Exploring the experiences and perspectives of Iraqi healthcare providers on the challenges and determinants of HIV management: a qualitative study

Exploring the experiences and perspectives of Iraqi healthcare providers on the challenges and determinants of HIV management: a qualitative study Shlova Najim Talabani1,2, Ehab Mudher Mikhael2 1 Naser Hospital, Directorate of Health - Kirkuk, Iraqi Ministry of Health, Kirkuk, Iraq 2 Clinical Pharmacy Department, College of Pharmacy, University of Baghdad, Baghdad, Iraq Corresponding author: Ehab Mudher Mikhael (ihab[email protected]u.iq) Received 29 June 2025♦ Accepted 14 September 2025♦ Published 10 October 2025 Citation: Talabani SN, Mikhael EM (2025) Exploring the experiences and perspectives of Iraqi healthcare providers on the challenges and determinants of HIV management: a qualitative study. Pharmacia 72: 1–15. https://doi.org/10.3897/pharmacia.72.e163561 Abstract A Physician non-adherence to guidelines and resource constraints hinder optimal HIV care and patient outcomes; however, little is known about providers’ experiences in Iraq. This qualitative study explored physicians’ practices, challenges, and suggestions for improving HIV management across three Iraqi HIV centers. From February to April 2025, we conducted semi-structured face-to-face interviews in Arabic with 17 physicians (minimum six months of experience in managing HIV patients), using an expert-validated guide. Thematic analysis identified four themes: clinical management of HIV patients, healthcare professionals’ roles, patient adherence to anti-HIV therapy, and healthcare services for HIV patients. Most physicians reported following Iraqi Ministry of Health and WHO protocols, with tenofovir–lamivudine–dolutegravir (TLD) favored as first-line therapy for its efficacy and tolerability. Major barriers to patient adherence included stigma, shame, low health literacy, misconceptions, and follow-up challenges. Although providers deemed existing services satisfactory, they recommended establishing specialized dental, surgical, and psychiatric clinics, and expanding patient education, psychosocial support, and engagement to enhance comprehensive care. In conclusion, current HIV treatment align with international standards; meanwhile addressing sociocultural barriers and resource gaps through supportive services may improve adherence and health outcomes for people living with HIV in Iraq. Keywords health personnel, HIV infections, qualitative, social stigma, treatment adherence and compliance Introduction The human immunodeficiency virus (HIV) is a retrovirus that targets the human immune system, specifically Cluster of Differentiation 4-positive (CD4+) T lymphocytes, leading to progressive immune suppression (Masenga et al. 2023), which can increase the risk of developing infections and, consequently, morbidity and mortality (Pyarali et al. 2020). In Iraq, a country with a population of over 47 million, an annual growth rate of 2.1%, and a median age of 20.8 years – making it the 34th most populous country in the world – HIV prevalence is relatively low. Recent data from the World Bank, WHO, and the Iraqi Ministry of Health indicate that the prevalence of HIV among individuals aged 15–49 remains at 0.1% (UN 2024). Copyright Talabani SN & Mikhael EM. This is an open access article distributed under the terms of the Creative Commons Attribution License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Pharmacia 72: 1–15 DOI 10.3897/pharmacia.72.e163561 Research Article Talabani SN & Mikhael EM: Qualitative insights into HIV management in Iraq2 This rate is among the lowest both regionally and globally, despite an increase in the total number of reported cases. The 2024 report from Iraq’s Parliamentary Health and Environment Committee confirms that a total of 2,638 HIV/AIDS cases have been recorded since the start of the pandemic, with 470 deaths during this period. While these numbers might seem small at first, the annual growth rate of new HIV infections was 14.7% in 2019, showing a significant rise in recent years (WHO 2018; UNAIDS 2025). Additionally, it is worth noting that most new cases occur in males (over 83%), with an average age of 36.8 years for recently identified individuals, ranging from 16 to 68 years old. Most newly registered cases are concentrated among people under 45 years old (Talabani and Mikhael 2025). Since 1986, the HIV transmission pattern has evolved notably. Initially, approximately 66% of early cases were linked to hemophiliacs who received contaminated blood products, marking the first documented outbreak. More recently, heterosexual contact has become the dominant mode of transmission, increasing from 17% in 2012 to over 60–70% in recent studies. Vertical transmission, or mother-to-child spread, has historically accounted for 5% of cases but remains rare today due to improved blood screening and antenatal interventions. Other modes, such as intravenous drug use and homosexual transmission, are likely underreported or not fully captured in official records, though concerns about under-detection persist, especially within key populations. Additionally, emerging risks include exposure in unlicensed beauty salons and tattoo parlors and the impacts of increased international travel, highlighting the shifting and expanding landscape of HIV transmission routes (Simonsen et al. 1999; De Cock et al. 2000; Abu-Raddad et al. 2010; Gökengin et al. 2016; Saleh et al. 2020). Fortunately, numerous antiretroviral drugs (ARVs) are now accessible, which can enhance survival rates and eliminate the risk of transmitting HIV (Sisay et al. 2019). However, the optimal management of HIV in healthcare settings relies not only on the clinical efficacy of treatment regimens but also on the practices of healthcare providers (Hawk et al. 2017). Numerous studies indicate that many physicians do not consistently adhere to the latest clinical guidelines when prescribing treatment regimens (Cabana et al. 1999; Lugtenberg et al. 2009a; Lugtenberg et al. 2009b; Ibraheem Ali et al. 2019; Ali et al. 2025a). This inconsistency can arise from various factors, including the complexity of the guidelines, levels of institutional support, and the heavy workload faced by providers (Suárez-García et al. 2014; Tandon et al. 2019). Such deviations create significant barriers to optimal patient care, ultimately impacting treatment outcomes and the quality of life for individuals living with HIV. Inadequate training and knowledge about HIV management among healthcare professionals is a prevalent issue in Iraq, which further contributes to suboptimal patient care (Hamid Albujeer et al. 2015; Naif et al. 2019; Kaladharan et al. 2021). Additionally, poor communication between patients and healthcare providers can hinder patients’ understanding of their treatment plans and decrease their engagement in their care (Budhwani et al. 2022). These challenges are further compounded by a broader context of limited healthcare resources, which diminishes providers’ capacity to deliver comprehensive care (Kitahata et al. 2002). In Iraq, the distribution of healthcare facilities is uneven, with advanced hospitals and clinics concentrated in established urban areas, resulting in substantial geographic disparities. Despite the comprehensive framework, the health system continues to face ongoing challenges in resource allocation, personnel distribution, and supply management, as detailed in the 2024 Health Sector and Parliamentary Health Committee reports. In this regard, specialized HIV care and ART are available at eight dedicated centers distributed in Baghdad and some major cities like Kirkuk, Basrah, and Erbil (Saleh et al. 2020). Additionally, Iraq had over 11,000 registered laboratories, predominantly located in urban areas, with the most advanced facilities situated in Baghdad and other major cities. HIV diagnosis primarily relies on rapid tests, with confirmatory ELISA and Western blot conducted at designated laboratories; however, molecular testing capacity for confirmatory diagnosis and viral load monitoring remains limited. Viral load testing is in its early stages and available at less than 50% of HIV care sites, posing significant challenges for long-term treatment and management (WHO 2024). Understanding the healthcare landscape surrounding HIV management is crucial for developing targeted interventions that improve care and support for patients living with HIV. Unfortunately, to date, there is a significant lack of data regarding the specific role of healthcare providers in the management of HIV among Iraqi patients. Therefore, this study aims to gain in-depth insights into the practices and challenges faced by healthcare providers in managing HIV patients in Iraq, as well as their recommendations for improvement. By identifying these critical challenges and understanding the perspectives of healthcare providers, this research seeks to inform policymakers of existing gaps and contribute to the development of more effective healthcare strategies that enhance HIV management and ultimately improve health outcomes for patients living with HIV in Iraq. Methods Study design To achieve the study’s objectives, a qualitative study was conducted using face-to-face, individual-based interviews with physicians currently working in HIV centers. The study was ethically approved by the Research Ethical Committee at the College of Pharmacy, Baghdad University (Approval No. REC06202567R, dated 13 October 2024). Development and validation of the interview guide The study authors developed the interview guide (Suppl. material 1) based on relevant information from previous studies (Rivero-Méndez et al. 2010; Campbell et al. 2011; Pharmacia 72: 1–15 3 Renju et al. 2017; Igihozo et al. 2022; Pant et al. 2022). The content validation of the guide was conducted by sending it to a panel of four experts (three academic pharmacists with extensive experience in qualitative research, along with a consultant physician who works at an HIV center). All experts were requested to evaluate each question using a 3-point scale: “relevant and essential,” “relevant but not essential,” and “not relevant.” Additionally, experts were asked to provide feedback on any language and phrasing issues. Lawshe’s method was used to evaluate the content validity of the interview guide (Lawshe 1975). All participating experts considered all items in the developed guide to be relevant and essential. Setting and participant recruitment method The study sample included physicians who work in HIV centers at three different governorates in Iraq (Baghdad, Kirkuk, and Erbil). To ensure sufficient experience in managing and dealing with HIV patients, only physicians with at least 6 months of working experience at the HIV center were considered eligible to participate in this study. All eligible physicians were contacted before the interview to inform them of the study’s purpose. Given the limited number of physicians working at the HIV centers, all eligible physicians who provided their written informed consent were included in the study through a consensus sampling approach. All physicians were interviewed in a quiet area at the HIV center. Data collection The interviews were conducted using semi-structured, open-ended questions from the developed and validated interview guide (Suppl. material 1). Probes were used to gather additional comments as needed. The interviews were carried out in Arabic by the first author, a master’s candidate in clinical pharmacy, following training in qualitative interviewing techniques through pilot interviews supervised by the second author, who holds a PhD in clinical pharmacy and has experience in conducting and publishing qualitative research. All interviews were audio-recorded with a mobile device. Each interview lasted approximately 15 to 30 minutes. To reach the required sample, the interviews continued from February to April 2025. Thematic analysis All interviews were manually coded by the first author and used to sort the qualitative data. A codebook was developed to ensure consistent coding across interviews. Codes were aggregated to generate themes and subthemes using a hybrid framework (a combination of deductive and inductive models) (Fereday and Muir-Cochrane 2006; Gale et al. 2013). In the inductive part, a previously prepared template based on the sections of the interview guide was used. The six steps of Braun and Clarke’s model for thematic analysis were applied in the deductive approach (Braun and Clarke 2006). For the purpose of presenting participants’ quotations, the first author translated verbatim into English. Results Demographic information Seventeen physicians working in HIV centers were invited to participate and were interviewed in the current study. Seven physicians were working at Al-Karama HIV Center (Baghdad), five at Kirkuk HIV Center, and five at Erbil HIV Center. The average age of study participants was 33.24 years, with a range from 26 to 59 years. The duration of working experience at HIV centers averaged 21.71 months, ranging from 5 months to 6 years, as shown in Table 1 and Table 2. Study themes The data obtained from the study interviews led to the identification of four key themes essential for the effective management of HIV patients. These included clinical practices in the management of HIV, the roles of healthcare professionals, patient adherence to prescribed anti-HIV therapy, and the healthcare services available to HIV patients, as shown in Table 3. Clinical practice in the management of HIV patients Factors considered in the selection of the treatment regimen Regarding the basis for selecting treatment regimens for HIV patients, most participants (n = 13) reported adhering to the Iraqi Ministry of Health (MOH) guidelines; of these, five indicated that the MOH guidelines are based on WHO guidelines. Only two physicians reported that their treatment selection was solely based on WHO guidelines. Table 1. Demographic characteristics of the interviewed physicians. Parameter Value Age (years) Range 26–59 Mean ± SD 33.24 ± 9.75 Sex Male,n (%) 7 (41.18) Female,n (%) 10 (58.82) Academic degree Board 2 (11.76) Master 1 (5.88) Board student 10 (58.82) BSc 4 (23.53) Specialty or field of practice Internal medicine 6 (35.29) Family medicine 10 (58.82) Clinical immunology 1 (5.88) Working experience (in months) Range 5–72 Mean ± SD 21.71 ± 20.46 Talabani SN & Mikhael EM: Qualitative insights into HIV management in Iraq4 Among those physicians, four considered drug availability at the HIV center in addition to the treatment guidelines when prescribing HIV therapy. Additionally, two participants noted that factors such as viral load, CD4 counts, or comorbid conditions could influence their decision-making process. “The selection of treatment regimens for HIV patients is typically based on the Ministry of Health guidelines, which the WHO approves. Additionally, we consider the availability of the regimen at the center.” P3 “The selection of a treatment regimen for an HIV patient is based on several important factors, including CD4 count, viral load, and comorbid conditions. “ P2 Recommended first-line treatment regimen All the participating physicians agreed that TLD is the first-line regimen most frequently recommended to HIV patients in their institutions. They cited several reasons for this preference, including higher effectiveness (n = 7), lower risk of side effects (n = 5), reduced risk of resistance (n = 2), greater acceptability of this regimen compared to older options, and its availability (n = 3) at HIV centers. “Nowadays, we use TLD as first-line therapy for HIV patients due to its low risk of side effects.” P6 “In Iraq, the treatment protocol for HIV patients consists of TLD, which is recommended by the WHO guidelines due to its high effectiveness in lowering viral load.” P2 Barriers in the management of HIV patients In exploring the challenges faced by physicians in managing HIV/AIDS patients, participants reported experiencing multiple difficulties. The most frequently identified challenge was patients’ limited adherence to prescribed treatment, reported by eight physicians. Additionally, five physicians highlighted limited adherence to follow-up Table 2. Detailed demographics of study participants. Number of participants Age Sex Academic degree Specialty Working experience P1 56 Male PhD Internal medicine 5 years P2 59 Male PhD Internal medicine 6 years P3 40 Female MSc clinical immunology 5 years P4 27 Female 3rd board Family medicine 9 months P5 28 Female Resident Family medicine 1 year & 2 months P6 26 Female 2nd board Family medicine Almost a year P7 28 Female Resident Family medicine Year & 5 months P8 29 Female Resident Family medicine Year & 6 months P9 27 Female Resident Family medicine Year P10 33 Male 3rd board internal medicine Year P11 30 Male 2nd board Internal medicine 10 months P12 33 Male 3rd board Internal medicine Year & 3 months P13 31 Male 3rd board Internal medicine Year P14 33 Male 3rd board Internal medicine Year P15 29 Female 2nd board Family medicine Year P16 29 Female 2nd board Family medicine Year P17 27 Female 4th board Family medicine 10 months Table 3. Study themes. Theme Subtheme Clinical practice in the management of HIV patients Factors considered in the selection of a treatment regimen Recommended first-line treatment regimen Barriers in the management of HIV patients Roles of healthcare professionals in the management of HIV patients Monitoring response to prescribed therapy Monitoring side effects of prescribed therapy Prevention and treatment of the adverse effects of prescribed anti-HIV therapy Adherence of patients to prescribed anti-HIV therapy Level of medication adherence Consequences of medication non-adherence Barriers to medication adherence Facilitators of medication adherence Implemented strategies to enhance patient adherence to prescribed therapy Healthcare services for HIV patients Quality of healthcare services Availability and accessibility of HIV centers Recommendations to improve care for HIV patients Pharmacia 72: 1–15 5 visits as a significant barrier. Some physicians also noted that patients’ refusal to initiate treatment (n = 4) and misconceptions about the disease, such as beliefs that HIV is incurable (n = 3), were common obstacles in effective management. Other difficulties included poor compliance with physician instructions (n = 2), a limited level of trust in the efficacy of the drug (n = 1), and a limited level of trust in the physician’s competence (n = 1). These findings suggest that multiple patient-related factors contribute to the complexities of HIV/AIDS management from the physicians’ perspectives. “The most common barriers to treating HIV patients are related to patients’ perceptions that HIV is a fatal disease and their concerns about prognosis, often asking about the date of death. Additionally, patients with limited health literacy face challenges, as they may believe that visiting the HIV center for treatment will result in quarantine or stigma. This misconception leads to missed appointments and poor adherence to their treatment regimen.” P3 “I think that the main barrier in the treatment of HIV patients is related to their poor compliance with physician instructions. For example, some patients did “Hijama,” which may increase the chance for transmission of HIV to healthy individuals.” P12 Roles of healthcare professionals in the management of HIV patients Monitoring response to prescribed therapy All participating physicians reported engaging in monitoring the response of HIV patients to prescribed treatment. Among them, eight physicians indicated that monitoring was conducted 3 months after treatment initiation and then every 6 months thereafter. Four physicians described their monitoring practices as periodic but did not specify exact intervals. Two physicians reported monitoring during every monthly visit to the HIV center. Conversely, three physicians mentioned that they monitored patients without providing further details regarding the timing or frequency of assessment. All physicians agreed that monitoring patients’ response to treatment was their responsibility in accordance with their institution’s policies. They primarily relied on laboratory testing of viral load to assess treatment response. Additionally, some physicians reported evaluating other parameters, including complete blood count (n = 6) and patient weight (n = 2). Furthermore, six physicians indicated that they conducted clinical examinations and monitored patient symptoms as part of their approach to evaluate the effectiveness of prescribed therapy. “We monitor patients’ response to treatment by collecting essential data during each visit to the center. This includes conducting laboratory tests such as complete blood counts (CBC) and viral load assessments to evaluate the effectiveness of the therapy. “ P8 “Monitoring patient response to prescribed therapy is typically performed three months after initiating treatment, through viral load testing and complete blood counts (CBC). Additionally, we conduct a clinical examination, assess the patient’s weight, and evaluate their overall health status.” P14 Monitoring side effects of prescribed therapy Regarding the adverse effects associated with current antiretroviral therapies, several physicians identified both short-term and long-term side effects experienced by HIV patients. Thirteen physicians reported one or more shortterm adverse effects, including dizziness (n = 7), fatigue (n= 6), headache (n = 6), allergic reactions (n = 6), and nausea (n = 2). Notably, four respondents indicated that the side effects of TLD were generally less severe compared to those associated with older treatment regimens. In terms of long-term adverse effects, four physicians highlighted hyperlipidemia as a significant concern, with all reporting its occurrence among their patients. Additionally, two physicians mentioned the elevation of liver enzymes as a potential long-term complication related to TLD therapy. “Fatigue and dizziness can occur in patients but disappear within days. “ P 11 “Most patients do not suffer from side effects, but with long periods of use, lipid levels may be elevated, and liver function may also be impaired.” P8 All physicians reported monitoring patients for potential drug side effects, considering this an essential part of their responsibilities in accordance with institutional policies. Twelve physicians monitored one parameter, while five physicians monitored two or more parameters. Fifteen physicians routinely inquired about symptoms related to medication side effects; among them, eight advised patients to seek urgent medical attention if they developed abnormal symptoms, whereas the remaining seven assessed symptoms during routine visits at the HIV care center. Monitoring through laboratory investigations was reported by eight physicians, who utilized blood tests to detect adverse effects, especially long-term side effects. Additionally, three physicians described conducting physical and clinical examinations to assess the development of side effects during patient consultations. “Yes, it is our job to monitor patients for drug side effects through clinical examinations and by reviewing the results of laboratory tests.” P10 “During monthly visits, we assess the patient’s signs and symptoms. Additionally, side effects may be detected through continuous communication between the patient and physician, including physician-initiated follow-up calls and urgent patient-initiated calls in abnormal situations. Such actions are certainly the responsibility of the physician.” P17 Talabani SN & Mikhael EM: Qualitative insights into HIV management in Iraq6 Prevention and treatment of adverse effects of prescribed anti-HIV therapy In addressing the mitigation of adverse drug effects, four physicians highlighted the importance of patient reassurance through education about the typically transient nature of most side effects. One physician specifically emphasized the importance of counseling patients on healthy eating habits as a preventive measure. The remaining physicians reported that they did not implement specific strategies to prevent side effects but instead concentrated on managing and treating patients who experienced intolerable adverse effects and sometimes referred them to other specialists. “Educate patients to continue their treatment and not to stop it since most side effects will disappear in the first ten days.” P2. “For patients with persistent rash, we refer them to dermatologists. In cases of developing nausea and headache, we prescribe a treatment to relieve these side effects.” P16. Adherence of patients to prescribed anti-HIV therapy Level of medication adherence Most participating physicians (n = 16) perceived that most HIV patients demonstrated good adherence to their prescribed therapy. In contrast, only one physician reported that most HIV patients exhibited poor adherence to their treatment regimens. Regarding patient groups perceived as less likely to adhere to treatment, nearly all physicians identified at least one such group. The most reported group comprised elderly patients (n = 9), who were believed to have poorer adherence, potentially due to factors such as polypharmacy, forgetfulness, or feelings of hopelessness. Five physicians identified patients with low educational levels or limited health literacy as being at higher risk for non-adherence. Four physicians noted that newly diagnosed patients tended to have poor adherence initially; however, adherence often improved with subsequent visits and after obtaining low viral load results in laboratory tests. Additionally, three physicians considered younger patients more likely to struggle with adherence. The remaining physicians identified patients with specific occupational factors – such as those working night shifts (n = 2) or employed in demanding jobs (n = 1) – as being at higher risk for non-adherence. “Most patients are well adherent to their prescribed therapy except those who have night shift work.” P3 “Most patients were not adherent to their prescribed therapy, often missing the designated administration times and, in some cases, not taking the medication daily. “ P5 “Most patients adhere to their prescribed therapy; however, some elderly patients poorly adhere to their therapy, which may be due to their usage of many medications and due to forgetfulness.” P1 Consequences of medication non-adherence Regarding the consequences of non-adherence to medication, most physicians (n = 13) reported observing negative outcomes, primarily when non-adherence was prolonged. These included severe chest infections (n = 5), liver problems (n = 3), septic arthritis (n = 1), gastrointestinal infections (n = 1), weight loss (n = 1), and deterioration in overall health (n = 2). The remaining four physicians did not report witnessing any negative clinical consequences among non-adherent patients, other than increasing viral load. “I know a young patient who got septic arthritis and severe chest infection because she did not take her treatment for 2 years.” P9 “During my working period in this center, I did not observe and deal with any patient whose case deteriorated.” P11 Barriers to medication adherence From the physicians’ perspective, the main perceived barriers to patients’ adherence to prescribed therapy included misconceptions about HIV being a non-curable and fatal disease (n = 8), stigma and shame associated with visiting the HIV center for treatment (n = 7), limited educational levels among patients (n = 2), limited knowledge about the benefits of medical therapy (n = 1), and forgetfulness (n = 1). “Stigma and feelings of shame associated with visiting the HIV center or hospital each month to receive medical therapy can discourage some patients from attending, leading them to miss their monthly free medications.” P1 “Death is often the primary concern associated with HIV infection, which can lead to feelings of hopelessness among patients. This perception is considered a major barrier to their optimal adherence to prescribed therapy.” P13. Facilitators of medication adherence Regarding factors influencing medication adherence, most physicians (n = 8) identified patient education about HIV and its treatment as the primary determinant. Four physicians emphasized that psychological support could enhance adherence among HIV patients. Another four participants highlighted the importance of family support in improving adherence. Furthermore, four physicians considered continuous encouragement and regular contact between patients and healthcare providers to be crucial for promoting adherence. Lastly, two physicians suggested that improving patients’ privacy within healthcare settings could also contribute to increased adherence. Pharmacia 72: 1–15 7 “Increase patient awareness about the disease and educate patients about the treatment and consequences of missing treatment.” P6 “The main factor in ensuring optimal treatment is providing psychological support to the patient, along with support from their family.” P4 Implemented strategies to enhance patient adherence to prescribed therapy Regarding the strategies implemented at the HIV center to improve adherence to therapy regimens, most physicians (n = 9) indicated that patients were provided with the mobile number of a healthcare provider for emergency calls. They also reported that some patients were followed up through phone calls to remind them of scheduled clinic appointments and upcoming treatments (n = 3). Additionally, three physicians mentioned that periodic laboratory testing was performed to promote adherence. Furthermore, two physicians noted that ensuring the availability of free medications was an important measure to support patients’ adherence to their medication. “The physician’s mobile number is available for the patient to ask questions and express concerns.” P10. “Calling patients before their scheduled visit to the center to remind them of the routine check-up and to collect their monthly medications.” P14. Healthcare services to HIV patients Quality of healthcare services Most physicians (n = 10) considered the current healthcare services for HIV patients in their institutions to be good. However, seven participants viewed these services as good in certain areas but poor in others. The most recognized strength was the quality of care provided by healthcare providers, reported by 13 physicians. Other physicians highlighted that good services included the availability of free medications (n = 2) and free periodic laboratory testing (n = 2). Conversely, five physicians identified the lack of specialized services – such as dental clinics or surgical theaters – as the main factor contributing to lower healthcare quality in HIV centers. One physician reported that the absence of CD4 testing was a significant barrier to providing adequate healthcare, while another considered the suboptimal environment of the HIV center the primary obstacle to delivering good healthcare services. “The current services effectively provide patients with free medications and periodic check-ups. However, the center lacks a specialized area for performing minor surgeries or tooth extractions for HIV-positive patients. As a result, patients requiring tooth extractions must visit other hospitals or private clinics. Many patients are hesitant to disclose their HIV status due to fear that their cases may not be managed appropriately, which increases the risk of HIV transmission.” P1 “The health services provided by the center and the physicians to patients are of very good quality.”P4 Availability and accessibility of HIV centers Most participating physicians considered the current HIV centers in Iraq to be sufficient for the needs of HIV patients. However, two physicians believed that the number of centers was insufficient, given the rising number of newly diagnosed cases. Additionally, one physician expressed hope to increase the number of HIV centers, believing that expanding the facilities would help improve the quality of care provided to patients. “The current number of HIV centers is sufficient unless the number is significantly increased in the future.” P2 “The current number of HIV centers is insufficient; increasing their number would help improve the quality of health services.” P8 Recommendations to improve care for HIV patients To improve treatment outcomes for HIV patients, participating physicians offered various recommendations. Six participants suggested establishing a psychiatrist clinic within the HIV center, while three recommended adding a dental clinic. Four physicians emphasized the importance of ensuring greater privacy for HIV patients. Additionally, four physicians advocated for ongoing patient education about their disease and treatment to enhance medication adherence. Three participants recommended increasing the number of physicians working in HIV centers, and two suggested expanding the nursing staff. Three physicians emphasized the importance of ensuring the availability of all necessary laboratory tests. Lastly, two physicians proposed facilitating the hospital admission process for HIV patients, and another two believed that providing incentives to healthcare workers in HIV centers could improve patient outcomes. “Adding a psychiatrist clinic and a dental clinic within the HIV center. Increasing patient privacy is also recommended to improve the care for HIV patients.” P12. “Increasing the number of physicians, pharmacists, and nurses in the center is recommended to enhance care for the patients.” P10 “Provide financial incentives to healthcare workers in the HIV center to encourage them to work in this often-undesired setting.” P3 Participating physicians also recommended several measures to reduce the risk of HIV transmission. These Talabani SN & Mikhael EM: Qualitative insights into HIV management in Iraq8 initiatives included increasing patient and family awareness about the disease and its modes of transmission (n = 7), raising public awareness about HIV (n = 6), establishing free HIV testing units in public offices and universities (n = 3), and enhancing HIV awareness among healthcare providers (n = 2). “Increase public awareness about the disease to dispel myths and misconceptions through social media, alongside providing education on prevention methods.” P5 “Offer free HIV testing units in universities, schools, and workplaces to help prevent the transmission of the virus.” P13 Discussion The results of the current study underscore the multifaceted nature of HIV care, highlighting how each element contributes to treatment success. Understanding these factors is crucial for developing targeted interventions that enhance patient outcomes and optimize healthcare delivery within HIV management programs. The results of this study showed that most participating physicians reported adhering to the Iraqi Ministry of Health (MOH) guidelines, which are mostly based on WHO guidelines, in their selection of treatment regimens for HIV patients. Similarly, local guidelines for the management of African people with HIV agree with WHO guidelines (Scheier et al. 2025). Meanwhile, some physicians reported that their choice of HIV treatment regimen was influenced not only by established treatment guidelines but also by the availability of medications at the HIV center. This problem may arise from the fact that the Iraqi government finances ART and related HIV healthcare services through the Ministry of Health, as outlined in national health legislation, providing free diagnosis, treatment, and follow-up at designated HIV centers for all registered patients. However, funding fluctuations and delays in budget disbursement, as reported in the 2024 Parliamentary Health Committee report, have led to periodic shortages of medications and supplies, adversely affecting the continuity of care for HIV and other chronic conditions (Jadoo 2024; Ali et al. 2025b). Similarly, Iraqi patients with HIV experienced frequent interruptions in the supply of their anti-HIV medications (Talabani and Mikhael 2025). In line with these observations, recent recommendations from the Health Committee underscore the pressing need for improved health system funding, timely budgeting, and better workforce planning – all critical to sustaining essential services and hence enhancing the quality and reliability of HIV services (Saleh et al. 2020). On the other hand, a few participating physicians considered factors such as viral load or CD4 counts to influence their decision-making process. However, this approach contradicts current treatment guidelines, which recommend initiating antiretroviral therapy for HIV patients regardless of risk factors or CD4 count. This practice is also commonly observed among Ukrainian physicians (Ottesen et al. 2024). In addition, a few of the participating physicians in the current study reported that patients’ comorbid conditions could influence their selection of treatment regimens. This finding reflects good clinical practice, as physicians consider comorbidities and the potential interactions between antiretroviral medications and other drugs the patients are already taking for their comorbid conditions (Tseng et al. 2013). Although participating physicians identified various factors influencing their choice of initial therapy for newly diagnosed HIV patients, TLD remains the first-line regimen most frequently recommended to HIV patients across different HIV centers in Iraq. This recommendation was in line with the recommendations by the latest WHO treatment guidelines for HIV patients (Tegegne et al. 2024). Participating physicians cited several reasons for their preference for TLD, including its higher effectiveness, lower risk of side effects, reduced potential for resistance, greater acceptability compared to older regimens, and its availability at HIV centers. These advantages have been reported in numerous studies, supporting the widespread use of TLD in many lowand middle-income countries (Phillips et al. 2019; Kouamou et al. 2022). Despite these advantages of TLD, most physicians reported that patients experienced transient and mild adverse effects, especially at the start of treatment with TLD, such as dizziness, fatigue, headache, allergic reactions, and nausea. However, these side effects are generally less severe compared to those associated with older treatment regimens. Few physicians reported the development of long-term side effects among some patients on TLD, such as hyperlipidemia and an elevation of liver enzymes. Most of these side effects were also detected among African HIV patients using highly active antiretroviral therapy (Lesi et al. 2009; Namulindwa et al. 2022; Fimbo et al. 2024). Regarding the barriers in the management of HIV patients, several challenges were reported by participating physicians. The most prominent among these was patients’ inadequate adherence to prescribed treatment regimens and follow-up appointments. This issue is not unexpected, as the successful management of HIV largely depends on patients’ consistent adherence to antiretroviral therapy (Escartin et al. 2024). Additionally, patients’ refusal to initiate treatment and widespread misconceptions about HIV and its management were identified as significant barriers by Iraqi physicians. Similar challenges are observed among patients in Kenya and Uganda (Muhamadi et al. 2010; Kahn et al. 2013), where delays in starting antiretroviral therapy due to misconceptions are associated with poorer health outcomes and higher mortality rates. Regarding the roles of physicians in managing HIV patients, all participating physicians reported actively Pharmacia 72: 1–15 9 monitoring patients’ responses to prescribed treatments, as well as overseeing potential drug side effects. They regarded these responsibilities as essential components of their duties, in line with their institutional policies. In a similar vein, in Japan, physicians play a more prominent role than pharmacists in monitoring the effectiveness and side effects of prescribed antiretroviral therapy. However, effective collaboration between physicians and pharmacists – where physicians prescribe medications and pharmacists monitor drug efficacy, side effects, and patient adherence – can enhance outcomes for HIV patients (Urano et al. 2020). For monitoring the effectiveness of prescribed therapy, most physicians reported doing so by ordering laboratory tests such as viral load and CBC and conducting clinical examinations. This approach aligns with HIV treatment guidelines and reflects good clinical practice among Iraqi physicians in the management of HIV patients (Vajpayee and Mohan 2011). To address the short-term side effects of TLD, some physicians reported reassuring patients through education about the typically transient nature of most side effects. Additionally, most physicians routinely inquired about symptoms related to medication side effects and advised patients to seek urgent medical attention if they developed any abnormal symptoms. Furthermore, participating physicians reported conducting periodic laboratory testing for patients using TLD over extended periods to facilitate early detection and management of potential long-term side effects. This proactive approach reflects the best clinical practices aimed at ensuring optimal care for Iraqi patients living with HIV (Fernandez-Montero et al. 2013). The findings from physicians align with reports from HIV-positive patients, who generally perceived the healthcare services they received as good, particularly highlighting the attentive care provided by physicians (Talabani and Mikhael 2025). Regarding the adherence of patients to prescribed anti-HIV therapy, most participating physicians perceived that most HIV patients demonstrated good adherence to their prescribed therapy. The physicians’ perspectives align with the self-reports of Iraqi HIV patients (Talabani and Mikhael 2025). Similarly, most HIV patients in different African (Yaya et al. 2014; Letta et al. 2015) and Asian countries (Aye et al. 2017; Abadiga et al. 2020) had good adherence to their prescribed treatment. This good adherence may be attributed to the nature of the currently used treatment regimen (TLD), which is simple, taken once daily orally, and can be administered at any time of the day (Tegegne et al. 2024) without regard to meals, in addition to its good tolerability and minimal and transient side effects (Keene et al. 2021). Despite good adherence to anti-HIV therapy by most patients, a few were not adherent. In this regard, most physicians reported observing negative outcomes, particularly when non-adherence was prolonged. These included severe infections that often required hospitalization. This finding aligns with reports from Iraqi HIV patients, where some individuals who missed their treatment for several months experienced a significant increase in viral load (Talabani and Mikhael 2025). Similarly, a cross-sectional study among Indonesian HIV patients linked medication non-adherence with an elevation in viral load and an increased risk of opportunistic infections (Nursalam et al. 2024). According to the current study results, physicians identified forgetfulness, polypharmacy, feelings of hopelessness, limited health literacy, misconceptions about HIV, and stigma and shame associated with HIV as the primary barriers to patients’ adherence to antiretroviral therapy. Similarly, most of these challenges have been found to significantly reduce adherence among Indian HIV patients to their prescribed treatments (Achappa et al. 2013). Considering these barriers, many physicians in the current study regarded patient education about HIV and its treatment, along with psychological and social support, as crucial strategies to improve medication adherence. This perspective aligns with existing literature; for instance, a randomized study by Goujard and colleagues demonstrated that educational interventions significantly enhanced medication adherence by increasing patients’ knowledge about the disease and its treatment (Goujard et al. 2003). Meanwhile, several studies have also highlighted the positive impact of social and psychological support on medication adherence among HIV patients (Woodward and Pantalone 2012; Spaan et al. 2020). Regarding the strategies implemented at the HIV center to improve adherence to therapy regimens, most physicians reported providing patients with their mobile numbers for emergency contact. They also noted that some patients were followed up with through phone calls to remind them of scheduled clinic appointments and upcoming treatments. These strategies are well-documented in the literature as effective measures for enhancing medication adherence. For instance, a meta-analysis demonstrated that reminder follow-up calls significantly reinforced adherence behaviors (Jong et al. 2017). Additionally, a recent systematic review found that providing HIV patients with their physician’s mobile number can help build rapport, facilitate immediate support for addressing concerns, and thereby improve medication adherence, ultimately leading to better health outcomes for HIV patients (Ngcobo et al. 2022). Regarding the quality of healthcare services, most physicians considered the current healthcare services for HIV patients in their institutions to be satisfactory; however, some highlighted the importance of incorporating additional specialized services, such as dental clinics and surgical theaters, within HIV centers to enhance overall patient care. These findings are consistent with reports from patients at HIV centers in Iraq (Talabani and Mikhael 2025). In addition to the previously mentioned