R E S E A R C H Open Access © The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ameyaw et al. BMC Public Health (2024) 24:540 https://doi.org/10.1186/s12889-024-18004-z BMC Public Health *Correspondence: Jerry John Nutor Jerry.Nutor@ucsf.edu Full list of author information is available at the end of the article Abstract Introduction The role of social support in antiretroviral therapy (ART) uptake and retention among pregnant and postpartum women in Ghana’s capital, Accra, has received limited attention in the literature. This cross-sectional study extends existing knowledge by investigating the role of social support in ART adherence and retention among pregnant and postpartum women in Accra. Methods We implemented a cross-sectional study in eleven (11) public health facilities. Convenience sampling approach was used to recruit 180 participants, out of which 176 with completed data were included in the study. ART adherence in the three months preceding the survey (termed consistent uptake), and ART retention were the outcomes of interest. Initial analysis included descriptive statistics characterized by frequencies and percentages to describe the study population. In model building, we included all variables that had p-values of 0.2 or lesser in the bivariate analysis to minimize negative confounding. Overall, a two-sided p-value of < 0.05 was considered statistically significant. Data were analyzed using Stata version 14.1 (College Station, TX). Results In the multivariate model, we realized a lower odds trend between social support score and consistent ART adherence, however, this was insignificant. Similarly, both the univariate and multivariate models showed that social support has no relationship with ART retention. Meanwhile, urban residents had a higher prevalence of ART adherence (adjusted Prevalence ratio (aPR) = 2.04, CI = 1.12–3.73) relative to rural/peri-urban residents. As compared to those below age 30, women aged 30–34 (aPR = 0.58, CI = 0.34–0.98) and above 35 (aPR = 0.48, CI = 0.31–0.72) had lower prevalence of ART adherence Women who knew their partner’s HIV status had lower prevalence of ART adherence compared to those who did not know (aPR = 0.62, CI = 0.43–0.91). Also, having a rival or co-wife was significantly associated with ART retention such that higher prevalence of ART adherence among women with rivals relative to those without rivals (aOR = 1.98, CI = 1.16–3.36). The role of social support in antiretroviral therapy uptake and retention among pregnant and postpartum women living with HIV in the Greater Accra region of Ghana Edward Kwabena Ameyaw1,2,3, Jerry John Nutor4*, Jaffer Okiring5, Isaac Yeboah2,6, Pascal Agbadi2,7, Monica Getahun8, Wisdom Agbadi2,9 and Rachel G.A. Thompson2,10 http://creativecommons.org/licenses/by/4.0/ http://creativecommons.org/publicdomain/zero/1.0/ http://crossmark.crossref.org/dialog/?doi=10.1186/s12889-024-18004-z&domain=pdf&date_stamp=2024-2-21 Page 2 of 9Ameyaw et al. BMC Public Health (2024) 24:540 Introduction Despite the global commitment to combating Human Immunodeficiency Virus (HIV), it remains a major public health threat. Globally, a total of 39 million people were living with Human Immunodeficiency Virus (HIV) in 2022, with about 40.1 million associated deaths since its emergence [1]. There is significant variation across coun- tries and regions and globally, the World Health Organ- isation (WHO) African Region is the hardest hit, as almost 1 in every 25 adults (3.4%) living with HIV reside in the region [1]. This signifies over two-thirds of the per- sons living with HIV globally. The primary mode of transmission of HIV in Ghana is heterosexual intercourse (accounting for 75%-80% of all transmissions), followed by blood transfusion and vertical transmission from mother to child, with both accounting for about 20% [2, 3]. HIV is generally high among key populations which include men who have sex with men (MSM) and female sex workers (FSW) [4]. Ghana is committed to the global pursuit to ending HIV by the year 2030 [5]. Consequently, several interventions have been implemented. Thus, through agencies like the Ghana AIDS Commission, the nation has implemented several interventions including HIV/AIDS testing [6]. Over the years, successive governments have demon- strated strong commitment to combating HIV through diverse approaches and interventions, including antiret- roviral therapy (ART) [6]. The 2022 Consolidated Guide- lines on HIV care differentiates ART initiation by persons presenting to care when clinically well (Stage 1 and 2 and CD4 > 200 cells/mm3) or persons presenting to health- care with advanced HIV (Stage 3 or 4 and/or CD4 < 200 cells/mm3) [7]. The WHO also accentuates the need to initiate ART for all people living with HIV regardless of WHO clinical stage and at any CD4 cell count [8]. To guarantee that the patient is aware of the require- ments for taking ART and can make an informed deci- sion about starting and adhering to lifelong treatment, the patient must attend at least two sessions of adherence counseling before beginning treatment [2]. Considering the stigma and other negative interpretations ascribed to HIV, patients seeking ART may require some social sup- port from their partners, friends, family members and significant others [9, 10]. For instance, evidence from Uganda suggests that support from family and caregiv- ers enhances ART adherence [11]. Typically, people living with HIV who get others to remind them to take ART or go for refill tend to have higher adherence [12]. The association between social support and antiret- roviral therapy (ART) adherence among HIV patients has been explored in empirical studies [12]. Theoretical assumptions suggest a positive relationship, indicating that increased social support should enhance adherence rates. However, existing research has yielded conflicting findings, with some studies supporting this assumption [13, 14], while others have reported negative associations [15, 16] or no significant relationship at all [11]. These inconsistencies necessitate a deeper investigation into the complex interplay between social support and ART adherence, especially in a different social group of HIV patients. Therefore, this study aims to fill this research gap by reexamining the hypothesized relationship between social support and ART adherence among HIV- positive pregnant women (prenatal) and HIV-positive women (post-partum) in Ghana’s capital, Accra. Hence, the objective of the study was to investigate the associa- tion between social support and ART adherence among HIV-positive pregnant women (prenatal) and HIV-pos- itive women (post-partum). By focusing on a different social group, we aim to provide a nuanced understand- ing of the complex relationship between these variables. By examining the relationship between social support and ART adherence in a social group, this study will pro- vide valuable insights into how the association may vary across different populations of persons living with HIV. Our extensive search revealed that the role of social support in ART adherence and retention among preg- nant and postpartum women in Ghana’s capital, Accra, has received limited attention in the literature. This cross-sectional study, therefore, sets out to extend exist- ing knowledge by investigating the association between social support and ART adherence and retention among pregnant and postpartum women in Accra, Ghana. The findings of this study will offer a deeper understanding of whether social support enhances or inhibits the uptake and retention of ART, inform the Ministry of Health and the Ghana AIDS Commission about social support for pregnant and postpartum women living with HIV, thereby safeguarding the wellbeing of birthing mothers and their newborns. Besides, the findings will be useful to researchers whose research interest lies in HIV care and social support. Conclusion Our study showed that social support does not play any essential role in ART adherence among the surveyed pregnant and postpartum women. Meanwhile, factors such as having a rival and being under the age of thirty play an instrumental role. The study has signaled the need for ART retention scale-up interventions to have a multi-pronged approach in order to identify the multitude of underlying factors, beyond social support, that enhance/impede efforts to achieve higher uptake and retention rates. Keywords HIV, Antiretroviral therapy adherence, Social support, Pregnant women, Postnatal, Ghana Page 3 of 9Ameyaw et al. BMC Public Health (2024) 24:540 Theoretical framework This study is anchored in the Social Support Theory (SST) [17]. The main tenet is that the possibility of delinquency and crime is decreased by instrumental, informational, and emotional assistance. Providers of social support include family, friends, and the community’s capable members who are always willing to help. These networks are shaped by the people, events, and situations that are going on in the world now, specifically for HIV-positive pregnant women (prenatal) and HIV-positive (post- partum) women. This framework posits that social sup- port is a dynamic construct that is contingent upon the unique needs and circumstances of those in need of it) [17], thus HIV-positive pregnant women (prenatal) and HIV-positive (post-partum) women in the context of this study. According to the framework, an individual’s capac- ity to obtain social support is contingent upon personal attributes, which encompass their age, gender, and living situation in addition to their relationship status and other situational factors like their own expectations, resources, and demands. Underpinned by this framework, we inves- tigated the association between social support and ART adherence among HIV-positive pregnant women (prena- tal) and HIV-positive women (post-partum). Methods Study setting We implemented this study in the Greater Accra region of Ghana. The region is the smallest of the 16 administra- tive regions in Ghana, making just 1.4% of the country’s total land area [18]. The 2021 Population and Housing Census indicated that the region has a total population of 5,455,692 consisting of 2,679,063 males (49.1%) and 2,776,629 females (50.9%) [19]. Between 1984 (441) and 2000, the population density of the area doubled, partly due to migrant flows into the area. The region has a net- work of health institutions, including 707 CHPS facilities, 299 clinics, 101 maternity homes, 32 health centers, 22 polyclinics, and 111 hospitals, which provides healthcare services in the region [20]. Design and setting This cross-sectional study was implemented to bet- ter investigate HIV-infected pregnant and postpartum women’s adherence and retention of ART. The study was implemented in eleven public health facilities that provide HIV care, including ART administration. These facilities comprised 3 Municipal Hospitals, 2 District Hospitals, 4 Polyclinics, 1 Maternity Home and 1 Health Centre. These facilities had the highest concentration of HIV-positive residents in the Greater Accra region. Target population and sampling procedure We targeted ART-treated pregnant and postpartum women living with HIV who were at least 18 years old. The actual sample constituted the proportion of the tar- get population who consented to participate and gave written informed consent at the time of their pre- or post- natal visit at any of the eleven healthcare facilities. Con- venience sampling was used to select the participants. In the estimation of the sample size, we used a type I error of 0.025, standardized minimum detectable effect size from a standard normal distribution for adherence (since adherence was our primary outcome) β = 0.26 (equivalent to odds ratio of 1.30) and we simulated 100 to 150 individuals [21, 22]. This sample size of 150 individu- als returned a statistical power of 80%. We then adjusted for 30% stopping treatment (as a proxy of loss to follow- up), resulting in a sample size of 176 individuals. Data collection instrument We used a pretested electronic questionnaire for data col- lection. The questionnaire captured data on socio-demo- graphic characteristics, internalized stigma, anticipated stigma, enacted stigma, social support, ART adherence and uptake and retention in HIV care. The instrument was in the English Language. Data collection procedure Data collection occurred between 29th March and 27th May, 2023 with the aid of seven trained Research Assis- tants (RAs). The co-principal investigator of the project (IY) was the focal person who supervised the seven RAs. The RAs administered the questionnaire to all partici- pants who consented to participate in the study. Independent variable Social support was the key independent variable in the study, and this was gauged with a social support score. The parameters used are provided in Table 1. Each ques- tion had 4 frequency response options: As much as I would like, less than I would like, much less than I would like, and never, coded as 1,2,3, and 4 respectively. These questions were adapted from the social support index scale [23]. We assessed the reliability of these parameters, Table 1 Items used for social support score I get useful advice about important things in my life when I need it. I get chances to talk to someone about problems at work or with my housework when I need it. I get chances to talk to someone I trust about my personal and family problems when I need it. I have people who care what happens to me. I get love and affection. I get help with household-related work when I need it. I get help with money in an emergency when I need it. I get help with transportation when I need it. I get help when I am sick Page 4 of 9Ameyaw et al. BMC Public Health (2024) 24:540 and from our sample, the Cronbach alpha was 0.8792. Clearly indicating high internal consistency suggest- ing that probably the items measure the same underly- ing concept. The summative score ranged from 9 to 32. These values were categorized into 3 groups using equal width of 8. Hence, values between ‘9–16’indicated high social support, ‘17–24’ represented moderate social sup- port, while values between 25–32 represented low social support. In addition, we collected data on socio-demographic characteristics such as participant’s age, marital sta- tus, religion, education attainment, place of residence, whether partner’s HIV status is known, and whether par- ticipant has a cowife/cowives. Outcome variables The study had two main outcomes of interest, namely; consistent uptake of ART in the three months preceding the survey and retention in ART. A participant was con- sidered to have been consistent if the person indicated that she took the ART following the prescribed regimen without missing any dose. This category of participants was coded as “1”, whilst those who couldn’t take the dose fully were considered otherwise and coded as “0”. Fol- lowing the measurement of retention by some existing studies [24–27], retention was measured by asking the participant the last time they visited the hospital to col- lect their ARV drug. Participants were asked: In the past 3 months, have you taken your ARVs consistently in the correct dosage and at the right time as directed by your medical doctor? The response was “Yes/No”. Those who indicated “Yes” were coded as “1” while those who indi- cated “No” were coded as “0”. Data analysis Data were analyzed using Stata version 14.1 (College Station, TX). Initial analysis included descriptive sta- tistics characterized by frequencies and percentages to describe the study population. We assessed the associa- tions between social support score, participants’ socio- demographic characteristics, ART adherence within the 3 months preceding the study. This was done using chi- square test, and multivariate associations were assessed using a modified Poisson regression model with health facility clustered robust standard errors. We also exam- ined whether the covariates in the final model modified the relationship between social support and ART adher- ence. Similarly, associations between social support score, participants’ characteristics, and retention were analyzed using chi-square test and multivariate asso- ciations using a modified Poisson regression model with health facility clustered robust standard errors. In model building, we included all variables that had p-values of 0.2 or lesser in the bivariate analysis to minimize negative confounding. Overall, a two-sided p-value of < 0.05 was considered statistically significant. Ethics approval The Declaration of Helsinki was followed when conduct- ing the study, and two bodies offered ethical approval. Thus, the University of California San Francisco Institu- tional Review Board and the Ghana Health Service Ethics Review Committee approved the study’s protocol and the informed consent form, with approval numbers 21-35733 and GHS-ERC: 003/12/21 respectively. The authorized permission forms were used by respondents to provide their informed consent before participation. Participants were informed about the study objectives before data col- lection. We also explained the purpose of the study to all participants, informed them about their rights to partici- pate as well as the right to opt-out from the study at any time without any consequences. Results Socio-demographic characteristics of the study population Of the 176 participants who met study eligibility, all of them accepted to participate in the study (response rate 100%). The socio-demographic characteristics of the research participants are presented in Table  2. Median age was 32 years (IQR: 29–36), with the majority of the participants aged 30–34 (36.8%, n = 64) and those below 30 years of age constituting 31.0% (n = 54). More than half of the women were married/separated (55.7%, n = 98) with only 4% (n = 7) being single/never married/had no current partner. Most women knew their partner’s HIV status (63.1%, n = 111) and had co-wives (89.3%, n = 65). A considerable proportion had 1–2 children (47.4%, n = 82), however, 11.0% (n = 19) indicated that they had no chil- dren. Three out of ten were identified as Charismatics (32.4, n = 57) and Pentecostals (30.7%, n = 54). Most of the participants had completed primary or less educa- tion 60.8% (n = 107), whilst 39.2% (n = 69) had completed O-level or above. ‘About a third (32.4%, n = 57) were working in the informal sector with only 9.1% (n = 16) in the formal sector. Nearly half of the women earned less than 500 GHS (46.0%, n = 81) and 22.2% (n = 39) were not earning any income. When asked to describe their financial status, 77.3% (n = 136) revealed that they were poor. ‘Most of the participants (79.5%, n = 140 and 63.6%, n = 112)’ resided in the urban area and cooked with lique- fied petroleum gas (LPG), respectively. About seven out of ten (71.0%, n = 125) had low social support score with only 6.8% (n = 12) recording high social support score. Page 5 of 9Ameyaw et al. BMC Public Health (2024) 24:540 Regression results on social support, socio-demographic characteristics and ART adherence in the 3 months preceding the survey Bivariate results of social support, socio-demographic characteristics and ART adherence within the 3 months preceding the survey are presented in Table  3. At this level of analysis; age, knowledge of partner’s HIV status, and having rivals/co-wives were significantly associated with ART adherence in the 3 months. In multivariable analysis, two variables had significant relationship with ART adherence, namely age and knowl- edge of partner’s HIV status (Table 4). Compared to those below 30 years of age, women aged above 35 (aPR = 0.50, CI = 0.35–0.71) had lower prevalence of ART adher- ence. Similarly, women who knew their partner’s HIV status had lower prevalence of taking ART consistently as compared to those who did not know (aOR = 0.65, CI = 0.45–0.95). Although most covariates were insignificant, all the covariates in model in one way modified the relationship between social support and ART adherence. However, the effect of modification was dependent on the level of the covariate considered, for instance being 30 years and below of age modified social support from moderate to high relative to those with low social support. Specifi- cally, those aged 30 years and below had higher preva- lence of ART adherence among those with moderate Table 2 Socio-demographic characteristics of the study population Characteristics Category Frequen- cy (%) Age (n = 174)* Median (IQR) 32 (29–36) < 30 years 54 (31.0) 30–34 64 (36.8) > 35 years 56 (32.2) Marital status Married/separated 98 (55.7) In a relationship, living/not with a partner 71 (40.3) Single, never married, no current partner 7 (4.0) Partner’s HIV status known No 65 (36.9) Yes 111 (63.1) Have rival/co-wife or co-wives Yes 18 (10.7) No 151 (89.3) Number of children (n = 173)* None 19 (11.0) 1–2 children 82 (47.4) 3 or more children 72 (41.6) Religion Protestant/Catholic 33 (18.8) Pentecostal 54 (30.7) Charismatic 57 (32.4) Others (Adventist/Muslim) 32 (18.1) Education status Completed primary or less 107 (60.8) Completed O level or above 69 (39.2) Employment status Formal 16 (9.1) Informal 57 (32.4) Self-employed 54 (30.7) Unemployed 49 (27.8) Monthly income Zero income 39 (22.2) Below GHc500 81 (46.0) GHc500 or more 56 (31.8) Description of financial status Poor or not enough 136 (77.3) Enough or more than enough 40 (22.7) Fuel type mainly used LPG or natural gas 112 (63.6) Charcoal/wood 64 (36.4) Place of residence Peri-urban/Rural 36 (20.5) Urban 140 (79.5) Social support score Low 12 (6.8) Moderate 39 (22.2) High 125(71.0) *Variables with a lesser sample Table 3 Bivariate analysis of factors associated with ART adherence in the past 3 months preceding the survey Characteristics Category ART adherence p No (%) Yes (%) Social support index Low 87 (73.7) 38 (65.5) 0.518 Moderate 24 (20.3) 15 (25.9) High 7 (5.9) 5 (8.6) Place of residence Peri-urban/Rural 29 (24.6) 7 (12.1) 0.053 Urban 89 (75.4) 51 (87.9) Age < 30 years 28 (23.9) 26 (45.6) 0.013 30–34 46 (39.3) 18 (31.6) > 35 years 43 (36.8) 13 (22.8) Marital status Married/separated 72 (61.0) 26 (44.8) 0.098 In a relationship, living/not with a partner 41 (34.8) 30 (51.7) Single, never married, no current partner 5 (4.2) 2 (3.5) Partner’s HIV status known No 36 (30.5) 29 (50.0) 0.012 Yes 82 (69.5) 29 (50.0) Have rival/co- wife or co-wives No 105 (92.9) 46 (82.1) 0.033 Yes 8 (7.1) 10 (17.9) Number of children None/refused 10 (8.7) 9 (15.5) 0.323 1–2 children 54 (47.0) 28 (48.3) 3 or more children 51 (44.3) 21 (36.2) Religion Protestant/Catholic 25 (21.2) 8 (13.8) 0.705 Pentecostal 35 (29.7) 19 (32.8) Charismatic 37 (31.3) 20 (34.5) Others 21 (17.8) 11 (18.9) Education status Completed primary or less 68 (57.6) 39 (67.2) 0.219 Completed O level or above 50 (42.4) 19 (32.8) Employment status Formal 12 (10.2) 4 (6.9) 0.868 Informal 37 (31.3) 20 (34.5) Self-employed 35 (29.7) 19 (32.8) Unemployed 34 (28.8) 15 (25.8) Monthly income Zero income 28 (23.7) 11 (19.0) 0.554 Below GHc500 51 (43.2) 30 (51.7) GHc500 or more 39 (33.1) 17 (29.3) Page 6 of 9Ameyaw et al. BMC Public Health (2024) 24:540 social support compared to those with low, and yet those aged 30–34 years had lower prevalence of ART adher- ence among those with moderate social support com- pared to those with low social support. Clearly indicating that age modifies the relationship between social support and ART adherence. We provide more details in the sup- plementary table S1. Results on a modified Poisson regression between social support, socio-demographic characteristics and ART retention In Table 5, we present the results of the bivariate analysis of social support, socio-demographic characteristic and ART retention. None of the variables in the univariate model showed significant association with retention. In the multivariate model, having a rival had significant association with retention such that higher prevalence of ART retention was found among women with rivals relative to those without (aPR = 1.98, CI = 1.16–3.36) as shown in Table 6. Discussion This study investigated the association between social support and ART uptake/retention in Accra, the capital of Ghana. Evidently, social support has no relationship with ART uptake and retention. Our theoretical frame- work would have expected that women with this sup- port should have higher adherence and retention [17]. This finding suggests that social support, per se, does not guarantee ART uptake and retention among the surveyed pregnant and postnatal women, which possibly implies that other essential factors may rather enhance HIV- infected pregnant and postnatal women’s uptake and adherence to ART. Relatedly, a previous study that inves- tigated illness perceptions, social support and adherence to ART in the Greater Accra region, realized that sup- port from family, friends and other significant others was inversely related to adherence [15]. Similar findings have also been reported from Uganda, as no association was noted between social support (from friends, teachers and classmates) and adherence [11]. Meanwhile, evidence from a systematic review has shown positive impacts of social support toward ART adherence [14]. Additionally, a South African-based study has shown that social support enhances ART adherence and retention [13]. This inconsistency high- lights the role of other contextual factors which might present disparate opportunities and bottlenecks to HIV patients in accessing ART, in addition to social support. Our study design did not permit us to unravel the plau- sible enabling conditions that could foment these wom- en’s motivation for ART, meanwhile, this may be possible when the phenomenon is explored through a qualita- tive lens. Hence, further research might be required regarding the specific social support that can amplify ART adherence and retention in order to guide work- able interventions intending to augment ART adherence and retention, especially as positive association between social support and ART uptake/retention has been real- ized in other jurisdictions. The presence of a rival or co-wife was significantly asso- ciated with ART retention such that higher odds of ART retention was realised among women with rivals relative to those without rivals. Perhaps these patients are moti- vated to take good care of themselves to compete with their rivals. Additionally, as advanced by the theoretical framework, women who are co-wives may possess admi- rable character that attracts genuine social support that consistently motivates them to remain focused on their regimen [17]. The finding put forward that the presence Table 4 Multivariable regression model assessing factors associated with ART adherence in the past 3 months preceding the survey Characteristics Category Outcome Present, n (%) Multivariate analysis PR (95%CI) p Social support index Low 5/12 (41.7) Reference - Moderate 15/39 (38.5) 1.05 (0.51–2.14) 0.898 High 38/125 (30.4) 0.80 (0.36–1.79) 0.592 Place of residence Peri-urban/Rural 7/36 (19.4) Reference - Urban 51/140 (36.4) 1.88 (0.93–3.77) 0.077 Age < 30 years 26/54 (48.2) Reference - 30–34 18/64 (28.1) 0.60 (0.36–1.02) 0.060 > 35 years 13/56 (23.2) 0.50 (0.35–0.71) < 0.001 Marital status Married/separated 26/98 (26.5) - - In a relationship, living/not with a partner 30/71 (42.3) 1.12 (0.62–2.01) 0.712 Single, never married, no current partner 2/7 (28.6) - - Partner’s HIV status known No 29/65 (44.6) Reference - Yes 29/111 (26.1) 0.65 (0.45–0.95) 0.026 Have rival/co-wife or co-wives No 10/18 (55.6) Reference - Yes 46/151 (30.5) 0.76 (0.54–1.07) 0.122 Page 7 of 9Ameyaw et al. BMC Public Health (2024) 24:540 of a rival is associated with increased retention in ART among women living with HIV. Whereas the finding on the association between rivals and retention in HIV care is relatively new, prior research has suggested that social relationships, including both supportive and competitive ones, can have a significant impact on health behaviors and outcomes. For instance, one United States-based study found that social network characteristics, such as size and density, are associated with medication adher- ence among people living with HIV [28]. Urban residents had higher odds of consistent ART adherence relative to rural/peri-urban residents. This could be as a result of discrepancies in access to health- care facilities, health education, social support, and other factors [29–32]. Through a sub-Saharan African-based systematic review, Bärnighausen et al. [33] noted that rural residents had lower ART adherence compared to urban residents. Similarly, another study in Kenya indi- cated that rural residents had lower retention rates in HIV care compared to urban residents [34]. A study con- ducted in Nigeria also revealed that rural residents tend to have lower levels of HIV knowledge, hence resulting in relatively lower ART adherence [35]. Overall, the finding highlights that interventions aimed at enhancing ART retention and retention should consider the rural/urban dichotomy and the underlying contributory factors, in order to make greater strides. As compared to women below age 30, those aged 30 and above had lower odds of ART adherence. The finding is indicative that older women living with HIV have lower odds of consistently adhering to ART regimens. Multi- plicity of factors might account for this including comor- bidities, medication side effects, and socio-economic factors [31, 36]. A systematic review, however, unraveled that ART retention aligns positively with advanced age [37]. It is worth noting that different stages of life present distinct opportunities and limitations to women, hence the critical role of age in ART adherence/retention must always be accorded the requisite recognition in HIV care efforts. Strengths and limitations This is a cross-sectional study and as such, readers are cautioned not to draw causal inferences from this study. Secondly, our principal independent variable was “social support” and there is no absolute measure for this vari- able. Consequently, the association we found between social support and ART adherence/retention is driven by how we conceptualized it. Additionally, data on “dura- tion on ART” was not collected and yet it is known to influence ART adherence [38]. The study relied on self- reported data other than hospital records, hence there is Table 5 Bivariate analysis of factors associated with ART retention Characteristics Category Retention p No (%) Yes (%) Social support index Low 68 (68.7) 28 (77.8) 0.533 Moderate 23 (23.2) 7 (19.4) High 8 (8.1) 1 (2.8) Place of residence Peri-urban/Rural 20 (20.2) 4 (11.1) 0.310 Urban 79 (79.8) 32 (88.9) Age < 30 years 30 (30.6) 12 (34.3) 0.741 30–34 38 (38.8) 11 (31.4) > 35 years 30 (30.6) 12 (34.3) Marital status Married/separated 55 (55.6) 19 (52.8) 0.845 In a relationship, living/not with a partner 40 (40.4) 15 (41.7) Single, never married, no current partner 4 (4.0) 2 (5.6) Partner’s HIV status known No 32 (32.3) 17 (47.2) 0.111 Yes 67 (67.7) 19 (52.8) Have rival/co- wife or co-wives No 7 (7.4) 6 (17.7) 0.088 Yes 88 (92.6) 28 (82.3) Number of children None/refused 11 (11.2) 6 (17.1) 0.634 1–2 children 48 (49.0) 17 (48.6) 3 or more children 39 (39.8) 12 (34.3) Religion Protestant/Catholic 20 (20.2) 6 (16.7) 0.535 Pentecostal 28 (28.3) 15 (41.7) Charismatic 31 (31.3) 9 (25.0) Others 20 (20.2) 6 (16.7) Education status Completed primary or less 63 (63.6) 20 (55.6) 0.394 Completed O level or above 36 (36.4) 16 (44.4) Employment status Formal 11 (11.1) 3 (8.3) 0.723 Informal 32 (32.3) 10 (27.8) Self-employed 33 (33.3) 11 (30.6) Unemployed 23 (23.2) 12 (33.3) Monthly income Zero income 21 (21.2) 8 (22.2) 0.879 Below GHc500 46 (46.5) 18 (50.0) GHc500 or more GHC 32 (32.3) 10 (27.8) Table 6 Multivariable regression model assessing factors associated with retention on ART Characteristics Category Outcome Present, n (%) Multivariate analysis (N = 129) PR (95%CI) p Social support index Low 28/96 (29.2) Reference - Moderate 7/30 (23.3) 0.80 (0.53–1.23) 0.321 High 1/9 (11.1) 0.32 (0.04–2.95) 0.318 Partner’s HIV status known No 17/49 (34.7) Reference - Yes 19/86 (22.1) 0.71 (0.39–1.29) 0.256 Have rival/co- wife or co-wives No 28/116 (24.1) Reference - Yes 6/13 (46.2) 1.98 (1.16–3.36) 0.012 Describe your financial status Poor or not enough 23/103 (22.3) Reference - Enough or more than enough 13/32 (40.6) 1.77 (0.80–3.90) 0.159 Page 8 of 9Ameyaw et al. BMC Public Health (2024) 24:540 the possibility that the data was affected by some biases such as social desirability bias. Besides, a convenience sampling approach was used due to nature of the out- come variable and the sample size was relatively low for a quantitative survey. In spite of these limitations, our study uniquely advances the frontiers of knowledge on ART adherence and retention by filling a critical knowl- edge gap, and offering insightful leads for future HIV interventions. Conclusion Our study showed that social support does not play any essential role in the adherence and retention of ART among the surveyed pregnant and postpartum women. Meanwhile, factors such as urban residency, having a rival and being under age thirty appear to be promising in driving ART adherence and retention. The study has signaled the need for ART adherence/retention scale- up interventions to have a multi-pronged approach in order to identify the multitude of underlying factors that enhance/impede efforts to achieve higher uptake and retention rates. Further investigations may be worthwhile to unravel the specific social support indicators that can yield positive results for ART adherence and retention among pregnant and postnatal women in Accra. Sec- ondly, further engagements with caregivers may be useful in the quest to explore the drivers of HIV antiretroviral therapy in the Accra Metropolis. Abbreviations AIDS Acquired Immunodeficiency Syndrome aOR Adjusted Odds Ratio ART Antiretroviral Therapy CI Confidence Interval GHc Ghana Cedis GHS Ghana Health Service HIV Human Immunodeficiency Virus LPG Liquefied Petroleum Gas RAs Research Assistants WHO World Health Organisation MSM Men who have sex with men UNAIDS United Nations Programme on HIV/AIDS Supplementary Information The online version contains supplementary material available at https://doi. org/10.1186/s12889-024-18004-z. Supplementary Material 1 Acknowledgements We thank all the study participants at all the eleven public health facilities in Greater Accra. We also express our gratitude to nurses at the ART units in the health facilities. Author contributions JJN conceptualized the study. EKA drafted the manuscript. JO analyzed and drafted the results. RGAT, PA, MG, IY contributed to the study design. IY, RGAT and WA supervised data collection. All authors reviewed and approved the final manuscript. Funding This work was supported by University of California, San Francisco School of Nursing Gaines Research Fund under Grant number GRF-2021-02. Data availability materials. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Declarations Ethics approval and consent to participate Eligible survey participants were invited to take part in the survey after indicating their informed consent. The study protocol was approved by the University of California San Francisco Institutional Review Board and Ghana Health Service Ethics Review Committee. Written informed consent was sought from each participant of the study. We ensured privacy by engaging each participant privately and ensuring that they respond to the issue. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Author details 1Institute of Policy Studies and School of Graduate Studies, Lingnan University, Hong Kong, China 2Africa Interdisciplinary Research Institute, Accra, Ghana 3L & E Research Consult Ltd, Wa, Upper West Region, Ghana 4Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, CA, USA 5Infectious Diseases Research Collaboration, Kampala, Uganda 6Institute of Work Employment and Society, University of Professional Studies, Accra, Ghana 7Department of Sociology and Social Science Policy, Lingnan University, Hong Kong, China 8Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA 9Push Aid Africa, Accra, Ghana 10Language Center, College of Humanities, University of Ghana, Accra, Ghana Received: 6 June 2023 / Accepted: 6 February 2024 References 1. WHO. HIV, 2022. Retrieved from https://www.who.int/data/gho/ data/themes/hiv-aids#:~:text=Globally%2C%20384%20million%20 %5B33.9%E2%80%93,considerably%20between%20countries%20and%20 regions on 25th March, 2023. 2. Ghana AIDS, Commission. Ghana HIVAIDS, Strategic Framework. 2001–2005: Ghana AIDS Commission. 2001. Retrieved from https://www.ilo.org/aids/ legislation/WCMS_126717/lang-en/index.htm on 28th March, 2023. 3. Ba DM, Ssentongo P, Sznajder KK. Prevalence, behavioral and socioeconomic factors associated with human immunodeficiency virus in Ghana: a popula- tion-based cross-sectional study. J Global Health Rep. 2019;3:e2019092. 4. Ali H, Amoyaw F, Baden D, Durand L, Bronson M, Kim A, Grant-Greene Y, Imtiaz R, Swaminathan M. Ghana’s HIV epidemic and PEPFAR’s contribution towards epidemic control. Ghana Med J. 2019;53(1):59–62. 5. United Nations. Countries Commit to Action to End AIDS by 2030; 2016. Retrieved from https://www.un.org/en/academic-impact/ countries-commit-action-end-aids-2030. 6. WHO. Strengthening the fight against HIV in Ghana. 2023. Retrieved from https://www.afro.who.int/countries/ghana/news/strengthening-fight- against-hiv-ghana#~:text=The%20efforts%20have%20led%20to,services%20 without%20stigma%20and%20discrimination on 19th December, 2023. 7. National AIDS Control Programme. Consolidated Guidelines for HIV Care in Ghana., 2022. Retrieved from https://www.differentiatedservicedelivery.org/ https://doi.org/10.1186/s12889-024-18004-z https://doi.org/10.1186/s12889-024-18004-z https://www.who.int/data/gho/data/themes/hiv-aids#:~:text=Globally%2C%2038. https://www.who.int/data/gho/data/themes/hiv-aids#:~:text=Globally%2C%2038. https://www.ilo.org/aids/legislation/WCMS_126717/lang-en/index.htm https://www.ilo.org/aids/legislation/WCMS_126717/lang-en/index.htm https://www.un.org/en/academic-impact/countries-commit-action-end-aids-2030 https://www.un.org/en/academic-impact/countries-commit-action-end-aids-2030 https://www.afro.who.int/countries/ghana/news/strengthening-fight-against-hiv-ghana#: https://www.afro.who.int/countries/ghana/news/strengthening-fight-against-hiv-ghana#: https://www.differentiatedservicedelivery.org/wp-content/uploads/CONSOLIDATED-GUIDELINES-FOR-HIV-CARE-IN- Page 9 of 9Ameyaw et al. BMC Public Health (2024) 24:540 wp-content/uploads/CONSOLIDATED-GUIDELINES-FOR-HIV-CARE-INGHANA. pdf on 20th December, 2023. 8. WHO. Consolidated guidelines on HIV prevention, testing, treatment, service delivery and monitoring: recommendations for a public health approach, WHO., 2021. Geneva;. Retrieved from https://www.who.int/teams/ global-hiv-hepatitis-and-stis-programmes/hiv/treatment/hiv-treatment-for- adults#:~:text=WHO%20recommends%20ART%20for%20all,HIV%20infec- tion%20throughout%20the%20world on 20th December 2023. 9. Tenkorang EY, Owusu AY. Examining HIV-related stigma and discrimination in Ghana: what are the major contributors? Sex Health. 2013;10(3):253–62. 10. Mumin AA, Gyasi RM, Segbefia AY, Forkuor D, Ganle JK. Internalised and social experiences of HIV-induced stigma and discrimination in urban Ghana. Global Social Welf. 2018;5:83–93. 11. Damulira C, Mukasa MN, Byansi W, Nabunya P, Kivumbi A, Namatovu P, Namuwonge F, Dvalishvili D, Sensoy Bahar O, Ssewamala FM. Examining the relationship of social support and family cohesion on ART adherence among HIV-positive adolescents in southern Uganda: baseline findings. Vulnerable Child Youth Stud. 2019;14(2):181–90. 12. Kelly JD, Hartman C, Graham J, Kallen MA, Giordano TP. Social support as a predictor of early diagnosis, linkage, retention, and adherence to HIV care: results from the steps study. J Assoc Nurses AIDS Care. 2014;25(5):405–13. 13. Knight L, Schatz E. Social Support for Improved ART Adherence and Reten- tion in Care among older people living with HIV in Urban South Africa: a Complex Balance between Disclosure and Stigma. Int J Environ Res Public Health. 2022;19(18):11473. 14. Shushtari ZJ, Salimi Y, Sajjadi H, et al. Effect of Social Support interventions on adherence to antiretroviral therapy among people living with HIV: a system- atic review and Meta-analysis. AIDS Behav. 2023;27:1619–35. 15. Anakwa NO, Teye-Kwadjo E, Kretchy IA. Illness perceptions, social support and antiretroviral medication adherence in people living with HIV in the greater Accra region, Ghana. Nurs Open. 2021;8(5):2595–604. 16. Nutor JJ, Agbadi P, Hoffmann TJ, Anguyo G, Camlin CS. Examining the relationship between interpersonal support and retention in HIV care among HIV + nursing mothers in Uganda. BMC Res Notes. 2021;14(1):224. https://doi. org/10.1186/s13104-021-05639-z. PMID: 34082834; PMCID: PMC8176692. 17. Kort-Butler L, Social. support theory; 2018. Retrieved from https://onlineli- brary.wiley.com/doi/10.1002/9781118524275.ejdj0066 on 20/12/2023. 18. Greater Accra Regional Co-ordinating Council, About GAR. 2016. Retrieved from https://www.gtarcc.gov.gh/index.php/about-gar/ on 20/12/2023. 19. Ghana Statistical Service. Population of Regions and Districts., 2021. Retrieved from https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&c d=&cad=rja&uact=8&ved=2ahUKEwiY5dGjpKSDAxWhoWMGHXLTAAMQF noECBMQAQ&url=https%3A%2F%2Fstatsghana.gov.gh%2Fgssmain%2Ffile Upload%2Fpressrelease%2F2021%2520PHC%2520General%2520Report%2 520Vol%25203A_Population%2520of%2520Regions%2520and%2520Distri cts_181121.pdf&usg=AOvVaw0oAt1cZCAn42icD1NZkTkc&opi=89978449 on 15th December, 2023. 20. Ghana Health Service, Greater Accra, Region. 2023. Retrieved from https:// ghs.gov.gh/greater-accra/ on 20/12/2023. 21. Bundy BN, Krischer JP, Type 1 Diabetes TrialNet Study Group. A model-based approach to sample size estimation in recent onset type 1 diabetes. Diab/ Metab Res Rev. 2016;32(8):827–34. 22. Julious SA. Sample sizes for clinical trials. CRC; 2023 Jun. p. 21. 23. Merz EL, Roesch SC, Malcarne VL, Penedo FJ, Llabre MM, Weitzman OB, et al. Validation of interpersonal support evaluation list-12 (ISEL-12) scores among english-and spanish-speaking Hispanics/Latinos from the HCHS/SOL Socio- cultural Ancillary Study. Psychol Assess. 2014;26(2):384. 24. Umeokonkwo CD, Onoka CA, Agu PA, Ossai EN, Balogun MS, Ogbonnaya LU. Retention in care and adherence to HIV and AIDS treatment in Anambra State Nigeria. BMC Infect Dis. 2019;19:1–1. 25. Mugavero MJ, Westfall AO, Zinski A, Davila J, Drainoni M, Gardner LI, et al. Measuring retention in HIV care: the elusive gold standard. J Acquir Immune Defic Syndr. 2012;61(5):574–80. 26. Mugavero MJ, Amico KR, Horn T, Thompson MA. The state of engagement in HIV Care in the United States: from Cascade to continuum to control. Clin Infect Dis. 2013;57(8):1164–71. 27. Yehia BR, Fleishman JA, Metlay JP, Korthuis PT, Agwu AL, Berry SA, et al. Comparing different measures of retention in outpatient HIV care. AIDS. 2012;26(9):1131–9. 28. Simoni JM, Huh D, Frick PA, Pearson CR, Andrasik MP, Dunbar PJ, Hooton TM. Peer support and pager messaging to promote antiretroviral modifying therapy in Seattle: a randomized controlled trial. JAIDS J Acquir Immune Defic Syndr. 2009;52(4):465–73. 29. Buregyeya E, Naigino R, Mukose A, Makumbi F, Esiru G, Arinaitwe J, Musinguzi J, Wanyenze RK. Facilitators and barriers to uptake and adherence to lifelong antiretroviral therapy among HIV infected pregnant women in Uganda: a qualitative study. BMC Pregnancy Childbirth. 2017;17(1):1–9. 30. Socías ME, Ti L, Wood E, Nosova E, Hull M, Hayashi K, Debeck K, Milloy MJ. Disparities in uptake of direct-acting antiviral therapy for hepatitis C among people who inject drugs in a Canadian setting. Liver Int. 2019;39(8):1400–7. 31. Bolsewicz K, Debattista J, Vallely A, Whittaker A, Fitzgerald L. Factors associated with antiretroviral treatment uptake and adherence: a review. Perspectives from Australia, Canada, and the United Kingdom. AIDS Care. 2015;27(12):1429–38. 32. Nutor JJ, Marquez S, Slaughter-Acey JC, Hoffmann TJ, DiMaria-Ghalili RA, Momplaisir F, Opong E, Jemmott LS. Water Access and Adherence Intention among HIV-Positive pregnant women and new mothers receiving antiret- roviral therapy in Zambia. Front Public Health. 2022;10:758447. https://doi. org/10.3389/fpubh.2022.758447. PMID: 35433591; PMCID: PMC9010721. 33. Bärnighausen T, Chaiyachati K, Chimbindi N, Peoples A, Haberer J, Newell ML. Interventions to increase antiretroviral adherence in sub-saharan Africa: a sys- tematic review of evaluation studies. Lancet Infect Dis. 2013;13(10):863–78. 34. Govindasamy D, Ford N, Kranzer K. Risk factors, barriers and facilita- tors for linkage to antiretroviral therapy care: a systematic review. AIDS. 2012;26(Suppl 1):205–S212. 35. Olowookere SA, Fatiregun AA, Akinyemi JO, Bamgboye AE, Osagbemi GK. Prevalence and determinants of non-adherence to antiretroviral therapy among people living with HIV/AIDS in Ibadan, Nigeria. Pan Afr Med J. 2015;20:1. 36. Gari S, Martin-Hilber A, Malungo JR, Musheke M, Merten S. Sex differ- entials in the uptake of antiretroviral treatment in Zambia. AIDS Care. 2014;26(10):1258–62. 37. Plazy M, Orne-Gliemann J, Dabis F, Dray-Spira R. Retention in care prior to antiretroviral treatment eligibility in sub-saharan Africa: a systematic review of the literature. Bmj Open. 2015;5(6):e006927. 38. Jiao K, Liao M, Liu G, Bi Y, Zhao X, Chen Q, Ma J, Yan Y, Cheng C, Li Y, Jia W. Impact of antiretroviral therapy (ART) duration on ART adherence among men who have sex with men (MSM) living with HIV in Jinan of China. AIDS Res Therapy. 2022;19(1):55. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. https://www.differentiatedservicedelivery.org/wp-content/uploads/CONSOLIDATED-GUIDELINES-FOR-HIV-CARE-IN- https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/treatment/hiv-treatment-for-adults#:~:text=WHO%20recommends%20ART%20 https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/treatment/hiv-treatment-for-adults#:~:text=WHO%20recommends%20ART%20 https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hiv/treatment/hiv-treatment-for-adults#:~:text=WHO%20recommends%20ART%20 https://doi.org/10.1186/s13104-021-05639-z https://doi.org/10.1186/s13104-021-05639-z https://onlinelibrary.wiley.com/doi/10.1002/ https://onlinelibrary.wiley.com/doi/10.1002/ https://www.gtarcc.gov.gh/index.php/about-gar/ https://www.google.com/url?sa=t https://ghs.gov.gh/greater-accra/ https://ghs.gov.gh/greater-accra/ https://doi.org/10.3389/fpubh.2022.758447 https://doi.org/10.3389/fpubh.2022.758447 The role of social support in antiretroviral therapy uptake and retention among pregnant and postpartum women living with HIV in the Greater Accra region of Ghana Abstract Introduction Theoretical framework Methods Study setting Design and setting Target population and sampling procedure Data collection instrument Data collection procedure Independent variable Outcome variables Data analysis Ethics approval Results Socio-demographic characteristics of the study population Regression results on social support, socio-demographic characteristics and ART adherence in the 3 months preceding the survey Results on a modified Poisson regression between social support, socio-demographic characteristics and ART retention Discussion Strengths and limitations Conclusion References