'Too much boredom isn’t a good thing': Adapting behavioral activation for substance use in a resource-limited South African HIV care setting

South Africa (SA) has the largest HIV/AIDS burden globally. In SA, substance use is prevalent and interferes with HIV treatment adherence and viral suppression, yet is not routinely treated in HIV care. More research is needed to adapt scalable, evidence-based therapies for substance use for integration into HIV care in SA. Behavioral activation (BA), originally developed as an efficacious therapy for depression, has been feasibly delivered to treat depression in low- and middle-income countries (LMICs) and to treat substance use in high-income settings. Yet, to date, there is limited research on implementing BA for substance use in LMICs. Guided by the ADAPT-ITT framework, this study sought to adapt BA therapy for substance use in HIV care in SA. We conducted semi-structured individual interviews with patients (n=19), and HIV care providers and substance use treatment therapists (n=11) at two clinic sites in a peri-urban area of Cape Town. We enrolled patients with moderate/severe substance use (WHO-ASSIST≥4) and detectable viral load, and HIV providers and substance use treatment therapists across roles and disciplines. We assessed patient and provider/therapist views on the appropriateness of the BA therapy model and sought feedback on Xhosa-translated BA therapy components. Participants identified the central role of boredom in contributing to substance use and saw the BA therapy model as highly appropriate. Participants identified church and religious practices, sports, and yard and housework as relevant substance-free activities in this community. These findings will inform adaptations to BA therapy for substance use and HIV medication adherence in this setting.