treatment access and adherence was complicated by multiple factors such as the need to buy and use additional medication to manage taking ART, accessing food before taking medication, and was negatively impacted by the use of illicit drugs and alcohol. However, a systematic review in low and middle-income settings showed that households have the potential to create a health-enabling environment for PLHIV through covering transport fees to the clinic and accompanying relatives when attending HIV care [The strengths of our study include that we drew on longitudinal, in-depth data allowing for thick and nuanced descriptions and a diverse sample of men and women of different ages in a resource-constrained setting. As a limiting factor for this nested-qualitative study, participants could also have viewed the researchers as another type of audience, where telling their stories allowed them to construct themselves and others as particular kinds of moral agents. However, through multiple interactions and observations with participants, researchers were able to learn more about the participants’ lives and gain their trust that made them share their stories in detail. Another limitation include that we only analysed a small sample of the qualitative data and the experiences of PLHIV from the Western Cape province. Therefore, our findings may not be generalizable to other settings, especially if the local social and health system contexts differ substantially.