Title : Effects of violence on adherence to antiretroviral therapy: The case of adolescents living with HIV in Lilongwe, Malawi

Background: Adolescents living with HIV (ALWHIV) face significant challenges to maintain ART adherence compared to other age groups in sub–Saharan Africa where HIV prevalence and violence are both high. In Malawi, evidence remains limited on how different forms of violence affect ART adherence among ALWHIV.

Methodology: A cross-sectional mixed-methods study conducted in April, 2025 among 190 ALWHIV aged 10–19 attending ART teen clubs in Lilongwe Malawi. Quantitative data were collected using Kobo Toolbox and analyzed in SPSS v22. multivariate logistic regression assessed associations between ART adherence and physical, emotional and sexual violence. Qualitative data were analysed thematically using NVivo.

Results: Among respondents, 56.3% (n=107) were females, only 54% attained optimal adherence. Viral suppression was at 78%. Prevalence of emotional, sexual, and physical violence was 76.8%, 53%, and 30.5% respectively. Chi-square bivariate analysis showed associations between all types of violence and adherence were statistically significant (p<0.05). Multivariate logistic regression revealed that emotional violence was associated with 60% lower odds of adherence (OR = 0.40; 95% CI: 0.21–0.78; p < 0.01), physical violence with 58.8% reduced odds (OR = 0.412; 95% CI: 0.20–0.87; p = 0.019). Qualitative data echoed these findings, linking violence to low self-esteem and poor adherence behavior. Adolescents were reluctant to report violence. Survivors of sexual violence would go to the facility if they have a sexually transmitted infection but health care workers only treated the STI and never probed for sexual violence

Conclusion: Emotional and physical violence are significantly associated with suboptimal ART adherence leading to high viral loads among ALWHIV. Routine screening for violence and enhanced clinical monitoring are recommended to improve ART outcomes and support progress towards HIV epidemic control.

Keywords: ART adherence, Adolescents, emotional, physical, violence, viral load, Lilongwe, Malawi

Virginia Thonyiwa, MPH, is a Public Health Specialist and Senior Technical Advisor with the U.S. Embassy/PEPFAR Malawi. She has more than 18 years of experience in HIV prevention, adolescent and youth health, maternal and child health, implementation science, health systems strengthening, and health diplomacy. She holds an MPH in Applied Epidemiology from Amref International University and a BSc in Public Health. She has led and coordinated major HIV programmes, supported national policy and strategy development, and contributed to more than 15 peer-reviewed publications and scientific products.