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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  +