Acceptability and perspectives on clinic-based urine tenofovir testing for antiretroviral therapy adherence monitoring: qualitative findings from a randomized controlled trial in South Africa

Real-time, urine tenofovir testing may allow for clinic-based monitoring of adherence to antiretroviral therapy (ART). We aimed to assess (1) the acceptability of monthly point-of-care urine tenofovir testing over the first five months following ART initiation and (2) perspectives on the implementation of point-of-care urine tenofovir testing among people living with HIV (PLWH) and healthcare providers participating in a randomized controlled trial which used the urine test in South Africa. We conducted in-depth interviews with 20 PLWH six-months post-ART initiation and with eight healthcare providers. We assessed the acceptability (using constructs from the Theoretical Framework of Acceptability), appropriateness, feasibility, and willingness to use the point-of-care urine tenofovir test, as well as participants’ preferred form of adherence monitoring and perspectives on differentiated implementation strategies. Participants found monthly point-of-care tenofovir testing highly acceptable, preferrable to self-reported adherence measures, appropriate for this population, and potentially feasible to integrate with standard-of-care ART monitoring. Participants’ overall acceptability of routine urine tenofovir testing was shaped by experiences and perceptions that shaped their overall acceptability. Routine urine tenofovir testing was well-liked, perceived to be low-burden with few opportunity costs, and perceived to have several positive effects. These included encouraging consistent ART adherence, strong client-provider relationship and communications, and accurate self-reporting of adherence. Participants’ desire to impress and build trust with their provider motivated them to take their ART daily to achieve a positive adherence test result at each clinic visit. Overall, point-of-care urine tenofovir testing may be an acceptable and beneficial tool for motivating optimal adherence, improving ART adherence monitoring, and strengthening client-provider relations.