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Table 2 Connections as presented in Fig. 2 and Additional file 1. The connection type represents the polarity of the connection. A positive connection type indicates that both elements evolve in the same direction (when element A increases, element B will increase too, and vice versa). A negative connection type indicates that both elements will evolve in the opposite direction (when element A increases, element B will decrease, and vice versa)

From: Exploring the mechanisms behind HIV drug resistance in sub-Saharan Africa: conceptual mapping of a complex adaptive system based on multi-disciplinary expert insights

From

To

Type

Acceptance of HIV status

Adherence

 + 

Acceptance of HIV status

Engagement and retention in care

 + 

Acceptance of HIV status

Priority given to treatment

 + 

Acceptance of HIV status

HIV status disclosure

 + 

Accessibility of health centre (including safety)

Engagement and retention in care

 + 

Adherence

Drug levels in body

 + 

Adherence counselling

Understanding of HIV infection and treatment

 + 

Adherence counselling

Readiness to start taking ART

 + 

Administrative and political barriers

Individual and community empowerment

-

Administrative and political barriers

Timely acting on unsuppressed viral load

-

Administrative and political barriers

Well-functioning supply chain

-

ART treatment approach / policy

Timely acting on unsuppressed viral load

 ± 

ART treatment approach / policy

Healthcare system workload

 ± 

ART treatment approach / policy

Correct prescribing practices

 ± 

ART treatment approach / policy

Required frequency of hospital visits

 ± 

ART treatment approach / policy

Competence of healthcare workers

 ± 

Assuring quality of ART

Efficiency of drug combination

 + 

Availability and quality of equipment

Timely acting on unsuppressed viral load

 + 

Availability of better drugs

Global effort to tackle HIVDR

-

Availability of better drugs

HIVDR selection

-

Community stigma and gossip

Engagement and retention in care

-

Community stigma and gossip

Distance to the healthcare centre

 +

Community stigma and gossip

Self-stigmatisation

 + 

Community stigma and gossip

Healthcare provider stigma

 + 

Community stigma and gossip

Adherence

-

Community stigma and gossip

HIV status disclosure

-

Competence of healthcare workers

Timely acting on unsuppressed viral load

 + 

Competence of healthcare workers

Correct prescribing practices

 + 

Competence of healthcare workers

Adherence counselling

 + 

Competence of healthcare workers

Patient-provider relationship

 + 

Concerns about side effects of ART

Adherence

-

Concurrent disease and opportunistic infections

Feeling and looking ill

 +

Concurrent disease and opportunistic infections

Pill burden

 + 

Concurrent disease and opportunistic infections

Drug-drug interactions

 + 

Concurrent disease and opportunistic infections

Healthcare system workload

 + 

Concurrent disease and opportunistic infections

Optimal absorption of drug

-

Correct prescribing practices

Efficiency of drug combination

 + 

Depression

Adherence

-

Depression

Priority given to treatment

-

Depression

Substance abuse

 + 

Distance to the healthcare centre

Accessibility of health centre (including safety)

-

Distance to the healthcare centre

Engagement and retention in care

 ± 

Drug levels in body

Viral load suppression

 + 

Drug levels in body

Side effects of ART

 + 

Drug prices

Resource allocation with focus on population

-

Drug-drug interactions

Optimal absorption of drug

-

Efficiency of drug combination

Viral load suppression

 + 

Engagement and retention in care

Adherence

 + 

Engagement and retention in care

Financial situation

-

Engagement in alternative care

Engagement and retention in care

 ±

Engagement in alternative care

Optimal absorption of drug

-

Engagement in alternative care

Misinformation

 ± 

Engagement in alternative care

Adherence

 ± 

Engagement in risk behaviour

Transmission of HIV(DR)

 + 

Feeling and looking ill

Community stigma and gossip

 + 

Feeling and looking ill

Engagement and retention in care

 ± 

Feeling and looking ill

Priority given to treatment

 +

Feeling and looking ill

HIV status disclosure

 + 

Feeling and looking ill

Concerns about side effects of ART

 + 

Financial situation

Accessibility of health centre (including safety)

 + 

Financial situation

Timely acting on unsuppressed viral load

 + 

Financial situation

Migration

-

Financial situation

Food insecurity

-

Financial situation

Priority given to treatment

 +

Food insecurity

Adherence

-

Food insecurity

Optimal absorption of drug

-

Forgetfulness

Adherence

-

Gender inequality

HIV status disclosure

-

Gender inequality

Adherence

-

Gender inequality

Engagement and retention in care

-

Gender inequality

Lower social status

 + 

Gender inequality

Engagement in risk behaviour

 + 

Global effort to tackle HIVDR

HIVDR Funding

 + 

Global effort to tackle HIVDR

ART treatment approach / policy

 + 

Having examples of well-functioning ART

Community stigma and gossip

-

Having examples of well-functioning ART

Acceptance of HIV status

 + 

Healthcare provider stigma

Engagement and retention in care

-

Healthcare provider stigma

Adherence counselling

-

Healthcare system workload

Adherence counselling

-

Healthcare system workload

Tracing of PLHIV

-

Healthcare system workload

Correct prescribing practices

-

Healthcare system workload

Timely acting on unsuppressed viral load

-

Healthcare system workload

Well-functioning supply chain

-

Healthcare system workload

Competence of healthcare workers

-

Healthcare system workload

Patient-provider relationship

 -

Healthcare system workload

Job satisfaction and motivation of healthcare workers

 -

HIV status disclosure

Social support

 ± 

HIV status disclosure

Community stigma and gossip

 + 

HIV status disclosure

Engagement in risk behaviour

-

HIV status disclosure

Adherence

 ± 

HIV status disclosure

Engagement and retention in care

 + 

HIVDR Funding

HIVDR Research focus

 +

HIVDR Funding

Stock availability of ART and reagents

 + 

HIVDR Funding

Availability and quality of equipment

 + 

HIVDR Funding

Resource allocation with focus on population

 ± 

HIVDR Funding

Need to show success of the ART programme

 + 

HIVDR Funding

Resistance (and subtype) testing

 + 

HIVDR Research focus

Availability of better drugs

 + 

HIVDR Research focus

ART treatment approach / policy

 + 

HIVDR Research focus

Required frequency of hospital visits

-

HIVDR Research focus

Resource allocation with focus on population

 + 

HIVDR selection

Global effort to tackle HIVDR

 + 

HIVDR selection

Viral load suppression

 -

HIVDR selection

Transmission of HIV(DR)

 + 

HIVDR selection

Healthcare system workload

 + 

Hospital design

Community stigma and gossip

 ±

Hospital design

HIV status disclosure

 ±

Incentive to search for information

Understanding of HIV infection and treatment

 + 

Incentive to search for information

Misinformation

 + 

Individual and community empowerment

Timely acting on unsuppressed viral load

 + 

Individual education level

Understanding of HIV infection and treatment

 + 

Job satisfaction and motivation of healthcare workers

Well-functioning supply chain

 + 

Job satisfaction and motivation of healthcare workers

Timely acting on unsuppressed viral load

 + 

Linguistic issues

Adherence counselling

-

Lower social status

Engagement and retention in care

-

Lower social status

Community stigma and gossip

 + 

Lower social status

Healthcare provider stigma

+

Migration

Healthcare system workload

 + 

Migration

Well-functioning supply chain

-

Migration

Engagement and retention in care

-

Misinformation

Understanding of HIV infection and treatment

-

Misinformation

Community stigma and gossip

 + 

Misinformation

Engagement in alternative care

 + 

Misinformation

Engagement in risk behaviour

 + 

Need to show success of the ART programme

HIVDR Funding

 + 

Need to show success of the ART programme

Administrative and political barriers

 + 

Optimal absorption of drug

Drug levels in body

 + 

Patient-provider relationship

Understanding of HIV infection and treatment

 + 

Patient-provider relationship

Engagement and retention in care

 + 

Patient-provider relationship

Adherence counselling

 + 

Patient-provider relationship

HIV status disclosure

 +

Peer support group

Required frequency of hospital visits

-

Peer support group

Understanding of HIV infection and treatment

 + 

Pill burden

Pill fatigue

 + 

Pill burden

Side effects of ART

 + 

Pill fatigue

Adherence

 -

Priority given to treatment

Adherence

 + 

Priority given to treatment

Engagement and retention in care

 + 

Punitive laws for MSM and sex workers

Engagement and retention in care

-

Punitive laws for MSM and sex workers

Transmission of HIV(DR)

 + 

Punitive laws for MSM and sex workers

Community stigma and gossip

 + 

Punitive laws for MSM and sex workers

ART treatment approach / policy

-

Quality of data systems

Tracing of PLHIV

 + 

Quality of data systems

Well-functioning supply chain

 + 

Quality of data systems

Timely acting on unsuppressed viral load

 + 

Readiness to start taking ART

Adherence

 + 

Religious beliefs

Self-stigmatisation

 + 

Religious beliefs

Engagement in alternative care

 + 

Required frequency of hospital visits

Engagement and retention in care

-

Required frequency of hospital visits

Healthcare system workload

 + 

Resistance (and subtype) testing

Correct prescribing practices

 + 

Resource allocation with focus on population

ART treatment approach / policy

 + 

Resource allocation with focus on population

Adherence

 + 

Self-stigmatisation

Acceptance of HIV status

-

Self-stigmatisation

HIV status disclosure

-

Self-stigmatisation

Depression

 + 

Side effects of ART

Feeling and looking ill

 + 

Side effects of ART

Adherence

-

Side effects of ART

HIV status disclosure

 + 

Social obligations

Financial situation

-

Social obligations

Priority given to treatment

-

Social support

Adherence

 + 

Stock availability of ART and reagents

ART treatment approach / policy

 + 

Stock availability of ART and reagents

Timely acting on unsuppressed viral load

 + 

Stock availability of ART and reagents

Job satisfaction and motivation of healthcare workers

 + 

Stock availability of ART and reagents

Required frequency of hospital visits

-

Stock availability of ART and reagents

Adherence

 + 

Substance abuse

Forgetfulness

 + 

Timely acting on unsuppressed viral load

Efficiency of drug combination

 + 

Tracing of PLHIV

Engagement and retention in care

 + 

Tracing of PLHIV

Timely acting on unsuppressed viral load

 + 

Transmission of HIV(DR)

Efficiency of drug combination

-

Transmission of HIV(DR)

Healthcare system workload

 + 

Understanding of HIV infection and treatment

Self-stigmatisation

-

Understanding of HIV infection and treatment

Engagement in risk behaviour

-

Understanding of HIV infection and treatment

Incentive to search for information

-

Understanding of HIV infection and treatment

Engagement and retention in care

 + 

Understanding of HIV infection and treatment

Adherence

 + 

Understanding of HIV infection and treatment

Acceptance of HIV status

 + 

Understanding of HIV infection and treatment

Individual and community empowerment

 + 

Understanding of HIV infection and treatment

Priority given to treatment

 + 

Understanding of HIV infection and treatment

Community stigma and gossip

-

Understanding of HIV infection and treatment

Engagement in alternative care

-

Viral load suppression

HIVDR selection

-

Viral load suppression

Concurrent disease and opportunistic infections

-

Viral load suppression

Required frequency of hospital visits

-

Viral load suppression

Healthcare system workload

-

Viral load suppression

Transmission of HIV(DR)

-

War and disease outbreaks

Accessibility of health centre (including safety)

-

War and disease outbreaks

Timely acting on unsuppressed viral load

-

War and disease outbreaks

Well-functioning supply chain

-

War and disease outbreaks

Migration

 + 

Well-functioning supply chain

Peer support group

 + 

Well-functioning supply chain

Stock availability of ART and reagents

 +