Countries with the highest HIV prevalence, Botswana, Eswatini, Lesotho and South Africa are also experiencing an increase in climate variability, rising temperatures and drought. This study investigates perceived challenges of high temperatures and water scarcity/rationing on monthly clinic attendance and ARV adherence for people living with HIV in Greater Gaborone, Botswana. A systematic random sample of adult women [n=419], including 67 pregnant women and mothers, and men [n=239] attending 21 HIV clinics were surveyed. Health care workers [n=84] were interviewed. Close-ended and open-
ended questions were analyzed using logistic and multilevel models and content analysis. Women and men reporting exposure to high temperatures were at increased odds of ARV non-adherence, especially in rural areas; missing clinic appointments due to heat in rural areas and water rationing in peri-urban and rural areas increased the odds of ARV non-adherence; almost half of respondents reported water rationing negatively affected their health; and perceptions of available clinic services during water shortages, differed for some men and health care providers. Infrastructural and health education messaging improvements are needed in HIV clinics, particularly in rural villages to adapt to climate
variability and ensure ARV adherence for people living with HIV in these areas.

Key words: HIV, antiretroviral therapy adherence, climate variability, water shortages, water rationing, ARV clinics, treat all program, Botswana.

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