Introduction
The Human Immunodeficiency Virus (HIV) is the responsible cause of the Acquired Immune Deficiency Syndrome (ADIS). AIDS is a disease that negatively affecting the individual immune system rendering it less efficient and thus, increases the vulnerability of the individual to many infectious agents.1,2 Its prevalence is increasing nowadays in many Arab countries like Palestine, and Yemen.3 A similar trend is observed in Iraq, where a total of 539 new HIV cases were recorded between 2010 and 2019, with 83.5% of these cases occurring in males. The proportion of these cases increased from 1.8% in 2010 to 29.1% in 2019.4
The good news is that many antiretroviral medications are available nowadays that can improve survival and eliminate the risk of transmitting HIV to their sexual partner(s).5 Although all antiretroviral therapy regimens are effective to reduce viral load, there is slight difference in their effectiveness;6,7 meanwhile, these regimens are mainly differ in their patients’ tolerability due to their side effects.7 Thus, many patients change their treatment regimen due to intolerance or resistance.7 Indeed, whatever regimen used, good adherence to the prescribed therapy is the key to achieve successful outcomes.8 Non-adherence to antiretroviral therapy is common among patients living in developing countries.9,10 Poor knowledge about AIDS among patients increases their chance for non-adherence to prescribed therapy.11 In Iraq, knowledge about AIDS is low among general population12 and even among medical college students.13,14 On the other hand, quality of healthcare services to HIV patients in low and middle income developing countries is poor.15,16
Inadequate facilities and poor patient-provider communication are among the factors that negatively affect the quality of care and treatment for AIDS patients in developing countries.17 To the best of our knowledge, there is limited information about the quality of care and the treatment regimens used in managing HIV patients in Iraq. Additionally, details regarding adherence to these regimens are lacking. By exploring treatment regimens, adherence patterns, and healthcare quality from patients’ perspectives, valuable insights can inform policymakers about targeted interventions to improve HIV management. Therefore, this study aims to gain an in-depth understanding of the treatment regimens, assess adherence levels, explore reasons for non-adherence, and identify factors that enhance adherence among Iraqi HIV patients. It will also evaluate the quality of healthcare services and identify barriers and facilitators to improving these services.
Methods
Study Design
To achieve the study’s aim, a generalized qualitative approach was employed. Due to the sensitive nature of HIV within Iraqi culture, face-to-face individual interviews—rather than focus group discussions—were conducted with individuals diagnosed with HIV who are currently receiving treatment.
Ethical Approval of the Study
This study complies with the principles of the Declaration of Helsinki and received ethical approval from the Ethics Committee of the College of Pharmacy, Baghdad University (Approval No. REC06202567R, dated 13/10/2024). Given cultural considerations and the potential reluctance of most Iraqi individuals to sign documents,18 the ethical committee granted a waiver for written informed consent. Consequently, verbal informed consent was approved by the Ethical Committee at the College of Pharmacy- University of Baghdad. Verbal informed consent with details about publication of anonymized responses/direct quotes were obtained from the study participants.
Development and Validation of the Interview Guide
The interview guide (Supplement A) was developed by study authors based on previous relevant literature.19–23
For content validation, the developed guide was emailed to a panel of experts (three academic pharmacists with robust experience in qualitative research; and one consultant physician (board in internal medicine) who works in HIV center.
The experts were asked to rate each question on a 3-point scale: “relevant and essential” “relevant but not essential” and “not relevant.” Additionally, they were encouraged to provide feedback on any language and wording issues. To assess the content validity of the interview guide, Lawshe’s method was employed.24 All experts deemed all guide items—except for one—to be essential and relevant. The one item was classified as irrelevant by a single expert. A few linguistic suggestions were made by two experts, and two experts recommended adding a new question. Incorporating the experts’ feedback, a revised guide was prepared. There was unanimous agreement on the relevance and importance of all items in the revised guide.
Setting and Participant Recruitment Method
The study included a sample of adult patients living with HIV from three HIV centers located in three different governorates of Iraq: Baghdad, Kirkuk, and Erbil.Patients were enrolled using a combination of convenience and purposive sampling strategies.25 The recruitment approach was determined by the healthcare center and the duration of the participants’ illness. This strategy allowed the researchers to capture a diverse range of perceptions regarding HIV treatment from various patient perspectives. To ensure sufficient experience in dealing with HIV treatment, HIV patients who use antiretroviral therapy for at least 3 months were considered eligible to participate in this study.
All eligible participants were contacted before conducting the interview to inform them about the study objectives. Only those who gave their verbal informed consent (Audio-recorded) and have sufficient time for the interview were enrolled. All participants were interviewed in a quiet area at the HIV center.
Data Collection
The interviews were conducted in Arabic by the first author (a master candidate in clinical pharmacy), after being trained on qualitative interviewing techniques through pilot interviews under supervision of the second author (PhD in clinical pharmacy and experience in conducting and publishing qualitative studies).
The interviews were accomplished through semi-structured open-ended questions. Probes were applied to obtain additional comments when necessary.
All interviews were audio-recorded using a mobile recorder. Each interview took approximately 10–20 minutes to be completed.
To protect patient confidentiality and privacy, only anonymized responses and direct quotes are included in the publication; participants were informed of this during the verbal consent process.
The interviews were conducted until the point of saturation was reached (whereby no more new information was acquired) at each one of the three HIV centers.This necessitate continuation of the interviews from November 2023 to February 2024.
For the aim of presenting participants’ quotations, the first author translated verbatim to English.
Thematic Analysis
All interviews were coded manually by the second author and used for the qualitative data sorting. A codebook was developed to ensure consistent coding across interviews. Codes were grouped to generate themes and subthemes using a hybrid framework (inductive and deductive) model.26,27 In the inductive approach, the researchers used an already prepared template based on literature for analysis of interviews. In the deductive approach, Braun and Clarke’s six steps for thematic analysis were used.28 These steps include getting to know the comments, generating codes, searching for themes, assessing themes, defining and labelling themes, and finally writing the results.
Results
Forty-seven patients were interviewed to reach saturation point in the current study. Eighteen patients from Al-Karama HIV center (Baghdad), seventeen from Kirkuk HIV center, and the last ten participants from Erbil HIV center. The average age of study participants was 37.87 years with an age range from 25–57 years. Meanwhile, the duration since HIV diagnosis averaged 3.95 years, ranging from 1 to 9 years. Details about demographic and clinical characteristics of the included patients are presented in Table 1.
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Table 1 Clinical and Demographic Characteristics of Study Participants
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Study Themes
The data obtained from the study interviews led to the development of three critical themes that are essential for the effective management of patients infected with HIV: treatment of HIV, Adherence to prescribed anti-HIV medications, and accessibility and quality of care for HIV patients (Table 2).
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Table 2 Study Themes
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Medications Used in Treatment of HIV
All patients reported currently taking a once-daily oral tablet that contains a combination of three drugs: tenofovir disoproxil, lamivudine, and dolutegravir (TLD). Among them, only 18 participants indicated that this was the sole treatment regimen prescribed to them, meaning their medications had remained unchanged throughout their treatment journey. Notably, all of these individuals had been on treatment for four years or less.
In contrast, the majority of participants (n=29) reported that TLD was not their initial treatment regimen, indicating that their HIV treatment had undergone changes. Among this group, most (n=19) experienced one change in their treatment regimen, while six participants reported two changes, and the last four noted that their treatment had been altered more than twice. It’s worth mentioning that even participants with just one year of treatment experience reported changes; however, multiple changes were more prevalent among those who had been on a treatment for more than 4 years.
Regarding the reasons for changing the treatment regimen, the majority of participants (n=22) cited unavailability of medication at the HIV center as the primary reason for the change. Additionally, seven participants indicated that they switched to alternative treatments due to experiencing side effects from their original medications.
In regard to the time of using TLD, most (n=43) participants reported that they were taking it at night according to physicians’ instruction. One participant reported taking the medication at 6 PM to separate it from alcohol consumption according to physician instruction; this illustrated the importance of personal circumstances in medication timing. A smaller group of participants (n=2), reported taking the medication in the morning after breakfast to be aligning with their personal routine, while another participant chose to take it at noon due to the nature of their work schedule. These diverse schedules highlight the varying approaches to adherence among participants, influenced by both clinical advice and personal lifestyle factors.
Once diagnosed with HIV, the physician prescribed a treatment to me. I used TLD at 10 pm according to physician instructions since that time. P6.
I am currently taking TLD once daily before going to bed according to my physician instructions, as I experience dizziness when I take the medication in the morning. Indeed, my treatment has undergone multiple changes due to unavailability of the medication at the center. P2
Time of Initiation HIV Treatment
The majority of participants (n=37) reported that they started to use treatment once diagnosed with HIV. On the other hand, 10 participants reported a delay in starting their treatment. Five participants started their HIV treatment within 1–2 weeks after diagnosis; three of them reported that routine administrative issues required for registering HIV patients as the reason for this delay. Meanwhile, the last two participants reported lack of the prescribed drug in the hospital as the reason for delay in starting treatment after their HIV diagnosis. Additionally, two participants reported a 6 months delay in starting their treatment due to disbelief regarding their diagnosis. The last three participants reported a delay of more than 1 year in starting treatment due to fear from drug side effects.
Once diagnosed with HIV, I started to use a treatment. P46
Four years ago, I was diagnosed with HIV during my preparation to deliver a baby; however, I refused to start treatment for 3 years due to fear from drug side effects. P31
I began the prescribed HIV therapy approximately one week after my initial diagnosis, following the completion of the required lab tests and necessary documentation for registration at the HIV center. P1
Side Effects of HIV Medications
Regarding medications related side effects, the majority of participants (n=36) did report experiencing one or more of drug related side effects. However, most of participants (n=34) who suffered drug-related side effects indicated that these problems occurred shortly after initiating treatment but subsequently subsided. Only one participant continued to experience some side effects, while another reported intolerable side effects that necessitated a change in treatment. The most commonly reported side effects include vertigo (n=21), fatigue (n=8), headache (n=7), rash (n=5), vomiting (n=4), fever (n=3), lethargy (n=2), nightmares (n=2), and reduced libido (n=1). In contrast, few participants (n=11) reported that they did not experience any side effects while using treatment for HIV.
I experienced fever, nightmares, lethargy, and vertigo while on HIV treatment; however, these side effects resolved on their own after a short period. P17.
I suffered from vertigo and headache which disappear after few days. I tried healthy eating with exercise to combat these effects. P 15
Concerns About HIV Medications
Most participants (n=32) reported no concerns about taking the prescribed medications. However, fifteen participants did express various concerns, including fear of long-term side effects from the drugs (n=9), uncertainty regarding the benefits of these medications (n=5), and anxiety about the potential difficulty in finding the prescribed drug in pharmacies (n=1).
Most participating patients (n=42) reported that they ask their caring physician if have concerns or questions about their medications. Among these patients, 29 contacted their physician by phone, while others sought answers through in-person visits, either at the HIV center (n=12) or at their private clinic (n=1). Of those who reached out to their physician, most (n=32) considered the responses to be satisfactory; eight participants found the physician’s advice to be very helpful, while only two participants considered such advice as somewhat useful. Meanwhile, two patients indicated that they checked the internet for information about their medications and found this information to be beneficial. Conversely, three patients reported that they did not have any questions about their medications.
After researching about the disease and its treatment on the internet, I became concerned about the potential side effects of the medications on my liver and kidneys. Whenever I have concerns about my condition or treatment, I typically contact my physician via WhatsApp and this option helped us to be cured. P3
I have concerns about the disease and the potential for a cure with treatment. Nonetheless, I visit the HIV center and discuss my concerns with the physicians there. P41
Level of Adherence to Anti-HIV Medications
Nineteen participants reported (based on their self-report) that they adhered to their prescribed treatment without missing any doses. In contrast, 28 participants indicated that they had missed one or more doses of their HIV therapy. Meanwhile, the majority of participants (n=16) reported that their last missed medication doses occurred many years ago, particularly when they were newly initiated on treatment. In contrast, three participants indicated that they missed a dose within the last month, while nine participants reported their most recent missed dose occurring within the past year.
The majority of participants (n=16) indicated that they missed their treatment for one day or so. Four participants reported missing their medications for a period of 1 to 2 weeks, while the remaining eight participants mentioned missing their medications for several months. Despite this, only one participant reported an increase in viral load after missing their treatment, while the remaining participants indicated that they experienced no negative effects from missing their medications.
For those who missed their treatment (n=28), only six of them reported taking the missed dose as soon as remembered, while others (n=22) reported that when they resumed, they just do so at their usual scheduled time.
I did not take my treatment for about 3 months 5 years ago. However, nothing occurred for me by this missing. I resumed my treatment after I was able to access HIV center to get my medications. P1
I missed my medications for one day three months ago when I was away from home. After returned home, I resumed taking the medication at the usual time. I did not experience any negative effects from this missed dose. P 23
I halted my medication for five months in 2017 during the early days of my treatment. During this time, my viral load increased. I resumed treatment after my physician prescribed me an alternative medication. P 30
Reasons and Challenges for Medication Non-Adherence
Several factors contributed to these missed doses. The primary reason cited for non-adherence was forgetting to take the medication at the scheduled time (n=10). Travel was another common reason; eight participants noted that they failed to remember to take their tablets while traveling, likely due to the distractions and stress associated with being away from home. Additionally, two participants specifically reported running out of medication during their travels. The unavailability of HIV medication in hospitals in Iraq presented a significant barrier for five participants, making it difficult for them to maintain their regimen. Family emergencies also played a crucial role in missed doses, affecting four individuals and disrupting their daily routines and priorities. Health issues were another factor; two participants reported experiencing headaches or vomiting related to the medication, which impacted their ability to adhere to their dosing schedule. Furthermore, challenges with refilling prescriptions emerged, particularly during exam periods (n=1) and due to COVID-19 restrictions (n=1).
I missed my medications because I was unable to obtain them from the HIV center due to COVID-19 restrictions. P1
I missed my medications because I ran out while I was in Turkey. P9
I missed my medications because I forgot to take them P12.
Factors Enhancing Adherence
Regarding the most helpful factors for adherence to prescribed therapy, most participants (n=40) identified a single factor, while others (n=7) reported multiple influences. Notably, 24 participants cited their desire to live a healthy life as the primary motivator for maintaining adherence to their medications. Four participants indicated that fear of premature death served as a critical incentive for regular medication use. Additionally, 12 participants found that positive and promising laboratory findings encouraged their adherence to treatment. Furthermore, family-related issues also played a significant role in medication adherence, including social support (n=9), the intention to build a family (n=5), and the desire to protect a spouse (n= 2).
The primary motivators for my medication adherence are the desire to stay healthy and achieve a viral load of zero. P4
I take medications because my wife and children encouraged me to do so. P24
I take my HIV treatment regularly because I fear from death. P16
Role of Healthcare Providers
All patients reported that their physicians educated them about the use of their prescribed treatment. Most participants (n=43) indicated that the local physicians at the HIV center were responsible for their education. In contrast, only four participants stated that the educating physician was of international origin: three Turkish and one Indian.
Most participants (n=19) expressed high satisfaction with the role of physicians in providing consistent and effective follow-ups. Sixteen participants identified the primary role of physicians as offering psychological support to patients. Conversely, fifteen participants noted that educating patients about their disease and treatment was a crucial aspect of a physician’s role in caring for individuals living with HIV. Additionally, seven participants highlighted the importance of providing patients with their physician’s contact number for urgent calls as a key component of effective care for HIV patients.
The physician in Turkey educated me about the way of using my treatment. In Iraq, the caring physician gave me his mobile number to contact when necessary. However, services to HIV patients in Turkey are better than in Iraq. P9
The internist in Kirkuk educated me on the proper use of HIV treatment. The physician at the HIV center consistently communicates with me, offering both my wife and me ongoing psychological support, which has been incredibly beneficial for us. P12.
Barriers in Accessing Healthcare Services
The main reported barrier to accessing healthcare services at the HIV center was interruptions in medication supply (n=13). Additionally, ten patients expressed a need to seek care from hospitals or physician clinics outside the HIV center. Among these, the majority (n=7) reported challenges in obtaining care, which included refusals for surgical procedures (n=3), the need for disposable equipment for dental procedures (n=2), a requirement for specially designed operating theaters for surgeries (n=1), increased costs associated with dental procedures (n=1) and discrimination in care (n=1). One participant reported hiding his condition from healthcare providers to avoid social discrimination. In contrast, only one participant indicated that they did not encounter any barriers to receiving care outside the HIV center.
Medications were not always available at the Ibn-Zuhir HIV center, and I also experienced mistreatment from a private nurse when I want to receive my injection. P34
I do not face any difficulties in obtaining services and care at the HIV center. However, when I had a nodule and sought treatment at a hospital, they refused to perform the surgery, stating that their surgical theater was not equipped to handle HIV patients. P5.
The Quality of Health Care at the HIV Center
Nearly all patients (n=45) rated the quality of healthcare they receive as good, with only two participants considering it moderate. Most participants (n=40) attributed the quality of care to physicians’ skills in effectively engaging with, cooperating with, and supporting HIV patients. Four patients indicated that the consistent availability of free medications contributed to their perception of good quality care, while one patient felt that the facilitation of treatment provision was a key aspect of quality healthcare.
I think that the healthcare services are moderate, particularly regarding how staff treat patient. I recall one staff member telling me to keep my distance and not approach while I was receiving my medications. However, the physicians are good and consistently provide us with support. P5
The current services at the HIV center are good, especially in terms of the communication and care provided by the physicians to individuals living with HIV. P16
Recommendations to Improve Care to HIV Patients
Five participants recommended establishing a dental clinic at the HIV center, and another five suggested increasing privacy for individuals with AIDS. Three participants expressed the need for a continuous supply of medications, while two recommended implementing a special identification card for AIDS patients. Additionally, five patients advocated for access to a psychiatrist at the HIV center to support patients. Lastly, two more patients suggested obtaining a special identity card to facilitate their access to care in hospitals.
I prefer to receive dental care at the HIV center. Additionally, I would like to see a psychiatrist at the center who can offer psychological advice and support to help HIV patients lead normal lives, pursue marriage, and start families. P5
I prefer to enhance privacy for HIV patients and to improve care that addresses both their psychological and physical needs. P9
Discussion
In addressing the study objectives, the current results shed light on the specific antiretroviral therapy regimens being utilized by HIV patients in Iraq, in which all patients reported currently taking TLD, a once-daily oral tablet that combines three medications. In this regard, only a few of the participating patients were naïve to treatment at the time of TLD initiation, while the majority were transitioned from different regimens ultimately to TLD, particularly those diagnosed with HIV more than four years ago. Meanwhile, most participants who experienced a change in their treatment regimen cited medication unavailability at the HIV center as the primary reason for the switch. While medication shortages are common in Iraqi hospitals,29 the current situation differs, as older regimens are no longer available following the supply of TLD by the Iraqi Ministry of Health to HIV centers. This shift is supported by evidence indicating that TLD is more effective30 and better tolerated31 than older regimens. This evidence has prompted many countries31–34 to adopt the WHO recommendation35 of transitioning patients from older regimens to TLD in their national guidelines. The information above highlights the global acceptance and utility of the TLD regimen in managing HIV patients. Furthermore, it underscores the commitment of physicians and health policies in Iraqi HIV centers to delivering optimal care and treatment for HIV patients.
The findings of this qualitative study indicate that over 90% of participants reported adhering to their physicians’ instructions by taking their medication at night, with only a small number adjusting their dosing time based on personal lifestyle and work schedules. Current data suggest that many clinicians tend to prescribe a fixed nighttime dosing schedule—an approach rooted in older HIV treatment regimens aimed at reducing dizziness and fatigue side effects.36 However, TLD can be taken once daily at any time—morning or evening—underscoring the importance of tailoring dosing schedules to individual patient preferences37 to improve adherence and convenience.38 Additionally, patients experiencing insomnia or sleep issues when taking TLD at night may benefit from shifting their medication to morning to enhance comfort and adherence.37 These findings highlight a potential gap in personalized medication counseling and suggest that physician practices should be updated and strengthened by more routinely incorporating patient-specific factors into dosing recommendations. Doing so could optimize treatment adherence, improve treatment outcomes, and enhance overall patient well-being.
Regarding the timing of HIV treatment initiation, nearly one-quarter of study participants reported experiencing delays in starting their therapy. Similarly, a cross-sectional study conducted in Pakistan found that delayed initiation of HIV treatment is common, with 28.5% of individuals diagnosed with HIV experiencing such delays.39 The primary reasons for delays among current study participants were institutional in nature, including difficulties with registration at HIV centers and the unavailability of prescribed medications. Only a few participants cited health beliefs about the disease or treatment as reasons for delaying therapy. In other developing countries, health-related beliefs and psychological distress are typically the main factors contributing to delayed treatment initiation.39,40 Notably, none of the aforementioned studies identify institutional barriers as a cause of delay, suggesting that such issues may be specific to Iraqi patients. Addressing these problems requires urgent action to facilitate administrative processes for HIV patients and ensure a consistent supply of medications at HIV centers.
Regarding medication-related side effects, the majority of participants reported experiencing one or more adverse effects, with dizziness, fatigue, headache, and vomiting being the most common. It is well established that the likelihood and type of side effects vary depending on the specific medication, drug class, and individual patient factors.41 However, due to the qualitative nature of this study and the diverse treatment histories of most participants—many of whom have long-standing HIV infections—the frequency of these side effects could not be quantified, and the exact drug regimens responsible remain unknown. Nonetheless, these reported side effects are consistent with those observed among HIV patients undergoing treatment in Sub-Saharan African countries.36 Meanwhile, most participants who experienced these side effects reported that the problems occurred shortly after starting treatment and then subsided, which can be seen as a positive outcome.
The current study revealed that nearly one-third of participants undergoing anti-HIV treatment expressed concerns, primarily centered on long-term side effects and uncertainties regarding the benefits of their medications. While similar concerns about long-term side effects have been documented among Canadian HIV patients,42 worries about the perceived benefits were not reported in that population. This highlights a gap in patient education among Iraqi patients. Meanwhile, all participants reported relying exclusively on physicians for information about their new treatments. Since pharmacists are typically better suited for patient education and counseling,43 this reliance on physicians may contribute to the existing gap.
On the other hand, most participants in the present study reported that they usually contact their physicians with medication concerns and expressed satisfaction with their responses, highlighting the effectiveness of physician reassurance. However, this raises questions about why such support is not routinely offered by pharmacists or provided proactively during the prescribing process. Addressing this gap through comprehensive counseling and education to patients by pharmacists could improve treatment adherence and overall patient outcomes.
Regarding adherence to anti-HIV medications, about three-quarters of study participants stated they are currently fully adherent to their therapy, with only a few having been non-adherent at the time of treatment initiation many years ago. In comparison, a meta-analysis of HIV-positive patients in North America found that about 55% achieved optimal adherence.44 Notably, the current study population demonstrates a higher level of adherence than the North American population. However, this difference may be influenced by variations in study design, data collection methods, and contextual factors between the two studies. On the other hand, approximately one-quarter of participants reported missing one or more doses within the past year, indicating suboptimal adherence to their HIV therapy. Additionally, half of these participants reported missing their treatment for several months. Surprisingly, only one individual experienced an increase in viral load following missed doses, while the remaining participants reported no negative effects from missing their medications—an observation that contrasts with typical expectations regarding the impact of missed doses on viral suppression.45,46 Although the exact reason for this finding is unknown, it is possible that the limited follow-up laboratory testing of viral load after periods of medication non-adherence led participants to believe that there were no negative effects. Nevertheless, this issue must be thoroughly investigated to determine the true underlying reasons, while simultaneously educating patients about the risks associated with medication non-adherence.
Regarding the reasons for medication non-adherence, some were patient-related, such as forgetfulness, travel, and family emergencies, while others were drug-related, including medication unavailability and side effects. Similar reasons for non-adherence have been reported among HIV patients in Botswana,47 Uganda,48 and Tanzania.45
To improve adherence, most participants cited their desire to maintain a healthy life and fear of premature death as the primary motivators for consistently taking their medications. These factors can be considered internal motivators, as they are related to patients’ perceptions of the severity of their illness.49 Healthcare providers can leverage this insight to improve medication adherence by providing education grounded in the Health Belief Model, emphasizing the severity of the condition and the benefits of consistent treatment.50 Additionally, many participants believed that achieving good laboratory results and receiving family support strengthened their commitment to treatment. Similar findings have been reported among HIV patients in South Africa.51 In this context, a key responsibility of healthcare professionals is to help patients understand the connection between disease improvement and medication adherence. They should consistently emphasize this link and use it as a motivational tool to encourage patients to adhere to their antiretroviral therapy.
Regarding the quality of healthcare at the HIV center, nearly all patients rated the services as good. Similarly, HIV patients across various global regions—including European, Asian, South American, and African countries—typically viewed healthcare services positively.52–55
Participants in the present study associated the quality of healthcare services with specific satisfaction towards caring physicians, emphasizing their role in conducting thorough and effective follow-ups, offering psychological support, and providing education about HIV and its treatment. A similar finding was observed in a qualitative study involving HIV patients at the University General Hospital of Alexandroupoli, Greece, which showed that psychological support and patient education by physicians significantly increased patients’ satisfaction with the healthcare services.56
Despite good satisfaction with the current healthcare services, most participants considered interruptions in medication supply as a barrier for accessing healthcare services at the HIV center. Although this problem seems to be commonly occur in other developing low income countries,57 it is so serious and have been found to increase the risk of opportunistic infection and death.46,58,59 Consequently, ensuring a continuous supply of medications is highly recommended for protecting these vulnerable patients and maintaining their well-being.
On the other hand, healthcare providers’ refusal to perform surgery, increased costs and the need for disposable equipment for dental procedures, and discrimination in care for HIV patients were the primary barriers to accessing healthcare services outside the HIV center. These obstacles led some participating patients to conceal their HIV status from healthcare providers outside the center. A nearly similar scenario was found among Iranian HIV patients.60,61 Thus, it seems that tackling this problem necessitates creating effective knowledge about transmission and correcting the socio-cultural beliefs of health providers about HIV patients.61
To overcome barriers to accessing healthcare services, many participating patients recommended establishing a dental clinic at the HIV center. This recommendation aligns with the views of Fox and colleagues, who argue that providing oral health services to vulnerable HIV patients is necessary for the attainment of general health.62
Other participants recommended implementing a special identification card to facilitate access to healthcare services at the HIV center; however, some felt this should not override patient privacy. Consequently, many participants specifically recommended increasing privacy protections for individuals with AIDS. This recommendation is highly anticipated from patients due to the prevalent stigma and discrimination they face,63,64 highlighting why protecting their privacy is considered paramount by healthcare professionals.
According to some participants, including a psychiatrist at the HIV center is highly recommended to support patients. Policymakers should consider this recommendation, as it is well known that psychiatrists can play an important role in screening and managing anxiety, stress, and even depression symptoms which are common among HIV patients,65 potentially enhancing their self-confidence, self-efficacy, and medication adherence, and ultimately improving therapeutic outcomes.65,66
Strength and Limitations of the Study
This study has several limitations. Firstly, the non-random sampling technique increases the risk of selection bias, though the use of convenience sampling was deemed acceptable given the small registered sample of HIV patients in Iraq and the challenges in reaching them. Secondly, the sensitive nature of HIV and the interview setting within the HIV center introduce the potential for social desirability bias, a common issue in qualitative research,67,68 where participants may feel pressure to provide socially acceptable responses. Thirdly, the reliance on a single interviewer may introduce interviewer bias; however, this mitigated by supervision and training mitigate of the interviewer. Lastly, the verbatim translation of Arabic quotations to English, while essential for reporting, carries the inherent risk of losing nuance or subtle meaning, a challenge frequently encountered in qualitative studies conducted in Iraq.68,69
While acknowledging its limitations, this study represents a pioneering effort to provide qualitative insight into HIV patient care in Iraq. The inclusion of participants from three distinct governorates further strengthens the generalizability of the results.
Conclusion
While HIV care in Iraq largely aligns with international guidelines, administrative delays significantly impede timely treatment initiation. Most patients reported good adherence, but interrupted medication supply and side effects are key drivers of intentional non-adherence. Enhancing care and adherence necessitates prioritizing continuous medication availability, strengthening social support, and implementing pharmacist-led education, alongside potentially establishing specialized services within HIV centers.
Funding
There is no funding to report.
Disclosure
The authors report no conflicts of interest in this work.
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