Discussion
Depressive, virological failure, depressive, depressive symptoms, depression
SENSITIVITY
Our study has assessed rates and sociodemographic and psychosocial factors associated with non-adherence as measured through self-report and pill count and virological failure among PLHIV in a South African rural population. We identified several demographic, socio-economic, and behavioural risk factors for non-adherence and virological failure and showed that there is limited overlap of markers of adherence with virological failure. We found that male gender was an independent risk factor for all outcomes. Depressive symptoms were independently associated with virological failure while household income and task-oriented coping score were protective against suboptimal pill-count adherence.In multivariable analyses we found that self-reported adherence difficulties, suboptimal pill count adherence and virological failure were more likely in men than women. The finding of increased problems with adherence to ART in men is consistent with other studies conducted in rural settings and may reflect poorer healthcare behaviour in men [Suboptimal adherence as indicated by pill count was associated with low household income, as also found by other studies [In this cohort, better adherence as indicated by pill count was associated with increased use of task-oriented coping. This was more evident in female participants. This suggests that counselling strategies addressing specific coping styles could have a positive effect on ART treatment outcomes. Moreover, it is likely that there also are indirect associations between coping strategies, sex, and adherence to treatment through markers of mental health. More research is needed to assess these relationships and guide future interventions.Furthermore, we found that the risk of virological failure was higher among participants with moderate or severe depressive symptoms. In stratified analysis, we found that while the prevalence of depressive symptoms was similar between men and women, the association was significant among female participants only. These findings are comparable to those of several studies assessing risk factors for non-adherence in PLHIV, which also found evidence that depression was associated with poor outcomes for HIV-infected patients on ART, especially in women [We encountered high levels of both self-reported adherence difficulties as well as suboptimal adherence as measured through pill count in this setting. In contrast, rates of virological failure in this cohort were more limited. While self-reported adherence difficulties and suboptimal pill count results were significantly correlated with each other and with virological failure, overlap between these outcomes was limited. Sensitivity analysis showed similar findings for self-reported adherence difficulties. Various studies have reported significant correlations between objective and self-report measures of ART adherence [