Table 3 Synthesized findings

Difficulty finding a parking place (U) [22]

Limited access to HIV-related healthcare services

1. Although the current healthcare systems have many barriers preventing PLWH with NCDs from accessing both HIV and NCD care, they can receive resources and knowledge through healthcare providers.

Challenges with transport costs (U) [21, 23, 30]

Medication shortage (U) [23, 27]

Long waiting times at healthcare centers (U) [29]

Limited income (U) [23, 30]

Mobility restrictions stemming from HIV (U) [30]

Challenges with physical disability (U) [30]

Ability of current healthcare system to meet PLWH needs (U) [31]

Fear of being stigmatized for having HIV (U) [29]

Unavailability of screening machines for hypertension and diabetes (U) [23]

Barriers to accessing healthcare for NCDs

Mobility restrictions stemming from other chronic conditions (U) [30]

Unavailability of medication for hypertension (U) [23]

Lack of care continuity (U) [29]

Insufficient care for chronic diseases (U) [29]

Lack of familiarity with the situations of PLWH among healthcare providers from NCD departments (U) [31]

Simultaneous acquisition of knowledge regarding the disease process and social support (U) [17]

Good aspects of the current healthcare systems

Utilization of the available resources to avoid isolation and depression (U) [17]

Satisfaction with providers (U) [17, 22]

Likely elimination of the stigma attached to the ARV clinic through the provision of integrated care through general systems (U) [29]

Understanding the consequence of nonadherence to treatment (U) [26]

Individual factors affecting care continuity and treatment adherence

2. The factors that can affect care continuity and treatment adherence for both HIV and NCDs among PLWH include the individual physical, mental, and financial statuses of PLWH; their relationships with clinicians; and fragmented healthcare systems.

Linking symptoms to not taking medication (U) [24, 26]

Active engagement in treatment (U) [30]

Substance abuse (U) [26]

Mental issues (U) [26]

Ease of obtaining prescriptions (U) [23, 26, 27]

Health insurance scheme (C) [27]

Financial issues (U) [27]

Encouragement to continue treatment due to improved symptoms (U) [27]

Fragmented and uncoordinated HIV care and chronic care (U) [21, 22, 29, 31]

Fragmented healthcare systems

Distance between the tertiary hospital and HIV clinics (U) [21]

Effect of mistrust of providers on treatment adherence (U) [22]

Patient-clinician partnership

Good partnership with clinicians (U) [17, 22]

HIV being beyond the scope of practice of generalists (U) [17, 22, 29]

Lack of communication (U) [22]

Effect of appearance on self-esteem (U) [17]

Appearance

3. PLWH with NCDs have long-term physical and psychological manifestations of disease. Psychological manifestations are severe and prevalent when PLWH are informed that they have NCDs. Some changes, including changes in appearance and sexual function, can affect individuals’ daily lives, especially among women living with HIV and NCDs.

Dental issues (C) [17]

Importance of maintenance physical appearance for women (U) [32]

Fear, anger, and rejection (U) [17]

Psychological manifestations

Stress and vulnerability due to the management of multiple conditions (U) [21]

Similarity between reactions to a cancer diagnosis and initial reactions to the HIV diagnosis (U) [22]

Fear of cancer diagnosis and treatments (U) [22]

Mental health treatment (U) [22]

Initial difficulty in accepting the diagnosis of hypertension (U) [24]

Negative emotions upon being informed of having multimorbidities (U) [29]

Effect on women, dyspareunia (U) [17]

Sexual function

Effect on one’s life (U) [17]

Extreme fatigue, neuropathy, and memory loss (U) [17]

Physical manifestations

Disability (U) [17]

Symptoms disrupting everyday life (U) [27]

Lack of an assumption that any new symptoms are related to HIV (U) [31]

Effects on employment (U) [17, 18]

Social consequence of having NCDs

4. Having more chronic conditions implies more medical costs for PLWH. The more severe the financial hardship of PLWH, the more negatively it affects their employment and family relationships.

Effects on relations between family members (U) [18]

Low confidence, even futility (U) [24]

Numerous hospital appointments (U) [18]

Struggles to obtain medication (U) [17, 23]

Financial and insurance issues

Battles with their insurance (U) [17, 32]

Reliance on a minimal state disability grant (U) [18]

Financial burden of HIV and cancer treatment (U) [22, 23, 27, 32]

Comparison of free ART with hypertension medication (U) [24]

Lack of income (U) [32]

Fear of rejection before acceptance (U) [17]

Double stigma

5. PLWH with NCDs experience double stigma toward their HIV and chronic conditions, which may exacerbate their perceived discrimination and lead to social and physical isolation.

Courtesy stigma (U) [18]

Discrimination leading to social and physical isolation (U) [18]

Personal insecurity within one’s home (U) [18]

Disowning or violent behavior toward the sick person (U) [18]

HIV stigmatization (U) [17, 18, 22, 27, 29]

Fear of stigma or addition of stress to relationships (U) [17, 27]

Stigma among support system and providers (U) [22]

New form of stigma toward cancer (U) [25]

Stigmatized social environment of multimorbidity with HIV (U) [31]

Waiting for as long as possible before sharing one’s diagnosis with family members (U) [17]

Disclosure

Openly sharing one’s diagnosis with friends but ultimately losing them (U) [17]

Pill burden for managing both conditions (U) [24]

Pill burden

6. PLWH with NCDs have high levels of polypharmacy burden for both ART and other medications. This population has difficulty maintaining high medication adherence due to medication fatigue, side effects, and the large numbers of pills to be taken. PLWH with NCDs may spontaneously use some strategies individually or collectively to achieve high levels of medication adherence.

Taking pills daily as a form of survivorship (U) [17]

Polypharmacy adherence

Taking multiple drugs as compensation for missed doses (U) [23]

Side effects of hypertension medication as an impediment to adherence (C) [24]

Simpler regimens with fewer side effects promoting adherence (U) [26]

Medication fatigue (U) [32]

Difficulty keeping up with the management regimens for their other comorbidities (U) [32]

Side effects of ART (U) [17, 28, 31]

Side effects

Side effects of hypertension medication as an impediment to adherence (C) [24, 28]

Side effects of medication interaction (U) [31]

Symptoms as the most consistent cue of hypertension (U) [24, 28]

Perception of taking pills

Shared cautionary stories of friends impacted by hypertension as sources of motivation (U) [24]

Perceived sickness only through the guise of physical symptoms (U) [24, 25]

Perceived symptoms as cues to take medication (U) [28]

Borrowing NCD medication from colleagues (U) [23]

Coping strategies for maintaining high polypharmacy adherence

Using home remedies (U) [23]

Using traditional herbs (U) [23]

Consulting traditional or faith healers (U) [24]

Taking both types of medications simultaneously (C) [24]

Establishing daily reminders (C) [24]

Involving family members in care (C) [24]

Having a shared ‘drug bag’ (C) [24]

View of hypertension as more deadly than HIV (U) [24]

Comparison of the experience of having HIV with having NCDs

7. Some PLWH with NCDs consider hypertension and cancer more concerning conditions than HIV. However, they still describe the ability of HIV to hibernate. Having NCDs may mask concerns regarding HIV and HIV-positive experiences, which can reinforce the self-management of NCDs.

Transmission (U) [24]

Perception of hypertension as more severe than HIV (U) [24]

View cancer as a totally different type of disease (U) [25]

Difference in the survival rates of HIV and cancer (U) [25]

Identification of cancer as the most concerning condition (U) [25]

Concerns regarding NCDs that mask concerns regarding HIV (U) [25]

View of having NCDs with HIV as the same as having NCDs without HIV (U) [31]

Describing HIV as in hibernation (U) [31]

View ART resistance as the most feared consequence (U) [24]

Comparison of ARTs with other NCD medication

Belief that medications for hypertension give PLWH energy (U) [24]

Belief that medications are necessary for HIV but not for hypertension (U) [24]

View the effectiveness of ART and antihypertensive medications (U) [24]

Contradictions between HIV and NCD treatment (U) [25, 26]

Conflicting treatment and information

Conflicting information (U) [21, 26]

Reinforcement of self-efficacy for one disease by self-efficacy for another disease (U) [24]

Reinforcement of the self-management of other diseases by HIV

Encouraging someone else to adhere to treatment based on one’s own experience of ART (U) [24]

Impact of long-term HIV care on adherence to CVD medication (U) [24, 28]

Acceptance of the hypertension diagnosis (U) [29]

Rethinking of the definition of self-management (U) [32]

Readiness to engage but awareness of limitations due to HIV and NCDs (U) [30]

Exercising

8. While facing HIV with NCDs, PLWH can develop positive coping strategies to accept the realities of living with multiple chronic conditions.

Physical impairments (U) [30]

Mental health challenges (U) [30]

Uncertainty (U) [30]

Social support (C) [30]

Perceptions and beliefs (U) [30]

Feeling of accomplishment (U) [30]

Familial support from either the immediate family or their partner (U) [17, 24]

Seeking family support

Occasional lending of money by family members to pay for drugs to maintain medication adherence (U) [17, 24]

Love burden (U) [24]

Familial support (U) [17]

Eagerness to share with their friends and/or loved ones for support (U) [17]

Companionship received from male partners as an inspiration to self-manage HIV and comorbidities (U) [24]

Simultaneous acquisition of knowledge regarding the disease process and social support (U) [17]

Changing life goals

Utilization of the available resources to avoid isolation and depression (U) [17]

Satisfaction with providers (U) [1, 4]

Likely elimination of the stigma attached to the ARV clinic through the provision of integrated care through general systems (U) [29]

Frustration with being told by healthcare providers to change lifestyle habits (U) [24]

Making lifestyle adjustments

Initial period of adjustment with beginning a new medication regimen and new lifestyle changes (U) [24]

CVD prevention knowledge inconsistent with PLWH CVD risk behavior (U) [28]

Factors motivating the adoption of and adherence to heart-healthy behaviors (U) [6, 10]

Motivation for adopting healthy behaviors

Lack of motivation or interest in exercise (U) [30]

Readiness to engage in exercise as a dynamic construct (U) [30]

Readiness to engage in exercise

Feeling of readiness to engage in exercise amidst unique circumstances (U) [30]

Resilience (U) [22]

Developing resilience

Struggles with tolerating treatment (U) [17]

Developing a self-capacity to manage HIV and comorbidities

Initiation of learning about the virus from the moment of accepting the diagnosis (U) [17]

Initiation of learning to be an example for others (U) [17]

Discordance between providers’ recommendations and the preferred strategy for CVD prevention among PLWH (U) [28]

Increased ability and desire to self-manage one’s health with age (U) [32]

Spirituality (U) [27]

Addressing spiritual needs

Addressing spiritual needs (U) [31]

From a state of ownership to one of self-advocacy (U) [17]

Increasing subjective initiative

Self-advocacy for one’s overall health (U) [17]

Frustration and struggles with new day-to-day routines (U) [17]

Daily struggles

9. Some PLWH living with chronic diseases struggle with new daily routines, emotional difficulties, and family issues. In extreme cases, PLWH may have suicidal ideation when experiencing high pressure.

Existing rather than living (U) [17]

Emotional and mental health difficulties (U) [22]

Daily family or personal issues (U) [22]

Profound psychological effects of physical and social dislocation from the family home on PLWH (U) [18]

Suicide

Combination of socioeconomic factors, political factors, and chronic illnesses (U) [21]

Suicidal ideation (U) [25]