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Background: Refugees living with HIV in sub-Saharan Africa suffer unique hardships that may increase their vulnerability to interruptions in antiretroviral therapy (ART)., Methods: To investigate refugees' experiences adhering to ART, we conducted inperson interviews with refugees on ART ( n  = 73) and HIV clinic staff ( n  = 4) in Nakivale Refugee Settlement in southwest Uganda from March to July 2011. Three analysts used a conventional content analysis approach to evaluate these data., Results: Refugees described profound motivation to adhere to ART and employed adherence strategies to facilitate success despite the austere setting. However, refugees spoke of specific hardships living in Nakivale that served as barriers to ART adherence, including difficulty accessing clinic when ill, food insecurity, drug stockouts, and violence and unrest in the settlement. For some refugees, need for ART inextricably linked them to the HIV clinic and prevented them from transitioning permanently away from the settlement., Conclusions: By learning about refugees' experiences we can design informed interventions to enhance ART adherence, thus minimizing morbidity and mortality, preventing transmission of HIV, and supporting refugees' abilities to move freely toward repatriation, resettlement or integration in their host country., Competing Interests: This study was approved by the Uganda National Council of Science and Technology (Kampala, Uganda; SS 2408) and the Partners Human Research Committee (Boston, MA, USA; 2010-P-001963/1). Written informed consent was obtained from all study participants in English, Kiswahili or Kinyarwanda. Participation was voluntary and there was no remuneration.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.