Key Social Norms Take-aways Social norms—particularly subjective norms such as peer approval, social support, stigma, and expectations around disclosure—play a critical role in shaping antiretroviral therapy (ART) adherence among female sex workers (FSWs). The discussion highlights that supportive norms (e.g., encouragement from peers, seeing others adhere to ART, and acceptance following disclosure) can enable adherence, while negative norms (e.g., stigma, discrimination, gender-based violence, and social disapproval of sex work and HIV status) undermine it. Importantly, social norms are closely tied to structural inequalities and social exclusion, meaning that improving ART adherence requires not only individual-level interventions but also community-level efforts to reduce stigma and strengthen supportive social environments.

Objectives The study aimed to explore the enablers of and barriers to ART adherence among female sex workers in mid-western Uganda, using the theory of planned behavior to understand how attitudes, subjective norms, and perceived behavioral control influence adherence.

Methods A descriptive qualitative study was conducted in Fort Portal City, Uganda. Data were collected through 30 in-depth interviews with female sex workers on ART for at least six months and six key informant interviews with healthcare workers and peer leaders. Thematic deductive analysis was applied using the theory of planned behavior framework. Social norms were examined through subjective norms, including perceived approval/disapproval, social support, stigma, disclosure, and peer influences.

Results ART adherence was facilitated by positive attitudes (e.g., perceived health benefits), supportive subjective norms (e.g., peer encouragement, disclosure, and observing others adhere), and enabling conditions (e.g., respectful healthcare workers, adequate counselling, food availability, and structured medication routines). Conversely, adherence was hindered by negative attitudes (e.g., misconceptions and fear of side effects), harmful subjective norms (e.g., stigma, lack of social support, nondisclosure, and gender-based violence), and structural barriers such as poverty, food insecurity, substance use, incarceration, and demanding work schedules. Social support and disclosure emerged as particularly influential in enabling adherence.

Conclusions The study concludes that ART adherence among FSWs is shaped by an interplay of individual, social, and structural factors. Interventions should prioritize strengthening counselling, enhancing peer and community support systems, addressing stigma and discrimination, and improving access to basic needs and healthcare services. Addressing social norms—especially those related to stigma and social support—is essential for improving adherence and health outcomes among FSWs.