Barriers and enablers to implementing health education for HIV virologic suppression among adult people living with HIV-HBV coinfection in Northwest Ethiopia: a consolidated framework for implementation research guided qualitative study.

Abstract

Human immunodeficiency virus (HIV) remains a major public health challenge, particularly in sub-Saharan Africa, where achieving sustained HIV virologic suppression continues to be difficult despite expanded access to antiretroviral therapy (ART). This challenge is further complicated among people living with HIV-HBV coinfection due to increased disease complexity, treatment burden, and adherence-related barriers. Health education plays an important role in improving adherence and virologic outcomes; however, its implementation remains inconsistent in resource-limited settings. This study explored barriers and enablers to implementing health education for HIV virologic suppression among adults living with HIV-HBV coinfection in Northwest Ethiopia. This study aimed to explore the barriers and enablers influencing the implementation of health education for HIV virological suppression among adults living with HIV-HBV co-infection in North-West Ethiopia. A facility-based interpretive qualitative study was conducted from November 13, 2025, to January 12, 2026, at the University of Gondar Comprehensive Specialized Hospital and Felege Hiwot Comprehensive Specialized Hospital in Northwest Ethiopia. A total of 28 purposively selected participants, including adult people living with HIV-HBV coinfection, healthcare providers, and HIV program managers, participated in in-depth interviews (IDIs), key informant interviews (KIIs), and focus group discussions (FGDs). Data were audio-recorded, transcribed verbatim, translated into English, and analyzed using reflexive thematic analysis with a deductive approach guided by the Consolidated Framework for Implementation Research (CFIR) using MAXQDA Analytics Pro 2024. Trustworthiness was ensured through triangulation, member checking, peer debriefing, and maintaining an audit trail. Ten barriers and eight enablers were identified across all CFIR domains. In addition to inaccurate information or graphics and transportation issues, the main reported hurdles included patient-level issues such as inadequate literacy, misconceptions about ART or viral load, anxiety about being seen attending sessions, and limited patient engagement in instructional design. Staff shortages, lack of commitment to counselling duties, a focus on ART refills rather than education, irregular or shortened sessions, lack of time, and the absence of a dedicated budget were all organizational and system-level barriers. Conversely, teamwork, clearly defined staff roles, the use of viral load monitoring tools, frequent review meetings, alignment with national HIV guidelines, patient motivation to achieve viral suppression, trust in provider advice, and improved adherence linked to education were all perceived enablers. Implementation of health education for HIV virological suppression among HIV-HBV co-infected patients is hindered by key barriers, particularly low patient literacy, misconceptions, stigma-related concerns, and systemic challenges such as staff shortages, limited time, and inadequate resources. However, strong teamwork, patient motivation, provider trust, and alignment with national guidelines serve as important enablers. Findings from this study informed the updating of the existing health education intervention to better address identified barriers and strengthen enabling factors. Testing the revised intervention for feasibility and acceptability is essential before wider implementation to improve adherence and achieve sustained HIV virological suppression in this population.