Competing priorities
SAID
Some participants reported that they struggled to balance between attending health services and/or going to work, both of which were deemed to be important for the well-being of PLHIV. For many people who were informally employed or earning minimum wage, there was little flexibility, and taking a leave of absence would compromise their much-needed employment. For instance, Thobela (39), who stayed with his two young-adult brothers and financially supported his extended relatives in the Eastern Cape province, would sometimes forego clinic appointments to go to work as a road construction worker. He explained that:I was in the Eastern Cape for six months. I don’t remember the year, but I think it was 2014. I took them [ARVs] very badly [infrequently] because when I came back, I quickly got a job. I didn’t have time for the clinic. At some point, I took my clinic card and sent children [to fetch his tablets] but they said [at the clinic] I must go there myself (Thobela, 39, Male).Thobela described that he wanted to access treatment and he tried to make alternative arrangements to have his medication collected. However, his employment and the responsibility of taking care of the financial well-being of his household took priority while that compromised his clinic attendance and his ability to access ART.Several PLHIV also reported that they often had additional health-related HIV costs as they had to purchase over-the-counter medication to counter side effects attributed to ART. Costs related to HIV care could, at times, not be met when resources were assigned to other necessities such as food, electricity, and school expenses. For example, Bongiwe (Linda’s mother) explained why Linda could not consistently take ART due to other costs:We went to fetch Linda’s treatment [from the clinic]. Her medication goes hand-in-hand with Overall, managing income was determined by decisions people made towards sharing of their expenditure. Adherence was complicated by a myriad of factors such as diverting incomes for substance use, employment commitments, and prioritising other basic household expenses over ART related costs.