In recent years, the WHO has prioritised the advancement of ARTs that are safer, more tolerable and highly effective (Cohn et al. 2015; WHO 2022). In 2013, the WHO recommended a fixed-dose combination regimen including efavirenz (EFV) as the first-line treatment for PLHIV. While EFV was widely adopted, it has been criticised for adverse side effects and a low genetic barrier to resistance (Calmy et al. 2020). These limitations present challenges to achieving Sustainable Development Goal (SDG) 3.3 and the UNAIDS 95-95-95 targets aimed at ending AIDS as a public health threat by 2030.

Over the past 25 years, there has been remarkable progress in various types of ART, which has significantly improved treatment outcomes for PLHIV. This progress has ushered in the era of highly active antiretroviral therapy (HAART), where three different agents work together to block viral replication (Ifedilichukwu & Joy 2023). Nonetheless, the challenge of achieving long-term viral suppression while minimising toxicity remains a key goal. In response to these challenges, the WHO has recommended the use of DTG-based regimens. These are usually paired with tenofovir (TDF), lamivudine (3TC) and DTG or with abacavir (ABC), 3TC and DTG (Lee et al. 2023). These regimens are recommended both for treatment-naïve patients and for those with prior ART experience. This includes adults and children aged 12 years and older who weigh at least 40 kg. This study focused specifically on the fixed-dose combination of TDF, 3TC and DTG.

Dolutegravir belongs to the integrase strand transfer inhibitor (INSTI) class and is favoured for its potency, safety profile and high barrier to resistance (Henegar et al. 2023). By mid-2019, the rollout of DTG-based treatment plans was already in progress in several low- and middle-income countries, including Uganda, Botswana and South Africa, but it was not until 2 years later that widespread implementation occurred (Bacha et al. 2023). Studies have shown that DTG-based regimen can efficiently lower viral loads rapidly, but there is still limited understanding of how PLHIV perceive and experience this treatment (Cahn et al. 2022; Casalini et al. 2023; Mathur 2023). In sub-Saharan Africa, DTG-based regimen research has concentrated on specific groups, like pregnant women or particular communities, which leaves a significant gap in our understanding of how the broader population views these regimens (Chapola et al. 2023; Rasi 2021). There is a clear need for more extensive research that investigates the perceptions of a broader population.

Emerging qualitative evidence from various settings highlights both positive and cautious perceptions of dolutegravir among PLHIV. Studies from several African contexts, including Uganda, Malawi, Nigeria and Kenya, reported that patients tend to have positive perceptions about the DTG-based regimen because of significantly faster viral suppression and fewer side effects (Chapola et al. 2023; Eze et al. 2023; Nalugga et al. 2022; Alhassan 2020). Nevertheless, concerns about insomnia, weight gain and uncertainty around safety, especially for women of reproductive age, were reported. The uncertainty and hesitancy about the DTG-based regimen’s effects on fertility were contributed to by limited support or counselling. This led to an ongoing misconception that raised concerns that were avoidable (Massawe et al. 2023). In India, similar mixed emotions were noted among participants, with study participants indicating overall appreciation of the DTG-based regimen’s effectiveness, while indicating it caused issues related to sleep and weight (Mathur 2023). Collectively, these findings suggest that, while there is an overall conception of the DTG-based regimen being accepted as a contemporary and effective therapy for managing HIV, patient experiences remain shaped by individual health responses, gender considerations and the degree of quality provided in health intervention information. This highlights the need for more context-specific research to delve deeper into this issue.

Despite all that, the WHO has recommended caution when prescribing DTG to pregnant women because of a potential increase in the risk of neural tube defects (Todorović, Dragović & Lukić 2024). In addition, patients with drug-sensitive tuberculosis (DS-TB), using DTG, require careful oversight as rifampicin can lower DTG plasma levels (De Nicolò et al. 2022). While adjusting the dosage can help manage this interaction, the limited availability of the drug in resource-limited settings can make consistent use a challenge (John 2024).

Given these factors, there’s an ongoing discussion about whether the advantages of the DTG-based regimen outweigh its potential downsides. The existing research has extensively concentrated on clinical effectiveness, with limited focus on the experiences of patients using the treatment itself. It is crucial to understand how patients perceive their treatment, as this could help identify what influences their adherence, shape counselling approaches and inform policy decisions. This understanding is particularly vital in South Africa, where the rates of HIV are among the highest in the world. Therefore, this study aimed to explore and describe the perceptions and lived experiences of PLHIV regarding the use of a DTG-based regimen in Limpopo province.

In Limpopo province, the transition to DTG-based regimens has been rapidly implemented as part of South Africa’s ART programme (Hanser 2021; Ramusilei 2023). The clinical experiences indicate that many patients are embracing this change and the acceptability of the new regimen; however, there have been reports of side effects such as rashes, nausea, vomiting and heavy menstrual bleeding that have caused some individuals to discontinue their treatment. These discontinuities risk undermining viral suppression efforts and reversing gains made in HIV care. There is a lack of empirical evidence on how PLHIV in Limpopo perceive the DTG-based regimen, what factors influence their acceptance or rejection of this treatment and how these views affect their adherence. Without this insight, any strategies aimed at addressing patient concerns and promoting the ongoing use of DTG might fall short. This study aims to fill that gap by examining and exploring perceptions of PLHIV regarding the use of DTG-based regimens in Limpopo province.

The purpose of this study was to explore the perceptions and lived experiences of PLHIV in Limpopo province regarding the use of DTG-based regimens in order to inform strategies for improving patient-centred HIV care.

This study aimed to shed light on context-specific evidence regarding perceptions, acceptance and concerns of PLHIV about DTG-based regimens in Limpopo province. The insights from patients about their experiences and the factors that affect their adherence will help shape targeted interventions to address the management of side effects, enhance treatment acceptability and maintain high viral suppression rates. In addition, the results will serve as a valuable tool for policymakers, healthcare providers and programme managers, helping them refine ART counselling, manage side effects and develop better patient support strategies to improve HIV treatment outcomes in similar resource-limited and rural areas.

This study aimed to explore the perceptions and lived experiences of PLHIV regarding the use of DTG-based regimens. Qualitative research is essential in understanding behavioural science, particularly when investigating the motivations and factors influencing human behaviour (Anas & Ishaq 2022). In this research, a qualitative, exploratory-descriptive and contextual approach was utilised to better comprehend the perspectives of PLHIV regarding the use of the DTG-based regimen. The exploratory design allowed the researcher to explore participants’ experiences and viewpoints and gain valuable insights into their perceptions of DTG-based regimen use. The descriptive aspect of this method aided participants in expressing their thoughts and lived experiences with the regimen. Lastly, the contextual design added significance as the research was conducted in clinics where participants receive ART. This ensured that the findings were rooted in the real-world settings of their treatment environment. This approach gave the researcher a complete picture of how patients view things in their everyday lives.

The research was conducted in Limpopo province, focusing on selected clinics within the Ephraim Mogale sub-district of the Sekhukhune District. The sub-district had a total of 10 primary healthcare clinics that provide HIV services. A systematic sampling was employed, and all 10 clinics were arranged alphabetically, and every third clinic was selected, starting with the first on the list. This procedure resulted in the inclusion of three clinics. This sampling approach ensured that the total number of clinics in the sub-district guided the sample size for the clinics. This promoted a balanced and fair representation across the area, with the feasibility required for in-depth qualitative data collection and equal opportunity for selection across clinics. Despite the small sampling frame, the systematic approach provided a transparent and unbiased means of site selection suitable for the qualitative nature of the study.

A population is a group of individuals that the researcher intends to study. Sampling is selecting a representative sample of individuals from the population of interest (Willie 2024). The study population consisted of PLHIV, who were males and females aged 18 years and older, who had been on a DTG-based regimen for at least 6 months and were willing to participate. A non-probability purposive sampling approach was used to recruit participants who could provide rich, relevant and diverse perspectives on the use of DTG-based regimens and have the characteristics to fulfil the study’s objectives. Given the topic’s sensitivity, the researcher also used convenience sampling, recruiting patients already present at the selected clinics during the recruitment process. Twenty participants were interviewed, and data collection continued until saturation was reached.

Data collection is gathering and measuring information on the variables of interest being studied (Depoy 2024). The first author, who was also a student researcher, will be referred to as the ‘researcher’ throughout this manuscript. Authors two and three were supervisors. The researcher was responsible for conducting all stages of the research process, including data collection and engagement with the study sites. The researcher reached out to the Sekhukhune Department of Health in Limpopo 1 week prior to the planned data collection date to obtain permission for access to the selected clinics. In addition, in-person visits were made to the Ephraim Mogale sub-district area managers and the operational managers of the selected primary healthcare clinics. During these visits, the researcher provided a brief study overview and presented all necessary approval letters from the university and the department of health, the national office that authorised conducting the study.

Semi-structured individual interviews were then conducted over a period of 6 days at the three selected sites in Ephraim Mogale sub-district, with 2 days spent at each clinic. Before each interview, informed consent was obtained by a research assistant. These 6 days effectively gathered rich data about the perceptions of PLHIV regarding the use of a DTG-based regimen. The researcher facilitated the interviews using an interview guide that included open-ended questions, with the primary question being, ‘What are the perceptions of PLHIV regarding the use of the dolutegravir regimen in Limpopo province?’ This was followed by probing questions. The interview guide was designed to address the study’s objectives. It was provided in Sepedi, which is the widely spoken language, and English to accommodate those who do not speak Sepedi.

Each interview lasted approximately 30 min; however, the duration of the interviews solely depended on the participant’s willingness and knowledge to engage in the topic studied. Audio recordings were made, but participants’ permission was asked prior to commencing the recording. Nonverbal cues and body language were also observed during interview sessions. The researcher transcribed the data, which were subsequently reviewed by supervisors experienced in qualitative research to ensure transcription accuracy. Data saturation, the point at which no new information emerged from the interviews, was reached after interviewing the 13th participant; however, seven additional participants were interviewed to confirm saturation.

Qualitative data analysis involves organising and making sense of the data collected (Depoy 2024). The authors also stated that researchers make sense of the collected data by identifying patterns, themes, categories and regularities. Thematic data analysis steps were used to analyse data. The analysis was done by reading each transcription to obtain its main idea. All 20 transcripts were analysed, and similarities were grouped to formulate themes and sub-themes. The principal researcher conducted the analysis. An independent co-coder experienced in qualitative research was sent the transcripts to verify the coding themes. Both the researcher and the co-coder agreed on the same themes. A meeting with the supervisors was held to compare the themes and the final themes, as a consensus was reached.

Thematic analysis was employed using Braun and Clarke’s six-step framework, as cited by Ahmed et al. 2025. The six steps are as follows: (1) becoming familiar with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing the themes, (5) defining themes and lastly (6) writing up final themes. The researcher evaluated every transcription to discover key concepts, categorising commonalities into themes and sub-themes. To ensure rigour, a skilled co-coder conducted an independent analysis of the transcripts, and both individuals (the researcher and the co-coder) agreed on the final themes. Supervisors additionally examined the themes to validate the analysis and enhance trustworthiness.

Trustworthiness is an essential aspect of any research study, and the authors defined trustworthiness as the researcher’s confidence in the study’s accuracy and truth (Depoy 2024 trustworthiness, the study would be of little value. Therefore, principles of credibility, transferability, dependability and authenticity were implemented in this study to maintain trustworthiness.

Credibility is the degree to which the research represents the actual voice of the research participants (Flanagan & Beck 2024). The researcher engaged in prolonged interactions during the interview sessions to ensure credibility, allowing for a deeper understanding of the participants’ realities. Prolonged engagement with participants allowed the researcher to probe for more in-depth narratives regarding their perceptions of the dolutegravir-based regimen in Limpopo province. The findings of the study are reliable and trustworthy. The research was conducted meticulously, with careful collection and analysis of the data. The conclusions drawn are supported by evidence from the literature, instilling confidence in the validity of the findings.

Transferability determines if the study’s findings can be applicable from one specific situation to another (Enworo 2023). For transferability purposes, the researcher developed a detailed research method, and a thick description of the participants’ perceptions regarding the dolutegravir-based regimen was outlined so that the reader could transfer the study’s findings to other settings.

Dependability refers to the ability of the findings to show consistency and repeatability (Enworo 2023). The researcher ensured dependability by repeatedly listening to the audio recordings and re-reading the transcripts to verify the accuracy of the identified themes and sub-themes. Additionally, the audio recordings and transcripts were submitted to the co-coder to confirm that the formulated codes accurately reflected the participants’ perceptions of using the dolutegravir-based regimen. The findings of this study align with previous research, indicating that a similar analysis could yield comparable results in different settings.

Confirmability is the degree to which the participants shape the findings of a study and not the researcher’s bias, motivation or interest (Enworo 2023). To ensure confirmability, the researcher remained neutral and unbiased during the execution of the study. Triangulation was used to check for consistency of the findings generated to ensure that they account for rich, robust and comprehensive findings of the lived experience of PLHIV regarding the use of dolutegravir-based regimens in Limpopo province.

Ethical clearance to conduct this study was obtained from the North-West University Health Research Ethics Committee (NWU-HREC) on 5 May 2022. The ethics approval number is NWU-00021-22-S1. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. This study used the NWU standardised consent form. The research question was used to formulate the interview schedule. The study involved human participants, and animals or human tissues were not applicable. Zandile R. Sibeko, who was a student at the time, undertook the study only after all necessary written ethical approval was formally granted. Prior to participation, all participants were fully informed about the study’s purpose, procedures, potential risks and their right to withdraw at any time without penalty. As all participants provided written consent, no alternative consent methods were employed. Approval to access the selected clinics was also obtained from the Limpopo Department of Health and the relevant district office. Their personal information was kept private, with any identifying details left out of the findings to maintain confidentiality. The participants were thoroughly briefed on the disclosure of the study results and their rights to confidentiality. The interviews took place in a private room that was not exposed to external disturbances.

The results are discussed in this section. Twenty participants took part in the study (see Table 1). The majority of participants were treatment-experienced patients. No gender was dominant in this study. The age group of participants was 30 years – 39 years.

Table 2 describes the themes and sub-themes that emerged through participants’ responses on their perceptions of using a DTG-based regimen.

The following themes and related sub-themes were identified in the study: (1) acceptance of new treatment, (2) level of knowledge regarding the new treatment of dolutegravir, (3) the burden of taking ART treatment, and (4) reasons for non-adherence to dolutegravir.

This study had several limitations that should be considered when interpreting the findings. It was conducted in selected primary healthcare facilities within Limpopo province, Sekhukhune district, which may limit the generalisability of the results to other provinces or settings with different healthcare contexts. This study also relied on self-reported perceptions, which may be influenced by social desirability bias, as participants might have provided responses they believed were expected. As this is a qualitative study, the findings provide depth of understanding but cannot be used to establish causal relationships between dolutegravir use and patient outcomes.

The following are recommendations from this study.

For practice:

For future research: