barriers to antiretroviral adherence for adolescents living with hiv infection and aids reporting at...
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Barriers To Antiretroviral Adherence ForAdolescents Living With HIV Infection And
AIDs Reporting At Chitungwiza Central Hospital’s OIC.
P Ndarukwa Dr O Moyo
Prof A Chideme-Munodawafa E. Chadambuka
Introduction
• Establishing and maintaining adherence to medication is a difficult goal for an individual with chronic illness even when
treatment regime is simple and the patient is clearly symptomatic (UNAIDS, 2008).
• Adherence is particularly problematic in adolescents (Guidelines for Antiretroviral for the Prevention and Treatment
of HIV in Zimbabwe (GATPT), 2013). • Particular attention should be paid to assessing adherence at
every visit and to providing adherence support (GATPT, 2013). Counselling on adherence should include exploring specific
reasons that may contribute to poor adherence (GATPT, 2013).
Intro….
• Adolescents face many psychosocial issues that affect their adherence and those should be assessed (GATPT, 2013).
• Nearly perfect compliance seems to be indispensable to obtain the maximum benefit from highly active antiretroviral treatment (HAART)
(Rao, et al., 2007) and prophylactic medications and is therefore crucial to their success (Tapper, et al., 2004).
• Non-adherence to HAART is a major cause of viral resistance to medication. Blood levels of medication can quickly drop below the
therapeutic threshold, due to the limited half-life of many ART agents, giving the virus an opportunity to develop resistance (Moatti and Spire, 2003). Designing interventions to optimize the management of HIV by
improving adherence is of major clinical importance (Tapper, et al., 2004).
Intro…
• A news article in the Newsday (9/09/2011) on health issues indicated that Zimbabwe had over 100000 adolescents who were registered with HIV care
services whose adherence was dependent on caregivers. • The article further indicated orphanhood as a barrier to adherence to ART, stigma,
lack of support of by family and lack of disclosure to the adolescents the reasons for continued taking of medication as also barriers to adherence.
• Ministry of Health and Child Care (2013) identified lack of knowledge of HIV status as a leading factor to poor adherence to ART and suggested that adolescents should be involved in the discussion about HIV testing and their HIV status should be disclosed to them. Disclosure is recommended as a gradual process that should be carried out with the involvement of the guardian, a counsellor and the doctor if
adherence is to be maintained (MOHCC, 2013). • All these possible solutions to effective adherence are not conclusive to barriers to
antiretroviral adherence for adolescents living with HIV infection and AIDs, hence the need to determine such barriers to antiretroviral adherence for adolescents.
Problem Statement
• Despite government’s effort of making availability antiretroviral drugs, through AIDS and TB programme in the Ministry of Health
and Child Care there is a high level of non-adherence by adolescence at Chitungwiza Central Hospital’s OIC.
• There is 60% non adherence rate among the adolescents at Chitungwiza Central Hospital. According to Chitungwiza Central
Hospital’s OIC annual Report of 2013, non adherence rate is 3adolescence per 5 adolescences.
• This is unacceptable given the benefits of antiretroviral therapy which has had a good survival rate among those who are taking
antiretroviral therapy. Therefore, this study would wish to identify the possible barriers to antiretroviral therapy among adolescence
taking antiretroviral medications at Chitungwiza Central Hospital’s Opportunistic Infection Clinic in 2014
BROAD OBJECTIVETo determine barriers to antiretroviral adherence for
adolescence living with HIV infection and AIDs reporting at Chitungwiza Central Hospital’s OIC.
SPECIFIC OBJECTIVES• To determine the adolescents’ knowledge on the use of ARVs• To determine adolescents’ attitudes on the use of ARVs.
• To describe the practices of adolescents that affect adherence to ARVs.
• To identify the type of services delivered to adolescences receiving ARVs at the OIC.
• To describe the kind of the social support given to adolescences taking ARVs.
• To come up with recommendations for policy, practice & education
STUDY DESIGN
• The researcher used triangulated cross-sectional descriptive and correlational analytic
designs
STUDY SETTING• Chitungwiza Central Hospital’s OIC.
STUDY POPULATION
The researcher made use of the following populations;• The Adolescents who are aged 12-19years who were
coming to collect their antiretroviral therapy medications.
• Medical records of adolescents attending scheduled reviews were reviewed for adherence to ART
medications.• Health care providers who are working in the OIC department were interviewed in order to establish the
type of services provided for adolescents receiving ARVs.
SAMPLE SIZE
• This study estimated levels of non-adherence among the adolescence with HIV infection and
AIDS. The sample size was calculated using one proportion formula using the WHO
sample Size determination for Health Studies version.
Barriers To Antiretroviral Adherence For Adolescents Living With HIV Infection And
AIDs Reporting At Chitungwiza Central Hospital’s OIC.
P Ndarukwa Dr O Moyo
Prof A Chideme-Munodawafa
SAMPLE SIZE CONTI....
• The following parameters were used to calculate the sample size: proportion of adherence (P) among the HIV/AIDS
adolescents at CCH‘s OIC is 60%, the absolute precision (d) is 5% and the confidence level is 95%. This gives a sample size
of 368. The selected sample size was increased by 5% (19 cases) to allow for incomplete interviews. The minimum
survey sample was 387.
SAMPLE SELECTION• Maximum variation which is a strategy of purposive sampling
was used to identify participants for the study. Those adolescents who are aged 12-19years and registered at
Chitungwiza Central Hospital were selected purposively between March 2014 and Mid April 2014. Every adolescent who come for collection of ART supplies were interviewed
either individually or in a group.
ResultsSocio-demographic characteristics of respondents N=136
Characteristics (N=136) Adolescent patient (ARV Users) N=100(73.5%) Health Care ProvidersN=36 (26.5%)
GenderFemaleMale
6139
2313
Age(years)12-1415-1718-19
174340
N/AN/AN/A
Education levelPrimarySecondaryCollegeUniversity
2751139
N/AN/A2511
Employment StatusNot employedEmployed
8317
N/A
Time since onset ofART<1year>or =1year
3466
N/A
Location of Adolescent to ART services.UrbanRural
6337
N/A
Adolescent living withParentsGrandparentsChild headed familyOthers
3150290
N/A
Qualitative Data Analysis Framework
The following themes and sub-themes were indentified during the qualitative data analysis process.
How do ARV adolescents adhere to their regimen?• Knowledge, belief and perception of ART• Fear of consequences of non-adherence• Benefits of ART• Contrary conception between health care providers and
patients• Drug holidays/ feeling better
Which strategies ARV users applied to help them adhere to their ART?
• Adherence aid• Personnel appropriate time to take medication• Chewing medications• Borrowing medications from others
Personal factors• Age• Gender• Personal characteristics,health locus of control, self-efficacy• Alcohol use• Illicit drug use
Disclosure and Stigma as threats to ART adherence• Influence on ART adherence• Discrimination of the adolescent on ART• Reasons for non-disclosure• Examples of HIV/AIDS disclosure• Importance of HIV status and ART discrimination among
adolescents
Treatment-related factors• Complexity of regimen• Side effects• Cost and travel to clinics• Health service issues
Family and Social support• Poor support from family• Self help groups
Quantitative Data Analysis Framework Sociodemographic Data Number of
respondents
Percentage
Sample (%)Sex Females
Males
143
108
57
43
Age (Min 12; Max 19; Mean: 16.0±2.1 12-14
15-17
18-19
63
112
76
25.1
44.6
30.3
Education level : Primary
Secondary
College
University
44
161
35
11
17.6
64.1
13.9
4.4
Employment History Not employed
Employed (Formal)
Employed (Informal)
200
16
35
79.7
6.4
13.9
Number of years Since HIV first detected (Min: 1; Max 16years; Mean 6.0±3.99): <1year
1-4years
4-7years
7-12years
>12years
17
73
80
62
19
6.8
29.1
31.9
24.7
7.5
Self-reported mode of HIV acquisition At birth
Sexual Intercourse
Shared needles
154
90
7
61.3
35.9
2.8
Treatment Characteristics of the AdolescentsTreatment and clinical characteristics Number of respondents Percentage of Sample (%)
ART regimena. (AZT+3TC+NVP)b. (AZT+3TC+EFV)c. (TDF+3TC+NVP)d. (TDF+3TC+EFV)e. Other
5043134177
19.917.153.46.82.8
Duration of ART(Min:1; Max:12years;Mean:9.6±3.04)<=2years2-10years10-12years
1734200
6.813.579.7
CD4 count at baseline(Min:21;Max:731;Mean:168.9±127.6)<=100cells/µl101-200cells/µl>200cells/µlMissing
81121409
32.348.215.93.6
Tuberculosis treatmentCurrentIn the pastNever
3716198
14.76.478.9
Cotrimoxazole prophylaxis useCurrentIn the pastNever
1099151
43.436.320.3
The Use of Adherence Aids (N=251)
characteristics Number of Percentage of Sample respondents (%)
Use of adherence aids 202 80.5%
Kind of adherence aids Clock alarm
Mobile phone alarm
Calendar
TV/Radio program
Pill box
Other
103
123
43
11
190
19
41%
49%
17.1%
4.4%
75.7%
7.6%
Useful level of adherence aids Not at all
A little
Somewhat
A lot
18
45
13
175
7.2%
17.9%
5.2%
69.7%
Univariate Analysis of Socio-demographic Factors by Dose Non-adherence N=251.Socio-demographic factor Adherence Non-adherence Unadjusted OR
(95% CI)P-value
Sex Female Male
10180
4228
10.84(0.48-1.47) 0.55
Age 12-14 15-17 18-19
529039
112237
11.16(0.52-2.57)3.88(2.03-7.42)
0.72>0.001
EducationPrimarySecondaryCollegeUniversity
27117307
174454
10.60(0.30-1.20)0.44(0.16-1.21)3.43(0.73-16.17)
0.150.110.11
Current jobNot employedEmployed (formal)Employed (informal)
161119
39526
11.88(0.62-5.71)6.36(1.73-23.34)
0.260.003
No of years since HIV first detected <1yr1-4yrs4-7yrs7-12yrs>12years
1151634313
62217216
10.79(0.26-2.41)0.63(0.30-1.30)1.81(0.86-3.82)0.95(0.31-2.84)
0.680.210.120.92
Univariate Analysis of Clinical and treatment factors by dose Non-adherence N=251.Socio-demographic factor
Adherence Non-adherence Unadjusted OR (95% CI)
P-value
Sex Female Male
10180
4228
10.84(0.48-1.47) 0.55
Age 12-14 15-17 18-19
529039
112237
11.16(0.52-2.57)3.88(2.03-7.42)
0.72>0.001
EducationPrimarySecondaryCollegeUniversity
27117307
174454
10.60(0.30-1.20)0.44(0.16-1.21)3.43(0.73-16.17)
0.150.110.11
Current jobNot employedEmployed (formal)Employed (informal)
161119
39526
11.88(0.62-5.71)6.36(1.73-23.34)
0.260.003
No of years since HIV first detected <1yr1-4yrs4-7yrs7-12yrs>12years
1151634313
62217216
10.79(0.26-2.41)0.63(0.30-1.30)1.81(0.86-3.82)0.95(0.31-2.84)
0.680.210.120.92
Self reported mode of HIV acquisitionAt birthSexual intercourseShared needles
120565
34342
12.14(1.21-3.79)0.66(0.12-3.59)
0.0080.63
Conti...Treatment and Clinical characteristics
Adherence Non-adherence Unadjusted OR(95% CI) p-value
ART regimena. (AZT+3TC+NVP)b. (AZT+3TC+EFV)**c. (TDF+3TC+NVP)d. (TDF+3TC+EFV)**e. Other
313210394
29113183
10.37(0.16-0.86)0.88(0.40-1.94)2.95(1.05-8.30)0.84(0.14-4.97)
0.020.740.030.85
Duration of ART<=2years2-10years10-12years*
1023161
71139
10.68(0.21-2.28)0.51(0.23-1.13)
0.530.09
Distance from residence to clinic<=5km5-10km**>10km*
189287
142713
10.38(0.17-0.86)0.51(0.25-1.05)
0.020.06
Tuberculosis treatmentCurrentIn the past**Never
319132
6766
14.02(1.07-15.03)0.64(0.23-1.80)
0.030.40
Cotrimoxazole prophylaxis useCurrentIn the pastNever *
807233
291918
10.73(0.38-1.41)2.07(096-4.44)
0.350.06
Univariate Analysis of Alcohol and Drug Use by Dose Non-adherence N=251.
Alcohol and drug use Adherence N=161 Non-adherenceN=90 Unadjusted OR(95% CI)
p-value
Alcohol use (last month)Noyes
9071
3159
12.41(1.41-4.12) 0.001
Heavy alcohol use (≥5 drinks within two hours)NoYes
13724
4149
16.82(3.74-12.43) <0.001
Ever used illicit drugNoYes
10061
3555
12.58(1.52-4.38) <0.001
Illicit drug use (last month)NoYes
11447
4446
12.54(0.96-2.82) <0.001
Multivariate Analysis of factors associated with dose non-adherence N=251.
Factors No. of adolescent Crude OR Adjusted OR (95% CI) P-value
Sex FemaleMale
143108
10.84 3.10(1.37-7.03) 0.007
Age 12-1415-1718-19
6311276
11.163.88
11.16(0.37-3.56)3.88(1.56-9.92)
0.720.003
EducationPrimarySecondary CollegeUniversity
441613511
10.600.443.43
0.55(0.20-2.56)1.87(0.65-5.60)2.26(0.62-23.77)
0.160.110.16
Clinical factors
Distance from residence to clinic<5km5-10km>10km
32119100
10.380.51
12.48(0.68-13.31)8.17(2.49-57.61)
0.090.002
Conti...Alcohol use and drug use
Heavy alcohol use (last month)NoYes
17873
16.82
10.80(0.25-2.51) 0.002
Illict drug use (last month)NoYes
16685
11.64
10.48(0.21-1.11) 0.01
Use of adherence Aids No Yes
76175
10.69
14.26(1.76-10.14) 0.002
Multivariate analysis of factors Associated with ART Dose non-adherence N=251
Factor Mean of adherent group
Mean of non-adherent group
Crude OR Adjusted OR (95% CI)
P-value
Side-effects experienced
20.64 27.19 1.02 1.04(1.02-1.05) <0.001
Chance health locus of control
16.6 18.69 1.06 1.06(1.02-1.10) <0.001
Social related factors
Perceived quality of information from HCPs
23.32 22.16 0.91 0.94(0.88-0.99) 0.04
Satisfaction with received support
8.49 7.73 0.88 0.92(0.84-1.00) 0.06
Social connectedness
10.89 9.65 0.90 0.94(0.88-0.99) 0.04
Social isolation 4.68 5.20 1.08 1.00(0.91-1.10) 0.96
Univariate Analysis of Sociodemographic Factors by Time Non-adherence N=251.
Socio-demographic factor
Adherence N=180 Non-adherence N=71 Unadjusted OR (95% CI)
P-value
Sex Female Male
9783
4625
10.64(0.36-1.12) 0.12
Age 12-14 15-17* 18-19*
578241
63035
13.48(1.36-8.89)2.33(1.26-4.32)
0.0070.006
EducationPrimarySecondaryCollegeUniversity*
28114344
164195
10.63(0.31-1.28)0.74(0.33-1.67)4.72(1.05-21.29)
0.200.460.03
Current jobNot employedEmployed (formal)Employed (informal)*
1591011
41624
12.33(0.80-6.78)3.64(1.05-12.55)
0.110.04
No of years since HIV first detected <1yr1-4yrs4-7yrs7-12yrs>12years
1050644412
72316187
10.66(0.22-1.94)0.54(0.26-1.14)1.64(0.75-3.55)1.43(0.48-4.21)
0.450.100.210.52
Self reported mode of HIV acquisitionAt birthSexual intercourse*Shared needles
119583
34334
11.99(1.12-3.53)2.34(0.49-11.12)
0.020.27
Univariate Analysis of Clinical and treatment factors by Time dose Non-adherence N=251
Treatment and Clinical characteristics
Adherence N=180 Non-adherence N=71 Unadjusted OR(95% CI) p-value
ART regimena. (AZT+3TC+NVP)b. (AZT+3TC+EFV)**c. (TDF+3TC+NVP)d. (TDF+3TC+EFV)**e. Other
3034101105
2982743
10.24(0.10-0.61)1.14(0.47-2.74)1.50(0.44-5.14)1.50(0.24-9.46)
0.0020.780.520.67
Duration of ART<=2years2-10years*10-12years
928143
81647
10.64(0.21-2.00)0.58(0.29-1.15)
0.060.12
Distance from residence to clinic<=5km5-10km*>10km
1510065
113228
10.44(0.18-1.05)1.35(0.74-2.44)
0.020.33
Tuberculosis treatmentCurrentIn the pastNever*
2613141
121445
12.33(0.84-6.46)0.30(0.13-0.68)
0.100.003
Cotrimoxazole prophylaxis useCurrentIn the pastNever
847026
312317
10.89(0.48-1.66)1.99(0.92-4.31)
0.720.08
Univariate Analysis of Social Factors by Time Non-adherence N=251.
Adherence n=180 Non-adherence n=71t-test/Mann-Whitney
M SD M SD t DF P
Disclosure of ART treatment status
5.57 3.52 5.00 3.36 1. 85 249 0.07
Family support 9.33 2.86 8.81 2.99 2.01 249 0.05
Friend support 4.80 3.60 4.69 3.56 0.36 249 0.72
Social organisation support
4.51 3.72 4.47 3.79 0.11 249 0.91
Satisfaction with received support
8.40 2.48 8.06 2.38 1.59 249 0.11
Social connectedness
10.89 3.49 9.83 3.37 3.44 249 0.001
Social isolation 4.63 2.48 5.23 2.48 -2.71 249 0.007
Perceived quality of information from health care provider
23.23 3.11 22.55 3.52 2.385 249 0.02
Ability to initiate communication with health care provider
12.37 6.66 13.55 6.47 2.014 249 0.04
Multivariate Analysis of factors associated with time non-adherence N=251.Factors No. of adolescent Crude OR Adjusted OR (95% CI) P-value
Sex FemaleMale
143108
10.64 3.10(1.37-7.03) 0.007
Age 12-1415-1718-19
6311276
13.482.33
11.16(0.37-3.56)3.88(1.56-9.92)
0.720.003
EducationPrimarySecondary CollegeUniversity
441613511
10.630.744.72
0.55(0.20-2.56)1.87(0.65-5.60)2.26(0.62-23.77)
0.160.110.16
Clinical factorsDistance from residence to clinic<5km5-10km>10km
32119100
10.441.35
10.72(0.22-2.38)1.65(0.72-3.60)
0.450.09
Current jobNot employedFormally employedInformally employed
2001635
12.333.64
11.68(0.35-8.37)0.65(0.10-4.64)
0.360.53
Conti.....
Alcohol use and drug use
Heavy alcohol use (last month)NoYes
17873
14.88
15.38(4.14-13.61) 0.004
Illict drug use (last month)NoYes
16685
15.90
14.33(1.60-22.57) 0.007
Use of adherence Aids No Yes
71180
110.07
10.48(0.22-1.45)
0.02
Multivariate analysis of factors Associated with ART Dose non-adherence N=251
Factor Mean of adherent group
Mean of non-adherent group
Crude OR Adjusted OR (95% CI)
P-value
Side effects experience
20.26 27.17 1.03 1.07(1.05-1.09) <0.001
Chance health locus of control 16.69 18.18 1.04 1.04(1.00-1.09) 0.05
Social related factors
Disclosure of treatment status 5.57 5.00 0.95 0.94(0.88-1.02) 0.12
Family support 9.33 8.81 0.94 0.98(0.90-1.06) 0.53
Social connectedness
10.89 9.83 0.92 0.93(0.86-0.99) 0.04
Social isolation 4.68 5.23 1.09 1.08(0.98-1.20) 0.12
Perceived quality of information from HCPs
23.23 22.55 0.94 0.97(0.91-1.05) 0.49
Ability to initiate communication with HCPs
12.37 13.55 1.03 1.01(0.97-1.04) 0.81
Discussion
• The results of this study have shown that adolescents aged 12-19 years had challenges to adherence which included forgetfulness to take medication on time, being too busy that is being absorbed by something, special events which included weddings, parties, etc, being away from home and not taking medications with them,
oversleeping, problems with adherence reminders, bad memory (due to personal ability or side-effects of the pills).
• This study identified critical barriers to adherence as drug use, alcohol use, lack of disclosure, negative attitude and
inappropriate belief about who controls a patient’s health, medication side effects and long distance from residence to
clinics. The facilitators of adherence were identified as social and family support, disclosure of HIV status and treatment,
good interaction with people around them, high level of satisfaction with received support and good relationship
between health care providers and patients.
• In the bivariate analysis, association between the two types of ART non-adherence (i.e. dose and time) and the use of illicit drugs were strongly significantly associated. These were still
significantly associated with non adherence in the multivariate models. Literature has indicated that concurrent use of a
substance while taking ART leads to patients not adhering to their medications (Hill, Kendall and Fernandez, 2003; Laws,
Wilson, Bowser and Kerr, 2000, Remien, Hirky, Johnson, Weinhardt, Whittier and Le, 2003 and Remien, et al., 2003)• . In this study it was noted that non-adherence was significantly associated with each regimen of ART which
included effavirenz more side effects among the ART medications. This is supported by literature which said side
effects of ART have been identified to cause adherence problems in patients (Abel and Painter, 2003).
Recommendations
• There is need to improve family support system to assist in the disclosure of HIV status to adolescents, thus it
would improve adherence and reduce resistance of ART treatment
• This study found that long distance from area of residence to clinic was significantly associated with non-adherence.
It is therefore suggested that the government should increase the number of sites offering ART to adolescents as a way of working towards achieving the vision of the
health reforms of bringing health service as close to family as possible.
Recommendations Conti...
• This study also identified that side effects of the ART medicines played a significant role in barriers to ART
adherence among adolescents. Therefore, it is suggested that there is need to identify medications with less side effects to be supplied to adolescents if adherence is to be maintained.• In this study the researcher identified that family and
community support was a facilitator of ART adherence. Therefore it is suggested that families and communities should be encouraged to form support groups focused on ART to help
with adherence strategies of coping with chronic illnesses.
References
• UNAIDS: 2008 Report on the global. HIV/AIDS epidemic 2008. Geneva Switzerland; 2008.
• Ministry of Health and Child Care, 2013, Guidelines for Antiretroviral Therapy for the Prevention and Treatment of HIV
in Zimbabwe • Abel E, Painter L. Factors that influence adherence to HIV
medications: perceptions of women and health care providers. J Assoc Nurses AIDS Care 2003 Jul; 14(4):61-9.
• Remien RH, Hirky AE, Johnson MO, Weinhardt LS, Whittier D, Le GM. Adherence to medication treatment: a qualitative study of
facilitators and barriers among a diverse sample of HIV+ men and women in four US cities. AIDS Behav 2003 Mar; 7(1):61-72.