Factors associated with adherence to HIV treatment among adolescent girls and young women in the Imagine pro- gramme in South Africa: A mixed-methods study protocol

Background. Adherence to antiretroviral therapy (ART) is critical to achieving viral suppression and reducing HIV-related morbidity and transmission. However, consistent adherence remains a challenge, particularly among adolescent girls and young women (AGYW) in sub-Saharan Africa (SSA), an already vulnerable group disproportionately affected by HIV. In SSA, AGYW account for the majority of new infections, and despite widespread availability of ART and ambitious national targets, optimal adherence is not being consistently achieved. Objectives. To identify factors associated with adherence to HIV treatment among AGYW enrolled in the Imagine programme, a school-based HIV and pregnancy prevention intervention implemented in 14 rural schools in North West and KwaZulu-Natal provinces, South Africa (SA). Methods. Employing a mixed-methods design, the cross-sectional study will conduct secondary quantitative analysis of data collected in the Imagine programme. Additionally, primary data will be obtained from in-depth interviews conducted with a subset of participants to explore perceptions, barriers and experiences related to adherence. Quantitative data will be analysed using descriptive statistics and logistic regression to assess associations between adherence and sociodemographic, behavioural and structural factors. Qualitative data will be analysed thematically to provide contextual insights. Conclusion. This study addresses a critical evidence gap by focusing on adherence in a rural AGYW population. The findings are expected to inform both programme implementation and broader adolescent HIV treatment strategies in SA.