Adherence to antiretroviral therapy in Nigeria: an overview of research studies and implications for policy and practice

'I take the drugs… to make the sickness to move out of me': key populations' and service provider perspectives about facilitators and barriers to ART adherence and retention in care in Nigeria

BACKGROUND

Adherence to antiretroviral therapy (ART) has individual and public health benefits and is critical to improving life expectancy, achieving viral suppression, and reducing the risk of HIV transmission. This qualitative study explored the experience of receiving care as well as perceived facilitators and barriers of treatment initiation, retention in ART care, and adherence to treatment.

METHODS

In-depth interviews were conducted among 28 men who have sex with men (MSM) and female sex workers (FSWs) receiving ART services in Lagos and Benue states. Key informant interviews were also conducted among 16 service providers engaged in counselling, clinical care, and ART treatment for MSM and FSWs. The Social Ecology Model guided the exploration of perceived barriers and facilitators of treatment initiation, retention in ART care and adherence to treatment. Qualitative data analysis was managed using NVIVO 11 software and themes were analysed using thematic analysis.

RESULTS

We found that the key barriers to ART adherence were low motivation to comply with medication regimen, work commitments, socioeconomic factors, stigma, negative provider attitude and distance to health facilities. Facilitators of adherence identified include the desire to live a productive life, strong family support and participation in support group programs. Comprehensive adherence counselling, support group programs and an effective follow-up system were factors identified by service providers as key to facilitating adherence.

CONCLUSION

To be effective, ART programs must address the unique challenges key populations face in accessing treatment and achieving optimal adherence regarding establishing a strong support system and follow-up. Community level interventions that support a stigma-free environment are critical to sustaining engagement in care.

Adherence determination using urine-tenofovir point-of-care testing and pharmacy refill records: A cross-sectional study

Pharmacy refill records (PRR), are an accessible strategy for estimating adherence in low- and middle-income countries (LMICs). However, the low-cost urine-tenofovir point-of-care test opens up the possibility of an objective metric of adherence that is scalable to LMICs. This study compared adherence to tenofovir-based regimens using urine-tenofovir point-of-care (POC) test with pharmacy refill records in a Nigerian population of HIV-positive persons. This was a cross-sectional study among 94 HIV-positive adults, which was conducted from June to August 2021, in a large outpatient clinic in Lagos, Nigeria. Adherence to pharmacy appointments was automatically calculated using a computerized pharmacy appointment system (FileMaker Pro™). Urine drops on the urine-tenofovir POC test strip developed 2 lines for a negative test (tenofovir absent) and one line for a positive test. Fisher's exact test was used to examine the association between pharmacy refill record and urine-tenofovir point-of-care test. Logistic regression was performed to predict viral suppression (<1000 copies/mL, based on WHO recommendations) using both methods of adherence determination. A Receiver Operating Characteristic (ROC) curve of the association between specificity and sensitivity was generated to evaluate the predictive value of adherence determined using pharmacy-refill record and urine-tenofovir point-of-care test in forecasting viral suppression. The statistical significance level was set at 0.05. Fisher's exact test showed no statistically significant difference in adherence using urine-tenofovir point-of-care test or pharmacy refill record. The logistic regression model showed that an increase in pharmacy-refill record of ≥ 95% was associated with viral suppression (P = .019). From the ROC curve, the sensitivity was same at 95.5% for both methods, but the specificity of the urine-tenofovir point-of-care test was greater (96.6% vs 95.5%) than pharmacy refill record (P = .837). Urine-tenofovir point-of-care test provided equivalent adherence data to pharmacy refill data.

Exploring the barriers to the antiretroviral therapy adherence among people living with HIV in Bangladesh: A qualitative approach

INTRODUCTION

Since the evolution of highly active antiretroviral therapy (ART), a near-perfect ART adherence level (>95%) is needed to control viral suppression. Non-adherence to treatment may lead to acquired immunodeficiency syndrome (AIDS) and drug resistance. Though the Bangladesh government provides free treatment and counselling services to people living with human immunodeficiency virus (PLHIV), only 22% of the identified PLHIV continue treatment. Therefore, this study aims to explore the barriers that obstruct the Bangladeshi PLHIV to ensure ART adherence.

METHODS

We conducted a qualitative study in Dhaka, Bangladesh, and recruited the sensitive study population following non-probability, mainly purposive sampling from a community-based registered organization for PLHIV. We conducted the in-depth interview using a semi-structured guideline with 15 consented respondents. We transcribed the audio-recorded interviews in the local language (Bangla) and then translated those into English for data analysis. During the data extraction process, the lead and corresponding authors independently extracted raw data to generate different themes and sub-themes and invited other authors to contribute when they could not solve any discrepancies.

RESULTS

The study identified three significant categories of barriers at the individual, community, and institutional levels that negatively interfered with ART adherence. The most dominant barriers were discrimination and rejection related to stigma, as almost all participants mentioned these barriers. Stigmatizing attitudes and the discriminatory act of the community people and healthcare providers critically affected their treatment adherence. Other leading barriers were improper inventory management of ART-related medicines and CD4 tests and lack of proper counselling. In addition, we found that a positive approach toward life and family support motivated some respondents to overcome the barriers.

CONCLUSIONS

We recommended strengthening Bangladesh's HIV/AIDS prevention, treatment, and management program with a special focus on the improvement of the supply chain of ART-related medicines and CD4 tests and ensuring proper counselling. In addition, we recommended strengthening the behaviour change communication and IEC activities at a large scale to destigmatize health facilities and community levels.

Magnitude of optimal adherence and predictors for a low level of adherence among HIV/AIDS-infected adults in South Gondar zone, Northwest Ethiopia: a multifacility cross-sectional study

OBJECTIVES

This study aims to identify levels of adherence to antiretroviral therapy (ART) drugs and factors associated with them in Northwest Ethiopia. We hypothesise that in the era of COVID-19, there would be suboptimal adherence to ART drugs.

DESIGN

An observational cross-sectional study was conducted. Factors associated with the level of adherence were selected for multiple logistic regressions at a p value of less than 0.2 in the analysis. Statistically significant associated factors were identified at a p value less than 0.05 and adjusted OR with a 95% CI.

SETTING

The study was conducted in one specialised hospital and three district hospitals found in the South Gondar zone, Northwest Ethiopia.

PARTICIPANTS

About 432 people living with HIV/AIDS receiving highly active ART in South Gondar zone public hospitals and who have been on treatment for more than a 3-month period participated in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Levels of adherence to ART drugs and their associated factors.

RESULTS

Among 432 study participants, 81.5% (95% CI: 78% to 85.2%) of participants were optimally adherent to ART drugs. Determinants of a low level of adherence: stigma or discrimination (OR=0.4, p=0.016), missed scheduled clinical visit (OR=0.45, p=0.034), being on tuberculosis treatment (OR=0.45, p=0.01), recent CD4 cell count less than 500 cells/mm³ (OR=0.3, p=0.023) and patients who had been on WHO clinical stage III at the time of ART initiation (OR=0.24, p=0.027) were factors significantly associated with adherence to ART drugs.

CONCLUSIONS

Level of adherence was relatively low compared with some local studies. The intervention targeted to reduce discrimination, counselling before initiation of treatment and awareness regarding compliance is advised to improve adherence to antiretroviral regimens.

Self-reported adherence to highly active antiretroviral therapy in a tertiary hospital in Nigeria

Background

Non-adherence to highly active antiretroviral therapy (HAART) favours drug resistance and wastes resources. These have negative implications for personal and public health.

Objective

To assess adherence levels, the associated factors and its association with increase in CD4 cell count in people living with HIV (PLHIVs).

Methods

In a cross-sectional survey, systematically selected adult PLHIVs attending a tertiary hospital in Nigeria self-reported their 28-day adherence to HAART and reasons for missing doses using an interviewer-administered questionnaire. Their 6-month difference in CD4 cell count was also assessed.

Results

The participants totalled 425. Their mean age was 38.6 (SD, 10.1) years and 309 (72.7%) had secondary or tertiary education. The 28-day mean adherence level was 96.8% (SD, 7.9%) and 354 (83.3%) participants had optimal adherence (≥ 95%). Socio-demographic characteristics, side effects and having human reminders were not associated with adherence level, but 100% adherence level since placement on HAART was positively associated with a 6-month increase in CD4 cell count (p < 0.01; OR = 1.87, 95%CI = 1.21 – 2.89). Reasons given by 156 respondents for missing doses included being too busy, 100 (64.1%), forgetting, 85 (54.5%) and sleeping off, 42 (26.9%).

Conclusion

Mean adherence was high and the majority of participants had optimal adherence. “Never missing a dose” was associated with improved CD4 cell counts, indicating better prognosis. Socio-demographic factors, side effects and human reminders were not associated with an increase in adherence. However, as there is no evidence that adherence improvement measures are detrimental, their use is still recommended.

Funding

None declared

Performance and trend for quality of service in a large HIV/AIDS treatment program in Nigeria

Background

As antiretroviral therapy (ART) programs expand access, there is an increase in burden to a healthcare system. These results are reduced provider-patient contact time and poor programmatic and patient outcomes. Quality management offers providers a standardized approach for addressing the appropriateness of care to be applied in resource-limited settings. This study aimed to determine the trend of performance on HIV/AIDS quality management indicators of health facilities providing ART over a period of 5 years.

Methods

The annual performance scores of quality of care (QoC) indicators of 31 health facilities providing ART was extracted from a database covering a period of 5 years (from October 2008 to September 2012). The data are percentages that indicate scores of each health facility assessed based on compliance to National ART guidelines categorized into several indicator domains. A Chi square statistic for the trend, as well as test for departure from the trend line was determined. The p value associated with each indicator provides the significant level for testing an alternative hypothesis that the rate of change over the period considered for that indicator does not equal to zero. The slope of the regression line also gives the magnitude of the rate of change for each indicator by healthcare level across the review period.

Results

Generally, performance trends showed improvement across most indicator domains. The highest improvement occurred for “3 month loss to follow-up” and “1 year no-visit”, with scores declining from 37 to 3%, and 42% to 12% respectively. However, there was a sharp decline in performance between 2010 and 2012 in weight monitoring of patients (p < 0.01), adherence assessment to ARVs (p < 0.01) and hematocrit measurements (p = 0.01). The aggregate rate of change β, as obtained from the slope of the trend line is highly significant (p < 0.01) for all the quality of care indicators considered, whether improving or declining.

Conclusion

Periodic assessment to determine HIV/AIDS quality of care can guide rapid scale-up of services to achieve universal coverage in resource-limited settings. Determining trends to understand patterns is very useful for improving programmatic and patient outcomes.

Gastrointestinal Parasitic Infections and Immunological Status of HIV/AIDS Coinfected Individuals in Nigeria

BACKGROUND

Parasitic infections of the gastrointestinal tract is one of the highest causes of morbidity and mortality among HIV infected individuals. This is due to the colonization of the intestinal tract by parasites influenced by induced enteropathy caused by HIV infection. CD+4 t-lymphocytes count is a marker of the immune status of HIV infected individuals.

OBJECTIVE

This study investigated the prevalence of gastrointestinal parasitic infections among HIV coinfected individuals in relation to their immunological status.

METHODS

CD+4 t-lymphocytes count was determined using fluorescence-activated cell sorting (FACS) count system. Parasitological examination of faecal samples was conducted using direct wet mount, modified Z-N and Giemsa stain techniques. All prepared slides were examined under x10 and x40 objectives.

FINDINGS

Out of the 891 HIV seropositive participants on antiretroviral therapy that were studied, 641 (71.9%) had CD+4 counts equals to or greater than 500 cells/mm3. All other seropositive participants had CD+4 counts below 500 cells/mm3. Gastrointestinal parasitic infections were recorded in 187 (20.9%) seropositive participants, with females (n = 108, 12.1%) having more infections than males. Multiple gastrointestinal parasitic infections were recorded in 28 (3.1%) seropositive participants. Out of the 150 seronegative participants, 79 (52.7%) of them had at least one gastrointestinal parasitic infection. Female seronegative participants also accounted for higher infection rate (n = 42, 28.0%) than males (n = 37, 24.7%). Multiple infections were also recorded in 18 (12.0%) seronegative individuals. The overall prevalence rate of infection between both positive and negative individuals was 25.5%. There was statistical significant difference in the infections of Cryptosporidium parvum (p < 0.003), Cyclospora cayetanensis (p < 0.011) and Cystoisospora belli (p < 0.011) between HIV seropositive and HIV seronegative individuals. Also, there was statistical significant difference in the infections of hook worm (p < 0.002) and Trichuris trichiura (p < 0.020) between seronegative and seropositive individuals. Gastrointestinal parasitic infection rate was significantly higher among seropositive participants with CD+4 counts between 200 and 350 cells/mm3 (n = 109, 58.3%).

CONCLUSION

The study shows that HIV infected individuals continue to experience gastrointestinal infections even with antiretroviral treatment, especially those with CD+4 counts below 350 cells/mm3. Health care providers should prioritise routine screening of HIV patients for gastrointestinal parasites and provide prompt treatment. Antiparasitic drugs should also be provided as prophylaxis.

Medication Side Effects and Retention in HIV Treatment: A Regression Discontinuity Study of Tenofovir Implementation in South Africa and Zambia

Tenofovir is less toxic than other nucleoside reverse-transcriptase inhibitors used in antiretroviral therapy (ART) and may improve retention of human immunodeficiency virus (HIV)-infected patients on ART. We assessed the impact of national guideline changes in South Africa (2010) and Zambia (2007) recommending tenofovir for first-line ART. We applied regression discontinuity in a prospective cohort study of 52,294 HIV-infected adults initiating first-line ART within 12 months (±12 months) of each guideline change. We compared outcomes in patients presenting just before and after the guideline changes using local linear regression and estimated intention-to-treat effects on initiation of tenofovir, retention in care, and other treatment outcomes at 24 months. We assessed complier causal effects among patients starting tenofovir. The new guidelines increased the percentages of patients initiating tenofovir in South Africa (risk difference (RD) = 81 percentage points, 95% confidence interval (CI): 73, 89) and Zambia (RD = 42 percentage points, 95% CI: 38, 45). With the guideline change, the percentage of single-drug substitutions decreased substantially in South Africa (RD = -15 percentage points, 95% CI: -18, -12). Starting tenofovir also reduced attrition in Zambia (intent-to-treat RD = -1.8% (95% CI: -3.5, -0.1); complier relative risk = 0.74) but not in South Africa (RD = -0.9% (95% CI: -5.9, 4.1); complier relative risk = 0.94). These results highlight the importance of reducing side effects for increasing retention in care, as well as the differences in population impact of policies with heterogeneous treatment effects implemented in different contexts.

The relationship between patient-related factors and medication adherence among Nigerian patients taking highly active anti-retroviral therapy

BACKGROUND

Through several initiatives, there are increasingly more people who have access to anti-retroviral therapy. Adherence to therapy is, however, necessary for successful management of disease.

OBJECTIVES

The objectives of this study were to describe adherence rates and determine what patient-related factors are related to adherence to anti-retroviral therapy among adult patients in an HIV clinic located in Lagos, Nigeria.

METHODS

Adherence was measured using the two-week self-recall method. Barriers, satisfaction with therapy, and socio-demographic and clinical variables served as independent variables. Data were collected via self-administered surveys.

RESULTS

Most of the patients (79.5%) reported 100% adherence. The significant (p<0.05) barriers to adherence were forgetfulness, running out of medication, alcohol use, and medication side effects. For every unit increase in the number of barriers, patients were 60.8% less likely to be 100% adherent (p <0.05, odds ratio, OR = 0.392, 95% CI = 0.295-0.523).

CONCLUSION

Interventions should target helping patients cope with forgetfulness, specifically employing strategies to overcome busyness in schedules, being away from home, and tiredness.

Nonadherence Factors and Sociodemographic Characteristics of HIV-Infected Adults Receiving Antiretroviral Therapy in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria

Adherence to treatment instructions with antiretroviral therapy (ART) is very crucial for successful treatment outcome. However, sticking to treatment instructions pose-great challenges to HIV/AIDS patients. This cross-sectional study was on HIV infected adults attending ART clinic in Nigeria to explore nonadherence factors in relation to their socioeconomic characteristics. Validated structured questionnaire was administered to 221 participants. Results showed a high nonadherence rate of 85.1%. The commonest occurring factors of non-adherence were forgetfulness (53.8%), busy schedule (38.8%), side effects of drugs (31.9%), and stigma (31.9%). Males were more likely to complain from busy schedule, feeling healthy, fear of partner disclosure, long waiting period, and long term regimen. Patients with no formal education were more likely to attribute non-adherence to poor communication, side effects of drugs, and stigma. Employed patients seemed to miss their drugs more than the unemployed and artisans. The high non-adherence rate has serious implications for the control of HIV in infected individuals and management of HIV in general. Nurses should intensify efforts on patient education and counseling.

Factors influencing adherence to paediatric antiretroviral therapy in Portharcourt, South- South Nigeria

INTRODUCTION

The efficiency of antiretroviral therapy (ART) depends on a near-perfect level of patient's adherence. Adherence in children poses peculiar challenges. The aim of the study was to determine the adherence level and factors influencing adherence among HIV-infected children and adolescents in University of Port Harcourt Teaching Hospital, Nigeria.

METHODS

A cross-sectional survey of HIV-infected children and adolescents on ART using self-report by the caregiver/child in the past one month.

RESULTS

A total of 213 caregivers and their children were interviewed. A hundred and sixty-two (76.1%) had adherence rates ≥95%. Only 126 (59.2%) were completely (100%) adherent. The commonest caregiver-related factors for missing doses were forgetfulness 48(55.2%), travelled 22(25.3%) and drugs finished 16(18.4%), while the child-related factors were refused drugs 10(11.5%), slept 8(9.2%), and vomited 8(9.2%). Sixty-eight (31.9%) caregivers reported missing clinic visit and reasons given were travelled 18(26.5%), caregiver ill 12(17.6%) and family problems 9(13.2%). Predictors of poor adherence include mother as the primary caregiver (OR 3.32; 95%CI, 1.33-8.67), younger than 5 years (OR 2.62; 95%CI, 1.30-5.31) and presence of a co-morbidity (OR 3.97; 95%CI, 1.92-8.33). Having a medication reminder strategy (OR 6.34; 95%CI, 3.04-13.31), regular clinic visits (OR 8.55; 95%CI 4.01-18.45) and status disclosure (p = 0.008) predicted a better adherence. The caregiver's age (p= 0.11), education (p = 0.86), socioeconomic status (p = 0.89), gender of the child (p = 0.84), type of ART (p = 0.2) and duration of ART (1.0) did not significantly affect adherence.

CONCLUSION

Adherence is still suboptimal. Since barriers to Paediatric ART adherence are largely caregiver-dependent, identifying and addressing these barriers in each caregiver-child pair will improve adherence and patient outcome.

Prevalence and determinants of adherence to HAART amongst PLHIV in a tertiary health facility in south-south Nigeria

BACKGROUND

Adherence to Highly active antiretroviral therapy (HAART) is a major predictor of the success of HIV/AIDS treatment. Good adherence to HAART is necessary to achieve the best virologic response, lower the risk of drug resistance and reduce morbidity and mortality. This study therefore aimed to determine the prevalence and determinants of adherence to HAART amongst PLHIV accessing treatment in a tertiary location in Cross River State, Nigeria.

METHODS

A cross-sectional study was conducted among patients on HAART attending the Presidential Emergency plan for AIDS relief (PEPFAR) clinic of the University of Calabar Teaching Hospital between October-December 2011. A total of 411 PLHIV visiting the study site during the study period were interviewed. PLHIV who met the inclusion criteria were consecutively recruited into the study till the desired sample size was attained. Information was obtained from participants using a semi-structured, pretested, interviewer administered questionnaire. Adherence was measured via patients self report and were termed adherent if they took at least 95% of prescribed medication in the previous week prior to the study. Data were summarized using proportions, and χ2 test was used to explore associations between categorical variables. Predictors of adherence to HAART were determined by binary logistic regression. Level of significance was set at p < 0.05.

RESULTS

The mean age of PLHIV who accessed treatment was 35.7 ± 9.32 years. Females constituted 68.6% of all participants. The self reported adherence rate based on a one week recall prior to the study was 59.9%. The major reasons cited by respondents for skipping doses were operating a busy schedule, simply forgot medications, felt depressed, and travelling out of town. On logistic regression analysis, perceived improved health status [OR 3.11; CI: 1.58-6.11], reduced pill load [OR 1.25; 95% CI: 0.46-2.72] and non-use of herbal remedies [OR 1.83; 95% CI: 1.22-2.72] were the major predictors for adherence to HAART. However, payment for ART services significantly decreased the likelihood of adherence to HAART. [OR 0.46; 95% CI: 0.25-0.87.].

CONCLUSIONS

The adherence rate reported in this study was quite low. Appropriate adherence enhancing intervention strategies targeted at reducing pill load and ensuring an uninterrupted access to free services regimen is strongly recommended.