Introduction:
South Africa has the largest HIV epidemic in the world, with 19% of the global number of people living with HIV, 15% of new infections and 11% of AIDS related deaths; and as well the largest antiretroviral treatment (ART) programme in the world (1), accounting for 20% of people on antiretroviral therapy globally (2). Although the prevalence of HIV in South Africa remains high, it has been stable over the last decade. This stability might be due to the rapid scale-up and success of the ART programme (3). The country, therefore, faces the major challenge of ensuring and sustaining the quality of service, including preventing and managing side effects, and improving drug adherence, which are all critical for the success of the programme (4).
Highly Active Anti-Retroviral Therapy (HAART) provides a unique tool in the AIDS response concerning mortality and morbidity reduction. Antiretroviral treatment is offered at public/government and private hospitals and health centres throughout South Africa; and it is provided free of charge. Medication adherence has been defined as “the patient’s conformance with the provider’s recommendations with respect to timing, dosage, and frequency of medication-taking during the prescribed length of time” (5). Global targets for scaling up ART include ensuring that 90% of patients on ART achieve viral suppression (6). Non-adherence to ART can result in drug-resistant HIV caused by failure to achieve maximal viral suppression (7).
The literature is fraught with several factors affecting ART adherence, such as, ART side effects (8-11). Amongst these are emotional depression (12); social stigma and discrimination (13); non-disclosure (13,14); unemployment (15); lack of transport (13,16,17); lack of education (18); lack of social support [financial and emotional] (19); food insecurity (11,13); alcohol/substance abuse (13,15,20-23); alternative forms of therapy (11,13); inadequate follow-ups (24); lack of patient confidentiality (24); high treatment difficulty or fatigue (11,12); work and family responsibilities (25); low self-efficacy (12); low treatment efficacy (12,24); low treatment satisfaction (12); time demands (12); distance to health facilities (17,25,26); rural residences (20); religious and festive activities (27,28) and food insecurity (29-31). These underlying reasons for non-adherence to ART are complex, and vary from one geographic setting to another. For example, knowledge was linked to non-adherence in Israel (32), while in Kenya, younger age, rural residence and substance use were associated with non-adherence (20). Yet, ART side effects, low self-efficacy, low treatment efficacy, low treatment satisfaction, high treatment difficulty and time demands and emotional distress had been reported as being the main barriers to ART adherence in Romania (12). Contrastingly, giving birth at home, quality and timing of HIV testing and counseling, fear of stigma, lack of male involvement, non- sero-status disclosure, young age and lack of education are linked to low ARV adherence among individuals in sub-Saharan Africa (18). Yet, food insecurity has been reportedly associated with increased risk of non-adherence to ART among HIV-infected patients in the Democratic Republic of Congo (29), Atlanta, USA (30), and French (31). Viewed from this perspective, understanding context specific reasons for ARV non-adherence is important to design contextually specific interventions. Additionally, while studies on ART adherence are available in other regions of South Africa (14,33-38), scanty information exists in the Eastern Cape Province.
Methods
Study design
This was a cross-sectional study conducted at six health clinics in East London over a period of five months from March to July 2017, among people living with HIV and AIDS (PLWHA), on ART for least six months.
Setting
The study’s setting was Duncan Village Day Community Healthcare centre, situated at Duncan village. Duncan Village serves patients from Duncan Village, Mooiplaas, Kwelera, Cintsa, Chalumna and Fort Grey. It has the emergency unit, chronic and acute outpatient units, ARV unit, Antenatal, Family planning, paediatric unit and maternity and adolescent youth friendly services. The clinics in East London, render antenatal care, chronic and acute services, HIV/AIDS services, family planning services and paediatric services.
Population, sample and sampling procedure
The target population were adult HIV positive patients on ARVs, who attend the Primary Health Care facilities in East London, Eastern Cape. Participants were included in the study, if they were HIV positive patients and on ARV treatment for six months or more. A purposive sampling selected 371 patients on ARV who attended the ARV unit in six conveniently selected primary health care facilities in East London.
Data collection tool
Data were collected through a questionnaire-assisted interview in English or the local language (isiXhosa), conducted by the first author (SP) to ensure good understanding of the questions. The questionnaire comprised the demographic profile of the participants, information concerning knowledge about HIV/AIDS and method of contraction, possible reasons for non-adherence, lifestyle behaviours, and quality of care received at health facilities by health professionals.
Data collection procedure
Using a self-designed questionnaire, the researcher held face-to-face interviews with the participants in a private room designated by the health facility manager. While waiting to receive their ARVs at the clinics, the patients had been briefed on the purpose and nature of the study. Participants who had indicated their willingness to participate and had signed the informed voluntary consent form, had the questionnaire administered to them; however, those who could not read nor write were assisted in the isiXhosa language. The questionnaire was collected on completion at the given venue. A total of 371 questionnaires were submitted and these were used for statistical analysis.
Ethical considerations
The University of Fort Hare’s Research Ethics Committee granted approval for the study (Ref: Yako11SPET01). The Eastern Cape Provincial Department of Health gave permission to the researcher to conduct the study in a public sector health care facility. The clinical governance of the respective clinics added its stamp of approval. With processes and protocols observed, the study participants submitted informed, voluntary, written, consent forms and then data collection commenced.
Data analysis
Data was analysed through descriptive and inferential statistics. Frequencies and percentages summarised the data set. A Chi-square test determined the variables associated with non-adherence to ARVs. Furthermore, logistic regression analysis determined the factors influencing ARV non-adherence among the participants. The level of statistical significance was set at 0.05. Statistics were analysed using the Statistical Package for Social Sciences (SPSS) version 22.0.
Results
Table 1 presents the demographic characteristics of the participants. A total number of 371 participants were included in the analysis. The majority of participants were females (84.4%), age range between 20 to > 51 years; and most participants were from the urban area (65.2%). The majority of the participants were Africans (94.6%), never married (68.0%), had at least secondary qualifications as the highest level of education (83.3%), and were unemployed (51.1%). Most participants were Christians (89.9%) living with their families (81.1%). About 81(23.3%) participants were on ARVs for six months, while the majority of participants had been using ARVs for more than two years (50%). More than half of the participants were on regimen one (88.7%).
| Table 1: Demographic characteristics of the participants |
| Variables |
Frequency |
Percentage |
Gender |
Male |
58 |
15.6 |
Female |
313 |
84.4 |
Age (years) |
<20 |
13 |
3.7 |
21-25 |
38 |
10.8 |
26-30 |
58 |
16.5 |
31-35 |
72 |
20.5 |
36-40 |
58 |
16.5 |
41-45 |
72 |
12.8 |
46-50 |
58 |
8.8 |
>51 |
45 |
10.3 |
Residence |
Urban |
202 |
65.2 |
Semi-urban |
94 |
30.3 |
Rural |
14 |
4.5 |
Ethnic origin |
African |
351 |
94.6 |
Coloured |
20 |
5.4 |
Marital status |
Married |
87 |
23.6 |
Never married |
251 |
68.0 |
Divorced /separated |
16 |
4.4 |
Widowed |
9 |
2.4 |
Co-habiting |
6 |
1.6 |
Highest level of education |
No formal education |
2 |
0.5 |
Primary |
32 |
8.7 |
Secondary |
305 |
83.3 |
Tertiary diploma |
21 |
5.7 |
Tertiary degree |
6 |
1.6 |
Employment status |
Unemployed |
189 |
52.2 |
Grant recipient |
62 |
17.1 |
Employed |
98 |
27.1 |
Pensioner |
1 |
0.3 |
Self-employed |
7 |
1.9 |
Student |
5 |
1.4 |
Religious affiliation |
Christian |
329 |
89.9 |
Non-Christian |
21 |
5.7 |
No religion |
16 |
4.4 |
Duration on antiretroviral |
Six months |
81 |
23.3 |
One year |
52 |
14.9 |
Two years |
41 |
11.8 |
More than two years |
174 |
50.0 |
Regimen type |
Regimen I |
268 |
88.7 |
Regimen II |
34 |
88.7 |
Table 2 presents the reasons for non-adherence to ART. The majority of participants had had sufficient money for transport (70.7%) and they had not lost income because of them having to come to the clinic. Regarding adherence counselling, more than half the participants had received counselling before starting on ARVs (92.2%). Interestingly, the majority of participants did not experience side effects (53.1%). The majority of participants had had someone to remind them to take their treatment and most participants had not spoken about their HIV status. Regarding skipping the medication, most participants had not skipped their medication. More than half the participants had taken their ARVs regularly in the previous month (75.2%).
| Table 2: Possible reasons for non-adherence |
| Items |
Yes
n (%) |
No n (%) |
Sometimes I don’t have transport money to visit the clinic |
87 (29.3) |
210 (70.7) |
Loss of income as result of coming to the clinic |
81 (24.3) |
252 (75.7) |
Counseled about adherence before starting my ARV medication |
306 (92.2) |
26 (7.8) |
Experienced of ARV side-effects |
142 (46.9) |
161 (53.1) |
Have someone who remind me to take ARV medication |
184 (56.4) |
142 (43.6) |
Talk to my mother about my HIV status |
150 (40.4) |
221 (59.6) |
Talk to my father about my HIV status |
44 (11.9) |
327 (88.1) |
Talk to my sister about my HIV status |
124 (33.4) |
247 (66.6) |
Talk to my friend about my HIV status |
39 (10.5) |
332 (89.5) |
Talk to my partner about my HIV status |
132 (35.6) |
239 (64.4) |
Talk to my religious leader about my HIV status |
13 (3.5) |
358 (96.5) |
Talk to my children about my HIV status |
36 (9.7) |
335 (90.3) |
Talk to my employer about my HIV status |
1 (0.3) |
370 (99.7) |
I skip my medication due to feeling better |
29 (20.7) |
111 (79.3) |
I skip my medication due to clinic not accessible |
37 (24.2) |
116 (75.8) |
I skip my medication due to taking too many tablets |
16 (12.0) |
117 (88.0) |
I skip my medication due to lack of support and care |
13 (9.8) |
120 (90.2) |
I skip my medication due to hospitalization |
7 (5.6) |
117 (94.4) |
I skip my medication due to feeling depressed |
20 (14.7) |
116 (85.3) |
I skip my medication due to sharing of ARV medication |
12 (9.0) |
121 (91.0) |
At times I forget to take my medication |
75 (38.9) |
118 (61.1) |
I forget to take my medication when I take alcohol |
33 (22.3) |
115 (77.7) |
I forget to take my medication when I take because I don’t want somebody to notice that I am taking ARVs |
28 (19.9) |
113 (80.1) |
I don’t take my ARVs every day because I don’t have food to eat |
31 (20.8) |
118 (79.2) |
I missed my pills in the last one week |
61 (18.2) |
274 (81.8) |
I take my ARVs regularly in a month |
252 (75.2) |
83 (24.8) |
| n=Number; % = Percentage; ARV= Anti-retroviral |
Interestingly, the majority of participants experienced no side effects. The most common side effect experienced was bad dreams (19.7%) (Table 3).
| Table 3: Side effects of antiretroviral treatment |
| Side effects |
Yes
n (%) |
No
n (%) |
Nausea |
52 (14.0) |
319 (86.0) |
Vomiting |
30 (8.1) |
341 (91.9) |
Diarrhoea |
13 (3.5) |
358 (96.5) |
Bad dreams |
73 (19.7) |
298 (80.3) |
Loss weight |
23 (6.2) |
348 (93.8) |
Gain weight |
16 (4.3) |
355 (95.7) |
Loss appetite |
17 (4.6) |
354 (95.4) |
Fatigue |
20 (5.4) |
351 (94.6) |
Mood changes (depression and anxiety ) |
16 (4.3) |
355 (95.7) |
Rash |
25 (6.7) |
346 (93.3) |
Dizziness |
30 (8.1) |
341 (91.9) |
Cracked nails |
1 (0.3) |
370 (99.7) |
Increased vaginal discharge |
1 (0.3) |
370 (99.7) |
Headache |
3 (0.8) |
368 (99.2) |
Lipodystrophy (changes in the distribution of body fat) |
0(0.0) |
371 (100.0) |
| n=Number; % = Percentage |
Adherence measures of the participants reflect in Figure 1. About 55.0% of the participants had a history of non-adherence, with 26.0% non-adherence rate in the previous month and 19.0% recorded in the previous week.
 |
Figure 1: Adherence measures |
Table 4 shows the variables associated with non-adherence to ARVs. Marital status (married) (p=0.005), having no formal education (p=0.035), being Christian (p=0.007), alcohol consumption (p= 0.021) and viral load suppression had a significant association with non-adherence to ARV treatment.
| Table 4: Chi-square statistics showing variables associated with non-adherence to ARVs |
| Variables |
Adherence n (%) |
Non-adherence n (%) |
p-value |
Age (years) |
15-25 |
33 (71.7) |
13 (28.3) |
0.862 |
Above 25 |
191 (70.5) |
80 (29.5) |
|
Gender |
Male |
36 (69.2) |
16 (30.8) |
0.875 |
Female |
199 (70.3) |
84 (29.7) |
|
Marital status |
Married |
64 (79.0) |
17 (21.0) |
0.055* |
Not married |
171 (67.9) |
81 (32.1) |
|
Education qualification |
No formal education |
0 (0.0) |
1 (100.0) |
0.035* |
Primary |
14 (51.9) |
13 (48.1) |
|
Secondary |
199 (71.8) |
78 (28.2) |
|
Tertiary diploma |
17 (85.0) |
3 (15.0) |
|
Tertiary degree |
3 (50.0) |
3 (50.0) |
|
Employment status |
Unemployed |
109 (66.5) |
55 (33.5) |
0.186 |
Grant recipient |
38 (70.4) |
16 (29.6) |
|
Employed |
72 (79.1) |
19 (20.9) |
|
Pensioner |
0 (0.0) |
1 (100.0) |
|
Self-employed |
6 (85.7) |
1 (14.3) |
|
Student |
3 (60.0) |
2 (40.0) |
|
Religious affiliation |
Christian |
218 (72.9) |
81 (27.1) |
0.007* |
Non-Christian |
9 (52.9) |
8 (47.1) |
|
No religion |
6 (40.0) |
9 (60.0) |
|
Consume alcohol |
Yes |
43 (58.9) |
30 (41.1) |
0.021* |
No |
189 (73.0) |
70 (27.0) |
|
Duration on anti-retroviral |
Six months |
55 (73.3) |
20 (26.7) |
0.411 |
One year |
31 (64.6) |
17 (35.4) |
|
Two years |
29 (78.4) |
8 (21.6) |
|
More than two years |
106 (67.1) |
52 (32.9) |
|
Ethnic origin |
African |
222 (70.7) |
92 (29.3) |
0.321 |
Coloured |
12 (63.2) |
7 (36.8) |
|
Viral load |
Suppressed |
74 (80.4) |
18 (19.6) |
0.000* |
Low vireamia |
28 (68.3) |
13 (31.7) |
|
Virological failure |
21 (46.7) |
24 (53.3) |
|
HIV knowledge |
Poor |
20 (58.8) |
14 (41.2) |
0.314 |
Fair |
60 (71.4) |
24 (25.1) |
|
Good |
155 (152.2) |
62 (28.6) |
|
| n= Number; %= Percentage; *Statistically significant at 0.05 |
After adjusting for confounders, only non-Christians and unsuppressed viral loads were the independent predictors of non-adherence. Participants who were non-Christians had 3.2 times the likelihood of failing to adhere to their ARVs compared to those who were Christians. Furthermore, participants with unsuppressed viral loads were 3 times more likely to be non-adherent to their ARVs compared to participants with suppressed viral loads (Table 5).
| Table 5: Logistic regression analysis of the determinants of ARV non-adherence |
|
Beta |
Wald |
AOR (CI) |
Religion |
Non-Christian |
1.17 |
5.2 |
3.2 (1.2-8.9) |
Christian (Reference) |
|
|
|
Viral load |
Not suppressed |
1.07 |
9.6 |
2.9 (1.5-5.8) |
Suppressed (Reference) |
|
|
|
| AOR; adjusted odd ratio CI; Confidence interval |
Figure 2 presents the rate of adherence of participants. The majority (70%) of the participants were non-adherents.
 |
Figure 2: Rate of adherence to antiretroviral treatment |
Table 6 shows the lifestyle behaviour of participants. Interestingly, most participants do not use alcohol (76.5%); however, those who consume alcohol (23.5%), take three or more bottles of alcohol. The quality of care the participants received while attending the health facilities (Table 7) indicated that the majority of participants were satisfied with the quality of care they had received.
| Table 6: Lifestyle behaviour of the participants |
| Variables |
Number |
Percentage |
Alcohol use |
Yes |
84 |
23.5 |
No |
273 |
76.5 |
Intensity of daily alcohol consumption |
One glass |
19 |
22.6 |
Two glasses |
15 |
17.9 |
One bottle |
11 |
13.1 |
Two bottles |
12 |
14.3 |
Three and above |
27 |
32.1 |
| Table 7: Quality of care of the participants |
| Variables |
Yes
n (%) |
No
n (%) |
I feel listened to at the clinic |
323 (87.1) |
25 (6.7) |
I am given a chance to state my problem while at the clinic |
316 (91.1) |
31 (8.9) |
Health workers provide answers to all my questions |
319 (93.8) |
21 (6.2) |
I am treated with respect |
334 (96.3) |
13 (3.5) |
I feel you can trust health workers |
319 (92.5) |
26 (7.5) |
I have privacy during consultation |
307 (89.8) |
35 (10.2) |
I receive counseling during consultation |
228 (66.3) |
116 (33.7) |
I find the clinic environment clean |
285 (83.1) |
58 (16.9) |
Figure 3 presents the waiting times of the participants before receiving attention. Strangely, as much as the participants were satisfied with the quality of care they received, they had had to wait more than two hours to receive it.
 |
Figure 3: Waiting time before receiving attention |
Concerning viral load distribution (Figure 4), out of the 371 participants, only 195 participants had viral load results available, 52% were undetectable, 26% unsuppressed and 22% suppressed.
 |
Figure 4: Viral load distribution of participants |
Discussion
The present study design determined the underlying contributing factors to non-adherence of antiretroviral treatment among HIV positive patients in selected health facilities in East London, South Africa. Consistent with other studies (39-41), the present study determined that marital status had an impact on adherence, as unmarried participants were more non- adherent than married participants. This suggested that those with family support seem to have a lower non-adherence score than those who receive support from partners, friends and other relations. Perhaps, married participants effectively motivated their spouses to continue treatment. This suggests a possible support system effect on the extent of non-adherence. Yarney et al. maintain that the support from loved ones in the form of financial aid, encouragement, information, reminders about taking treatment and so on improved adherence to ARVs (42); this furthermore stresses the importance of HIV disclosure status. Several studies have reported that HIV sero-status disclosure is associated with increased adherence to ART (27,43-45). Seemingly, HIV disclosure is the first stage of creating a supportive relationship with the sexual partner and with the family, and that would facilitate the adherence and the continuation of ART (43). Health providers should advise HIV-infected patients who are yet to disclose their HIV status to do so. The concept of HIV disclosure should start from the point of patient healthcare.
The present study found that educational levels significantly correlated with the HIV knowledge of the participants. Participants with no formal education had very poor (100%) or non-adherence to the treatment. Previous studies have shown that some patients default on their treatment due to a poor understanding of disease and its treatment; these authors have associated this with their low levels of education (43,46,47). It was also reported that HIV positive women with inadequate knowledge about antiretroviral treatment (ART) were more likely to default their treatment (48,49). The need for formal education is thus important and does have an impact on ARVs adherence. Intuitively, educated people exhibit better adherence to ART because of their ability to follow the instructions related to the treatment provided by health professionals in their settings. In the Yaya et al. study, PLWHA who attended at least secondary school were almost 3.6 times more likely to adhere to ART (43).
Patients may sometimes have wrong beliefs because of inadequate health knowledge or a negative relationship with the health care provider. Adequate knowledge about the purpose of the therapy and the consequences of non-adherence should be cascaded to the patients. A healthy relationship and good communication between the patient and the healthcare provider would also foster the patient’s compliance (50). Good adherence education should emphasize the importance of adherence at the time the therapy is initiated; the consequences of non-adherence; spending adequate time with the patient; inquiry about adherence at each visit; motivating patients to incorporate drug adherence into their lifestyles; and it should emphasise the importance of designing and implementing intervention strategies that improve adherence to self-medication (51). Authors state that providing health education on adherence to treatment has significantly improved the total health status of patients (52). Positive reinforcement can also greatly help patients maintain high levels of adherence. The technique to foster adherence includes informing patients of their low or suppressed HIV viral load and the increase in CD4 cell counts (53).
The present study indicates that religious beliefs have influenced patient’s adherence to ART. In our study sample, non-Christian participants had a high non-adherence rate (60%) compared to those who were Christians (27.1%). This finding is consistent with other studies reported elsewhere (27,54-56). Togarasei et al. argue that the negative attitude to ARVs reported by the Pentecostal Christian churches’ understanding of life, death and healing through traditional Bible-based interpretations arose because some churches view the ability of ARVs to prolong life as challenging God who is the source of life and healing (57). Mbirimtengerenji et al. hold a different perspective; they postulate that a strong religious believer thinks that God has supernatural powers able to heal HIV and AIDs. Such beliefs seem to be strongly associated with the non-adherence of women in Malawi (58). Boateng et al. maintain that some persons still hold the notion that HIV is a spiritual disease, and therefore warrants seeking spiritual interventions (49). Igbende et al. maintain that belief in the potency of spiritual healing affects adherence to ARVs, which implies that HIV/AIDS patients who believe that their current health predicament can be cured spiritually are less likely to adhere to therapy, but instead spend much time praying, doing rituals and visiting prayer houses and herbalists for cures (28). Religion has offered support that helped several participants manage their challenging HIV and ARV medication experiences; however, some described the ways in which the HIV stigma intersected with their religious beliefs. This intersection might complicate ARV adherence (59). Sometimes doctors refused treatment such as termination of pregnancy and contraception on grounds of conscientious objection, particularly because of religious beliefs. According to the Constitutional rights entrenched in Chapter 2 (Bill of Rights) of the South African Constitution (60), doctors are not compelled to provide treatment that is against patients’ beliefs and religions. There are many grounds for refusing to treat a patient, but non-adherence is not a good reason, unless it continues ad infinatum, thereby influencing the doctor-patient relationship negatively. In such a case, a doctor must do everything possible to ensure compliance, and should not abandon the patient (61).
This study revealed that alcohol consumption has an effect on non-adherence. Clients who take alcohol do not take their medication; some claim they are scared to mix treatment with alcohol. Yet, some participants agreed that after taking alcohol, it becomes difficult for them to remember their treatment. Several studies have reported the association of alcohol with non-adherence (15,22,36,43,62-64). Although there was no delay in ARV initiation among heavy drinkers, alcohol use was associated with earlier death. One possible explanation was that although women with heavy alcohol consumption were receiving ARVs, their increased mortality may be secondary to lower adherence and, consequently, poorer response to ARVs. Studies have shown that alcohol use is a risky sexual behaviour for contracting and transmitting HIV (65), and particularly in HIV patients on ARVs, this will influence their adherence to treatment. Alcohol use as a co-factor in risky behaviour influences progression via non-compliance. Da Santos et al. maintained that alcohol has a negative influence on health status and adherence to treatment, it increases the risk of virus transmission and unprotected sex; and the harmful and hazardous use of alcohol was found to have direct significant impacts on all forms of ARV adherence (missing or stopping ARVs) (23). However, those who missed their ARVs were also more likely to stop them, indicating an indirect effect for problematic drug use (66). Adherence counseling is very important on alcohol –drug interaction because it makes the patients aware. Alcohol has a damaging effect on the brain: it affects normal walking movements; the person has blurred vision, slurred speech, slowed reaction times and impaired memory (67). As such, HIV patients on ARVs who drink alcohol are at risk of possibly developing brain damage.
The current study revealed suppressed viral load (19.6%) for non-adherent participants. This finding is contradictory, as one would expect that the high non-adherence rate of the participants would translate to high viral load. Kalichman et al. also revealed high rates of unsustained HIV suppression among drinkers taking ARVs (68). More than half of the participants, all of whom were receiving ARVs and drinking alcohol, demonstrated unsustained HIV suppression. Viral load suppression is one of the most reliable indicators of adherence and it acts as a positive reinforcement to encourage continuous adherence by patients. When patients initiating ARVs fail to achieve viral suppression within 24 weeks of treatment, the possibility of suboptimal adherence and other impact factors need assessment. Similarly, treatment failure as measured by detectable viral load during chronic care is most likely the result of non-adherence (53). Viral non-suppression is a common phenomenon even among people with good adherence, which highlights the need to ensure wide coverage and viral load testing services (69). The association between adherence and clinical progression, however, might not entirely explain the full suppression of viral load. While full and durable viral suppression requires nearly perfect adherence, despite the average rate of adherence, few patients on combination ARVs do progress to AIDs and death (70). Viral failure can result from failing to take treatment (defaulting) or by the ARVs no longer working even though the individual was taking the treatment regularly. In this present study, 53.3% had viral failure due to non-adherence, which is worrisome, given the health implications of HIV/AIDS. This portends a health burden to the country because, as disease progression among these participants become more rapid, they would return to the health facility to continue treatment with ARVs. This indicates the need for increased health education with emphasis on the etiology of the disease both at the health facility level and at that of the community level (71).
The finding of the study demonstrated that although the majority of the participants had no apparent reason for their non-adherence to AVR treatment, the majority of them did not adhere to their ARV treatments (70%). However, very surprisingly, the majority of the participants indicated having a good knowledge of HIV/AIDs and methods of contraction (64%).
The only common side effect reported by the participants in the present study was bad dreams (19.7%). However, other studies have shown that individuals on ARVs do report several side effects such as memory loss, numbness of feet, dizziness and dermatological symptoms (hair loss, skin rash, change in skin tone) (8), fever, fatigue, chest pain, suicidal thoughts (9), bone disorders, muscular disorders, cardiovascular, liver disorders, immune disorders, metabolic disorders and kidney side effects. Anti-HIV therapy, affects the entire body, and the various drugs may cause adverse reactions in almost all organs and systems (72). This is not surprising, since the drugs often interfere with genetic and cellular processes that are common to both viruses and human cells. However, certain classes of drugs are more often associated with specific types of side effects, for example, some nucleotides’ analogs are associated with low blood cell counts and mitochondrial toxicity, whereas some non-nucleotides reverse transcriptase inhibitors (NNRTIs) are associated with skin reactions. Furthermore, long-term treatment, especially with regimens that include a protease inhibitor, is associated with increased blood fat levels and body fat distribution (73,74).
Interestingly, although the majority of the participants felt satisfied with other indicators of quality of care they had received, the majority of participants indicated having to wait for more than two hours before receiving attention at the health facility. Long waiting times and limited clinic hours would lead to non-adherence (14,40,41,62,75). The positive patient’s experiences with the quality of care and patient satisfaction with the clinic are important elements in quality improvement work at the facility; they are also indicators of the quality of health care (24). Several studies have reported non-adherence linked to unpleasant experiences with clinic staff (14,40,76,77); and both nurses and patients affirmed that good clinical care included providing counseling and supportive environment to help patients develop optimal adherence strategies (78). The active participation of patients in their care can improve the effectiveness of care as well as their satisfaction with their care. Patients who receive respect, are maintain their dignity, are well informed and able to participate in treatment decisions are more likely to comply with their treatment plans. Empowering individuals with the skills and tools to care for themselves is especially important for individuals with chronic illness or disability. Enabling users to assess their health practice preventive health care, and self-care, will improve their health and reduce unnecessary health care services and costs (79).
In the present study, after adjusting for confounders in the logistic regression analysis, only non-Christians and unsuppressed viral loads were the independent predictors of non-adherence. Participants who were non-Christians had 3.2 times likelihood of failing to adhere to their ARVs compared to those who were Christians. Furthermore, participants with unsuppressed viral loads were 3 times more likely to be non-adherent to their ARVs compared to participants with suppressed viral load. Zuo et al. reported that belief in the healing power of prayer was not significantly associated with a person’s hypothetical willingness to begin ARV treatment. Instead, willingness was associated with age, education and ARV knowledge (80). This suggests that while a small fraction of people may decline ARV treatment because of their belief in the healing power of prayer, in the majority of cases religious beliefs about HIV pose no obstacle to the acceptance of medical treatment.
Limitations
Due to some limitations in this study, caution should prevail when interpreting the findings. This study’s sample, among PLWHA sampled in six health clinics in East London, may not be representative of the whole Province nor of South Africa. Furthermore, given that ART adherence was by self-report, the possibility of recall bias cannot be overruled. Additionally, only patients on ART treatment who came to the clinic at the time of data collection were included in the study. This suggests a selection bias because day patients not retained in the clinic and those who had missed clinical appointments during the period were not included. Finally, due to the cross-sectional design of this study, the variation of adherence of the participants to ART, which could have occurred over the time, was not assessed (43).
Conclusion
The majority of participants did not adhere to their ARV treatment. The main contributing factors to ART non-adherence among the participants on ARVs were marital status, level of education, religion and alcohol consumption. Non-Christians and unsuppressed viral loads were the independent predictors of non-adherence among patients in this setting. Although the majority of the participants felt satisfied with other indicators of quality of care they had received, they indicated that waiting for more than two hours before being attended to at the health facility was unsatisfactory.
References
- Shashana O, Rehle T, Simbayi LC, Zuma K, Jootse S. Zungu N, et al. South African national HIV prevalence, incidence and behaviour survey 2012. Cape Town. HSRC Press. 2014.
- UNAIDS. Report on the global AIDS epidemic. 2017. Geneva: UNAIDS.
- National Department of Health. National HIV Counselling and Testing Policy (HCT) Policy Guidelines. Pretoria: Department of Health, 2015.
- Health, N.D. National HIV Counselling and Testing (HCT) Policy Guidelines. Pretoria: Department of Health. 2010.
- CDC . Medication adherence. Atlanta, GA2013.
- Shubber Z, Mills EJ, Nachega JB, Vreeman R, Freitas M, Bock P, et al. Patient-reported barriers to adherence to antiretroviral therapy: a systematic review and meta-analysis. Plos One. 2016;13(11): e1002183.
- Heestermans T, Browne JL, Aitken SC, Vervoort SC, Klipstein-Grobusch K. Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review. BMJ Global Health. 2016;1:e000125.
- Chen WT, Shiu CS, Yang JP, Simon JM, Fredriksen-Golsen KI, Lee TSH, et al. Antiretroviral Therapy (ART) side effect impacted on quality of life, and depressive symptomatology: a mixed-method study. J AIDS Clin Res. 2013;4:218.
- Hima Bindu, Nanga Anusha, P. Adverse effects of Highly Active Antiretroviral (HAART). J Antivir Antiretrovir. 2011;3:60-64.doi: 10.4172/jaa.1000037.
- Fonsah JY, Njamnshi AK, Kouanfack C, Qiu F, Njamnshi DM, Tagny CT, et al. Adherence to Antiretroviral Therapy (ART) in Yaoundé-Cameroon: Association with opportunistic infections, depression, art regimen and side effects. PLoS ONE, 2017; 12(1): e0170893. https://doi.org/10.1371/journal.pone.0170893.
- Renju J, Moshabela M, McLean E, Ddaaki W, Skovdal M, Odongo F, et al. 'Side effects' are central effects that challenge retention in HIV treatment programmes in six sub-Saharan African countries: a multicountry qualitative study. Sex Transm Infect 2017;0:1–5. doi:10.1136/sextrans-2016-052971
- Dima AL, Schweitzer A, Diaconita R, Remor E, Wanless R. Adherence to ARV medication in Romanian young adults: Self-reported behaviour and psychological barriers. Psychol Health & Med. 2013;18(3):343-54.
- Azia NI, Makumbang FC, Van wyk B. Barriers to adherence to antiretroviral treatment in a regional hospital in Vredenburg, Western Cape, South Africa. Southern Afr J HIV Med. 2016;17(1):1-8.
- Kagee A, Nothling J, Coetzee B. The perspectives of users of antiretroviral therapy on structural barriers to adherence in South Africa. South Afr Fam Pract. 2012;54:540-544.
- Moremi, GS. Barriers to antiretroviral adherence of HIV/AIDS patients under the wellness program in Mogwase Health Centre. 2012.
- Langa, L. Lack of transport hampering treatment success. Southern Afr. HIV Clinicians Soc Nurs. 2010;1(3):7.
- Govinsamy D, Ford N, Kranzer K. Risk factors, barrier and facilitators for linkage to antiretroviral therapy care: a system review. AIDS, 2012;26(16):2059-67.
- Colombini M, Stöckl H, Watts C, Mayhew S. Factors affecting adherence to short-course ARV prophylaxis for preventing mother-to-child transmission of HIV in sub-Saharan Africa: a review and lessons for future elimination. AIDS Care. 2014;26(7):914-26.
- Martin F, Kiwanuka T, Kawuma R. Zalwango F, Seeley J. Tasks and strategies of self-management of living with antiretroviral therapy in Uganda. AIDS Patient Care STDS. 2013;27(12):697-706.
- Mukui IN, Ng’ang’a L,Williamson J,Wamicwe JN,Vakil S, Katana A, et al. Rates and predictors of non-adherence to antiretroviral therapy among hiv-positive individuals in Kenya: Results from the Second Kenya AIDS Indicator Survey. PLoS ONE 2016;11(12):e0167465.
- Neblett RC, Hutton HE, Lau B, McCaul M, Moore RD, Chander G. Alcohol consumption among HIV-infected women: Impact on time to antiretroviral therapy and survival. J Womens Health, 2011; 20(2): 279-286.
- Schneider M, Nueman M, Chersich M, Parry C. Alcohol and antiretroviral therapy- a lethal cocktail. J AIDS Clinic Res. 2012; S1:005:doi:10.4172/2155-6113, S1-005.
- Da Santos V, Galvao M, da Cuhna G, de Lima I, Gir E. Alcohol effect on HIV-positive individuals: treatment and quality of life. Acta Paul Enferm. 2017;30(1):94-100.
- Ndou TV, Maputle SM, Risenga PR. HIV-positive patient’s perception of care received at a selected antiretroviral therapy clinic in Vhembe district, South Africa. African J. Primary Health Care & Fam Med 2016;8(2):e1-6.
- Mathebula JB. Reasons for default follow-up of antiretroviral treatment at Thekganang ARV clinic. Masters Dissertation, University of Pretoria, South Africa; Available at: http://hdl.handle.net/2263/43174. 2013.
- Okoye OU, Diekedie A, Afemikhe OA. Perceived barriers to accessing and adhering to antiretroviral therapy by people living with HIV/AIDS (PLWHAs) in Akwa Ibom State, Nigeria. Res Hum Soc Sci. 2015;5(9):107-113.
- Wasti SP, Simkhada P, Randall J, Freeman JV, van Tejlingen E. Factors influencing adherence to antiretroviral treatment in Nepal: a mixed-methods study. PLOS ONE, 2012; 7(5): e35547. doi:10.1371/journal.pone.0035547.
- Igbende, Aumbur D, Dooior, Mkpelanga, Ogwuche, Chinelo, H. et al. Belief in spiritual healing, gender and adherence to medication among HIV/AIDS patients in Benue State, Nigeria. Int J Health Psychol Res. 2016;4(1):22-30.
- Musumari PM, Wouters E, Kayembe PK, Nzita MK, Mbikayi SM, Suguimoto SP, et al. Food insecurity is associated with increased risk of non-adherence to antiretroviral therapy among HIV-infected adults in the Democratic Republic of Congo: a cross-sectional study. Plos One. 2014;9(1):e85327.
- Kalichman S, Pellowski J, Kalichman M, Cherry C, Detorio M, et al. Food insufficiency and medication adherence among people living with HIV/AIDS in urban and peri-urban settings. Prevent Sci. 2011;12: 323-332.
- Pereti-Watel P, Spire B, Schiltz MA, Bouchnik AD, Heard I. et al. Vulnerability, unsafe sex and non-adherence on HAART: evidence from a large sample of French HIV/AIDS outpatients. Soc Sci Med. 62: 2420-2433.
- Najjar A, Amro Y, Kitaneh I, et al. Knowledge and adherence to medications among Palestinian geriatrics living with chronic diseases in the West Bank and East Jerusalem. PloS One, 2015;10(6):e0129240.
- Peltzer K, Preez NF, Ramlagan S, Anderson J. Antiretroviral adherence among HIV patients in KwaZulu-Natal, South Africa. BMC Public Health, 2010;10:111.
- Naidoo P, Peltzer K, Louw J, Matseke G, Mchunu G, Tutshana B. Predictors of tuberculosis (TB) and antiretroviral (ARV) medication non-adherence in public primary care patients in South Africa: a cross sectional study. BMC Public 2013;13:396.
- Schneider M, Chersich M, Temmerman M, Parry CD. Addressing the intersection between alcohol consumption and antiretroviral treatment: needs assessment and design of interventions for primary healthcare workers, the Western Cape, South Africa. Globalisation and Health, 2016;12: 45. doi 10.1186/s12992-016-0201-9
- Kekwaleswe CT, Morojele NK. Patterns and predictors of an antiretroviral therapy use among alcohol drinkers at HIV clinics in Tshwane, South Africa. AIDS Care, 2014;26(1):578-582.
- Dahah M, Charalambous S, Hamilton R, Fielding K, Kielmann K, Churchyard G, et al. ‘That is why I stopped the ART’: patients’ and providers’ perspectives on barriers to and enablers of HIV treatment adherence in a South African workplace programme. BMC Public Health. 2008;80(4):669-674.
- Miller CM, Ketlhapile M, Rybasack-Smith H, Rosen S. Why are antiretroviral treatment patients lost to follow-up? A qualitative study from South Africa. Trop Med Int Health. 2010; 15(1):48-54.
- Bhat VG, Ramburuth M, Singh M, et al. Factors associated with poor adherence to anti-retroviral therapy in the Gambia. AIDS Care. 2010;22:1340-1345.
- Boyer S, Clerc I, Bonono CR, et al. Non-adherence to antiretroviral treatment and unplanned treatment interruption among people living with HIV/AIDS in Cameroon: individual and healthcare supply-related factors. Soc Sci Med. 2011;72:1383-1392.
- Lyimo RA, Stutterheim SE, Hospers HJ, de Glee T, van der Ven A, de Bruin M. Stigma, disclosure, coping, and medication adherence among people living with HIV AIDS in Northern Tanzania. AIDS Patient Care STDS. 2014;28:98-105.
- Yarney L, Amankwah AK, Mba C, Asamoah K, Bawole JN. Facilitators and barriers to antiretroviral therapy adherence among Ghanaian patients: A multi-case study of Sunyani Municipal and Regional Hospitals in the Brong-ahafo Region. Afr Pop Stud. 2016;30(2): 2308-7858.
- Yaya I, Landoh DS, Saka B, Patchali PM, Wasswa P, Aboubakari A, et al. Predictors of adherence to antiretroviral therapy among people living with HIV and AIDS at the regional hospital of Sokode, Togo. BMC Public Health. 2014;14:1308.
- Pennap GR, Abdullahi U, Bako IA. Adherence to highly active antiretroviral therapy and its challenges in people living with human immunodeficiency virus (HIV) infection in Keffi, Nigeria. J AIDS Res. 2013;5:52-58.
- Li L, Lee S-J, Wen Y, Lin C, Wan D, Jiraphongsa C. Antiretroviral therapy adherence among patients living with HIV/AIDS in Thailand. Nurs Health Sci. 2010;12:212-220.
- Kalichman S, Caiz S, Ramachadran B. Barriers to HIV/AIDS treatment and treatment adherence among African-American adults with disadvantaged of education. J Natl Med Assoc. 1999;9:439-441.
- Munene E, Ekman B. Association between patient engagement in HIV care and antiretroviral therapy medication adherence: cross-sectional evidence from a regional HIV care centre in Kenya. AIDS Care. 2015;27:378-386.
- McGuire M, Munyenyembe T, Szumilin E, Heinzelmann A, Le Paih M, Bouithy N, et al. Vital status of pre-ART and ART patients defaulting from care in rural Malawi. Trop Med Int Health. 2010;1:55-62.
- Boatang D, Kwapong, GD, Agyei-Baffour, P. Knowledge, perception about antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) and adherence to ART among HIV positive women in the Ashanti Region, Ghana: a cross-sectional study. BMC Women’s Health, 2013; 13:2
- Jing Jin, Grant Edward Sklar, Vernon Min Sen Oh, Shu Chuen Li (2008). Factors affecting therapeutic compliance: a review from the patient’s perspective. Therap Clinical Risk Man. 2008;4(1):269–286.
- World Health Organisation. Adherence to Long –Term Therapies: Evidence for action. Geneva, 2003.
- Souza D. Effect of intensive health education on adherence to treatment in sputum positive pulmonary tuberculosis patients. Ind J Tub. 2003;50:33.
- Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents, limitations to treatment safety and efficacy: adherence to antiretroviral therapy. Department of Health and Human Services, 2014.
- Bezabhe WM, Chalmers L, Bereznicki LR, Peterson GM, Bimirew MA, Kassie DM. Barriers and facilitators of adherence to antiretroviral drug therapy and retention in care among adult HIV-positive patients: A qualitative study from Ethiopia. Plos One, 2014;9(5):e97353.
- Yakassai AM, Muhammad H, Babashani M, Jumare J, Abdulmumini M, Habib AG. Once-daily antiretroviral therapy among treatment –experienced Muslim patients fasting for the month of Ramadan. Trop Doctor, 2011; 41: 233-235.
- Finocchario-Kessler S, Catley D, Berkley-Patton J, Gerkovich M, Williams K, Banderas J, et al. Baseline predictors of ninety percent of higher antiretroviral therapy adherence in a diverse urban sample: the role of patient autonomy and fatalistic religious beliefs. AIDS Patient Care STDS. 2011;25:103-111.
- Togarasei L. Christian theology of life, death and healing in an era of antiretroviral therapy: reflections on the responses of some Botswana churches. Afr J AIDS Res, 2011;9 (4):429-435.
- Mbirimtengerenji ND, Jere G, Lengu S, Maluwa A. Factors that influence antiretroviral therapy adherence among women in Lilongwe urban health centres, Malawi. World J AIDS. 2013;3:16-25.
- Vasquez KS. “Intersection of religious and antiretroviral experiences and its implications for medication adherence in HIV positive individuals in León, Nicaragua” Public Health Theses. (2015).
- Bill of Rights (Chapter 2 of the Constitution of the Republic of South Africa. Act 108 of 1996. Western Cape Government, Cape Town, South Africa.
- Kling S. The ‘difficult’ patient – may i refuse to treat him? Current Allergy & Clinical Immunol. 2013; 26(1): 37-39.
- Vyankandondera J, Mitchell K, Asiimwe-Kateera B, Boer K, Mutwa P, Balinda JP, et al. Antiretroviral therapy drug adherence in Rwanda: perspectives from patients and healthcare workers using a mixed-methods approach. AIDS Care. 2013; 25:1504-1512.
- Elul B, Basinga P, Nuwagaba-Biribonwoha H, Saito S, Horowitz D, Nash D, et al. High levels of adherence and viral suppression in a nationally representative sample of HIV-infected adults on antiretroviral therapy for 6, 12 and 18 months in Rwanda. Plos One. 2013;8:e53586.
- Negash T, Ehlers V. Personal factors influencing patients’ adherence to ART in Addis Ababa, Ethiopa. J Assoc Nurses AIDS Care. 2013;24:530-538.
- National Institute on Alcohol Abuse and Alcoholism: Alcohol Alert, no.57, (September 2002).
- Kader R, Govender R, Seedat S, Koch, JR, Parry C. Understanding the impact of hazardous and harmful use of alcohol and/or other drugs on ARVs adherence and disease progression. PLos ONE. 2015;10(5):e0125088.
- U.S Dept. of Health & Human Services. Alcohol Alert, 2004: 16.
- Kalichman SC, Grebler T, Amaral CM, McNerney M, White D, Kalichman MO, et al. Viral suppression and antiretroviral medication adherence among alcohol using HIV positive adults. Int J Behav Med. 2014;21(5):811-20.
- Bulage L, Ssewanyana I, Nankabirwa V, Nsubuqa F, Kihembo, C, Pande, G, et al. Factors associated with virological non-suppression among HIV positive patients on antiretroviral therapy in Uganda. BMC Infect Dis. 2017;17:326.
- Machitinger EL, Bansberg DR. HIV in Site knowledge Base Chapter May 2005. Content Review, 2006. Available at: http://hivinsite.ucsf.edu/InSite?page=kb-03-02-09. Accessed 17th March 2018.
- Boateng D, Kwapong GD, Agyei-Baffour P. Knowledge, perception about antiretroviral therapy (ART) and prevention of mother-to-child-transmission (PMTCT) and adherence to ART among HIV positive women in the Ashanti Region, Ghana: a cross-sectional study. BMC Womens Health. 2013;13:2.
- National Department of Health. National consolidated guidelines for the prevention of mother-to-child transmission of HIV (PMTCT) and the management of HIV in children, adolescents and adults: Department of Health Pretoria. 2015.
- Highleyman L. Adverse effects associated with antiretroviral therapy. St Francisco AIDS Foundation, USA, 2000.
- Khan K, Khan AH, Sulaiman SA, Soo CT, Aftab RA. Adverse effect of Highly Active Anti-Retroviral Therapy (HAART) in HIV/AIDS patients. Indian J Pharmacy Pract. 2014; 7(3).
- Mbonye M, Seeley J, Ssembajja F, et al. Adherence to antiretroviral therapy in Jinja, Uganda: a six-year follow-up study. Plos One. 2013;8(10):e78243.
- Idindili B, Julu B, Mugus F, Tanner M. A case-control study of factors associated with non-adherent to antiretroviral therapy among HIV infected people in Pwani Region, eastern Tanzania. Tanzan J Health Res. 2012;14(3)194-203.
- Rasmussen DN, da Sliva Te D, Rodkjaer L. Barriers and facilitators to antiretroviral therapy adherence among patients with HIV in Bissau, Guinea-Bissau: a qualitative study. Afr J AIDS Res. 2013;12: (1):1-8.
- Campbell C, Scott K, Madanhire C, Nyamukapa C, and Gregson S. A good hospital: Nurse and patient perceptions of good clinical care for HIV- positive people on antiretroviral treatment in rural Zimbabwe-A mixed-methods qualitative study. Int J Nurs Stud. 2011;48(2):175-83.
- National Department of Health. A policy on quality in health care for South Africa. Pretoria. 2007.
- Zou J, Yamanaka Y, John M, Watt M, Ostermann J, Thielman N. Religion and HIV in Tanzania; influence of religious beliefs on HIV stigma, disclosure. BMC Public Health. 2009; 9:75.
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