This was a qualitative study conducted in December 2023 using in-depth interviews (IDIs) with 29 adolescents living with HIV in Eswatini. This approach provided valuable insights from adolescents living with HIV, who have a unique understanding of the types of interventions that may be most effective for them [28].

The study was conducted among adolescents living with HIV accessing ART care through Teen Clubs in the Hhohho region in Eswatini. The Hhohho region is located in the northwestern part of the country and houses the capital city, accounting for 30% of the total population [29]. This region is considered the most economically advanced in Eswatini, as it has the most urbanized population and is home to the headquarters of many corporations, as well as being dominated by the forestry industry, which is among the most important sectors of the country’s economy [29]. The region comprises both urban and rural settings and has 71 health facilities, including private, public, military, faith-based, and not-for-profit hospitals, health centers, public health units, and clinics [30]. These health facilities play a critical role in HIV prevention and management through services offered from the community level to the tertiary level (hospitals). These services include the differentiated models of ART care, such as Teen Clubs [9].

Teen Clubs, a model of ART care for adolescents with disclosed HIV status, use lay health care workers also known as expert clients to provide support and education about ART and HIV [9,31]. Expert clients are HIV-positive adults whose primary role includes providing adherence counseling, tracking clients lost to follow-up, conducting pill counts to monitor medication adherence, and supporting adolescents in navigating psychosocial challenges such as stigma, suicidal ideation, and orphanhood [31]. They work collaboratively with nurses to help alleviate the clinical workload involved in managing adolescents living with HIV [31]. In 2023, there were 99 Teen Clubs with 2308 members in the country (Swaziland National AIDS Programme, National Facility Teen Clubs, Eswatini Ministry of Health, unpublished report, 2023). Of these, 31 Clubs with 1464 members were from the Hhohho region. With the assistance of the Ministry of Health, Swaziland National AIDS Program (SNAP), and the National Paediatrics HIV Care and Treatment department, 5 clubs from the Hhohho region that had been active for at least 2 years were conveniently chosen for data collection [28]. Within each club, at least 5 adolescents living with HIV meeting the inclusion criteria were purposively selected [32]. To ensure the representativeness of perceptions and experiences of all adolescents living with HIV in Teen Clubs, the selected participants included both male and female participants, adolescents from both age groups (10-14 years and 15-19 years), and at least 1 peer educator from each club [32]. Peer educators are also known as community adherence to treatment support (CATS) and are involved in educating and supporting their peers using door-to-door campaigns, especially for adolescents living with HIV lost to follow-up or with poor ART outcomes [33]. The inclusion criteria required adolescents aged 10 to 19 years who were aware of their HIV status and had been members of the Teen Club for at least 6 months at the time of data collection to ensure a comprehensive ART history.

Expert clients assisted in the identification of potential participants and were referred to the researcher for further explanation of the study. Adolescents who were willing to be part of the study and met the inclusion criteria were given a detailed study information sheet in both siSwati and English. Adolescents aged below 18 years were given the information sheet, along with the researcher’s contact information, consent, and assent forms to share with their guardians. Adolescents aged 18 years provided their voluntary consent to participate in the study. Interviews took place in December 2023 following the receipt of signed consent and assent forms. A total of 29 adolescents meeting our inclusion criteria were recruited. The sample size was guided by the principle of data saturation in conducting qualitative studies [32]. The sample size for achieving data saturation was informed by previous studies conducted among similar populations, using comparable data collection tools, specifically semistructured interview guides [34,35]. Data saturation was achieved when no new relevant information emerged from the participants [28]. Data saturation was assessed by evaluating the repetitiveness of responses. Specifically, data collection continued until no new or significant information emerged from the interviews.

An IDI guide was developed based on an extensive literature review of studies examining barriers and facilitators of ART adherence, as well as interventions targeting ART adherence among adolescents living with HIV. The interview guide included topics on ART and ART adherence experience, mobile phone accessibility and usage patterns, barriers and facilitators to ART adherence, and perceptions of the use of mobile phones to facilitate ART adherence (Multimedia Appendix 1). To ensure the validity of the questions, the interview guide was pilot-tested through 2 interviews with adolescents living with HIV who were not included in the final sample [28]. The interview guide, along with all consent and assent supporting materials, was translated into siSwati to ensure comprehension by all participants. Consequently, the IDIs were conducted in either siSwati or English, depending on the participants’ preferences, and were audio-recorded. Each interview lasted about 45 minutes, and interviews were conducted in private rooms provided by each health facility or other locations of participants’ preference. To protect participants’ identities and ensure confidentiality, personal identifiers, such as names, were not used during interviews.

The audio recordings were transcribed verbatim, and those in siSwati were translated into English. Personal identifiers of participants were not included in both the transcripts and audio files; instead, codes were used to identify participants to maintain confidentiality. Both the transcripts and audio recordings were securely stored on a password-protected computer.

A deductive-inductive coding approach was used for data analysis [36]. The initial code frames were developed based on the research question being “Can mobile games be used to facilitate ART adherence?”, while additional themes emerged inductively from the participants’ responses. A code framework was developed, and transcripts were coded manually [28,32]. The code book was reviewed by 2 independent investigators (LDH and CSS) for comprehensiveness and appropriateness [37]. Differences were discussed and resolved collaboratively by the 2 investigators (LDH and CSS), and the final codebook was reviewed and validated by PSN.

Approval to conduct the study was sought from the Stellenbosch University Health Research Ethics Committee (reference number: S24/02/037) and Eswatini Health and Human Research Review Board of the Ministry of Health (protocol reference number: EHHRRB143/2023). Furthermore, a letter of support from hospital management teams was obtained from the Ministry of Health, Department of Health Services. Finally, all participants and guardians in case of participants below the age of 18 were given detailed information on the study and provided consent and assent. Participants were informed that participation in the study was voluntary, and they were free to withdraw from the study at any point.

A total of 29 participants (n=14 males and n=15 females) were included in the study. The majority (n=19, 65.5%) of the participants were aged 15 and above. The mean age of the participants was 16.5 (SD 1.08) years, with an average of 10.8 (SD 3.99) years on ART and 5 (SD 3.99) years of Club membership. The majority (n=23, 79%) of the participants were diagnosed with HIV from birth, while only 2 (7%) were diagnosed later in life (Table 1).

A total of 28 (96.6%) participants either owned (n=19, 65.5%) or shared (n=9, 31%) a phone with their guardian or siblings. Among those who owned or had access to a phone, 16 (57.1%) used a smartphone, while 12 (42.9%) used a feature phone (Table 2). The majority (17/19; 89.5%) of those who owned phones were older adolescents (15-19 years old), and younger adolescents (7/9; 77.8%) were most likely to share the phone with either guardian or siblings. Only older adolescents reported uncontrolled time on the phone, while younger adolescents had their phone usage controlled by guardians.

The study findings suggest that mobile phone access among adolescents living with HIV in Eswatini may be high, although this was a small qualitative sample, providing a potentially solid foundation for the implementation of mHealth interventions targeting this age group. Currently, mHealth use in the country is largely limited to calls and SMS text message reminders for clinical appointments sent by health care workers [9]. There may be opportunities to expand the scope of mobile phone–based interventions among adolescents.

Older adolescents reported owning smartphones, while younger adolescents often shared phones with siblings or caregivers. This suggests the need for tailored age-appropriate mHealth solutions, with younger adolescents requiring simpler, lower-bandwidth tools compatible with feature phones and shorter usage durations due to parental control, while older adolescents could benefit from more interactive, internet-based interventions as observed in a study conducted in Zimbabwe [38]. However, while smartphone ownership is critical for implementing internet-based mHealth solutions, such interventions require stable internet connectivity, which may be hindered by limited coverage, slow internet speeds, and high costs [38]. This is particularly important in Eswatini, where network and internet access remain limited in some places in the country [39]. As of 2024, only 50.3% of the population had internet access, and the cost of 1 GB of mobile data was US $5.82 [39]. Therefore, given that 58.9% of the population lives below US $3.65 per person per day, mHealth interventions requiring regular internet use should be implemented cautiously to avoid excluding lower-income users [40].

Additionally, phone usage patterns varied by age. All adolescents used phones primarily for calls, while older adolescents were more likely to engage with social media platforms too. This underscores the importance of designing mHealth interventions with adaptable features that align with adolescents’ communication habits and preferences [41]. For instance, a study in Uganda found that adolescents preferred not only voice calls but also SMS text messaging and WhatsApp messaging, highlighting the potential value of integrating social connectivity features into mHealth interventions [41]. However, such features should be used with caution in Eswatini due to the cost of mobile services. As of 2024, calls cost approximately US $0.07 per minute, while an SMS text message cost US $0.02 in Eswatini [39].

The study further identified 3 core themes: feasibility, desired qualities, and potential concerns, which are vital to informing the design of gamified interventions. These themes offer valuable insights into the practicality and acceptability of such interventions.

In terms of feasibility, participants expressed confidence in the potential of mHealth, particularly mobile games, to improve ART adherence, despite only a quarter having prior gaming experience. This highlights the importance of considering players’ prior experience in the design of gamified interventions. According to Fitzgerald et al [42], games that promote user engagement are typically those that are easy to play, intuitive, and do not require previous gaming skills or knowledge [42]. This is supported by Sardi et al [43], who emphasized that effective games should be adaptive, offering various modes of play to accommodate different player types and skill levels [43]. Consequently, involving users in the design process is critical to ensure that the resulting intervention is user-centered and tailored to their needs, preferences, and abilities [43]. Additionally, the selection of appropriate gaming elements or mechanics is crucial, as these features can significantly influence user engagement and motivation. For instance, storytelling or narrative elements help set clear expectations and create an immersive experience that puts players at ease, enhancing their willingness to engage with the game [44]. Other mechanics, such as onboarding tutorials, rewards, and leaderboards, have been shown to promote sustained engagement by guiding new players and offering in-game incentives that reinforce continued participation [44,45]. Despite participants’ limited prior exposure to gaming, existing evidence supports the effectiveness of gamified mHealth interventions in improving medication adherence among adolescents [19]. These findings highlight the feasibility and potential impact of well-designed, user-centered gamified tools in supporting ART adherence among adolescents living with HIV.

Regarding the desired features or qualities of the gamified intervention, the study highlighted the importance of aligning game content and features with the preferences and needs of end users. First, participants emphasized that effective gamified interventions must include relevant, accurate, and engaging educational content, particularly on HIV and the benefits of ART. This finding aligns with a study conducted among adolescents living with HIV in the United States, where the integration of health education into games improved knowledge retention and supported positive behavior change while maintaining user engagement [46].

Second, the study revealed that incorporating a strong support system within the intervention could enhance its effectiveness in promoting ART adherence. Participants identified support in the form of medication reminders and opportunities for networking with other adolescents as essential. Literature consistently highlights the value of such support in improving ART adherence among adolescents living with HIV [47,48]. In a gamified context, support can be delivered through features such as in-game pop-up messages reminding players of important health behaviors or through social connectivity that allows users to share progress and communicate with peers. Platforms such as social media can offer avenues for users to exchange experiences, provide encouragement, and reinforce positive behaviors. However, the inclusion of social features must be approached with caution. Participants expressed concern that social connectivity within the game could compromise their privacy and lead to unintended disclosure of their HIV status. This concern is echoed in broader literature, where privacy and confidentiality have been flagged as critical risks in mHealth interventions that incorporate social connection and collaboration features [45,49]. Although social connectivity ranks as the second most frequently used game element, it raises substantial concerns about exposing players’ identities, particularly among vulnerable populations such as adolescents living with HIV [45]. These findings emphasize the need to design stigma-sensitive and developmentally appropriate interventions [49]. Adolescence is a period marked by emotional and cognitive maturation, yet formal reasoning and risk assessment abilities may still be developing [50].

Therefore, developers must carefully evaluate whether and how to include socially driven elements. Recommended approaches include the use of anonymous avatars and nicknames, while disabling features such as voice and video calls, and restricting media sharing strategies successfully implemented in the design of the PEERNaija game [51]. In the context of Eswatini, the findings suggest that integrating gamified mHealth interventions into existing service delivery structures, such as Teen Clubs, could enhance both effectiveness and user safety. Teen Clubs are trusted, adolescent-friendly platforms that provide safe spaces for sharing experiences and peer support without compromising privacy [52]. Leveraging peer educators within these settings could further enhance the intervention’s reach and acceptability [52].

Finally, regarding potential concerns, the study highlighted the critical importance of privacy and confidentiality in the design of gamified interventions. Participants expressed concerns about the risk of unintended disclosure, particularly among younger adolescents who often share mobile phones with siblings or caregivers. Such unintended disclosure could lead to stigma and discrimination, which are well-documented barriers to ART adherence among adolescents living with HIV [53]. Therefore, the game’s design, including its name, features, and interface, must be carefully considered to prevent any breach of confidentiality that could negatively affect adolescents’ willingness to engage with the intervention [54].

In addition to privacy concerns, participants raised issues related to the financial burden of mobile gaming and limited access to network services. These concerns underscore the need to critically evaluate the economic feasibility of mHealth interventions in low-resource settings. Adolescents must not only own a mobile phone, ideally a smartphone, but also maintain consistent access to mobile data and internet services. This requirement presents a significant challenge in contexts such as Eswatini, where economic constraints and infrastructural barriers, such as poor network coverage, limited electricity, and low digital literacy, can impede the successful implementation of mHealth solutions [38]. Similar challenges have been observed in other low-income settings, where the high cost of smartphones and internet bundles has contributed to poor uptake and limited effectiveness of mHealth-based interventions [38,41,55]. To mitigate these barriers, recent innovations in offline mobile gaming have shown promise. Offline games eliminate the need for constant internet access, thereby reducing the financial burden on users and improving accessibility. Studies have shown that offline interventions are associated with higher uptake and more favorable outcomes, particularly in resource-limited environments [56]. As such, the development of offline gamified interventions could represent a practical and sustainable solution to improve ART adherence among adolescents living with HIV in Eswatini and similar contexts [57].

Nevertheless, for mHealth interventions to be applicable, engaging, feasible, and effective, they should be firmly grounded in behavior change theories [58]. These theories provide a comprehensive framework for understanding adolescent behavior, particularly during the adolescence stage, a developmental period characterized by significant psychological, social, and physiological changes that can influence ART adherence [50,59]. By applying these theories, designers can identify key determinants of adherence and gain valuable insights into how behavior change can be effectively promoted [50]. Behavior change theories also inform the selection of appropriate game elements and design features that resonate with adolescents’ needs and preferences, thereby ensuring that user concerns are addressed during the design process [58]. Furthermore, they guide the integration of behavior change techniques that can enhance the intervention’s overall impact on ART adherence [50,58,59].

Critically, involving adolescents in the design process is essential. Their participation enables the cocreation of game features that directly reflect their lived experiences, needs, and expectations, thereby increasing the likelihood of sustained engagement and intervention effectiveness [59]. Health behavior models, such as social cognitive theory, the information-motivation-behavioral (IMB) skills model, and motivational interviewing, have been widely applied in mHealth interventions targeting adolescents [50]. These models conceptualize ART adherence as a behavior influenced by a combination of accurate information, individual and social motivation, and the acquisition of behavioral skills. When applied effectively, they enhance adolescents’ self-efficacy and lead to improved ART adherence outcomes [50]. Thus, grounding intervention design in these theories, developers can ensure that components are aligned with adolescents’ realities and are both contextually relevant and capable of promoting sustainable behavior change [50,58].

A key limitation of this study is that it only included adolescents from one region of the country, specifically those who are members of Teen Clubs. Additionally, the small sample size is not representative of all adolescents living with HIV in the country or even within the Hhohho region. As a result, the findings cannot be generalized to all adolescents in Eswatini. Despite these limitations, this study is the first to explore and describe mobile phone access, usage patterns, and perspectives on gamified interventions among Swati adolescents living with HIV. The findings provide valuable baseline data and serve as a foundation for future research aimed at developing and evaluating gamified interventions to enhance ART adherence among adolescents living with HIV.

The study indicates that mobile phone access may be high among adolescents living with HIV in Eswatini, with the majority using their phones daily for various purposes. A considerable proportion of participants expressed a belief in the feasibility of gamified interventions to support ART adherence, highlighting the importance of supportive, educational, and privacy-assured features. Nonetheless, concerns related to confidentiality and economic barriers must be addressed to ensure the successful implementation and long-term sustainability of such interventions.

Given the promise of mHealth interventions, future research should focus on the co-design of gamified interventions rooted in behavior change theories to ensure alignment with their behavioral characteristics, preferences, and lived experiences. These interventions should also be rigorously evaluated for their effectiveness within the Swati context and considered complementary strategies within existing Ministry of Health programs aimed at improving HIV-related outcomes among adolescents.