The relationship of acceptance or denial of HIV-status to antiretroviral adherence among adult HIV patients in urban Botswana
Introduction
Poor adherence to antiretrovirals (ARVs) is the most important factor known to be associated with treatment failure for HIV patients in both developed and developing countries (Chesney et al., 2000, Hofer et al., 2004, Knobel et al., 1998, Laniece et al., 2003, Laurent et al., 2002, Paterson et al., 1999). Additionally, transmissible drug-resistant strains have been found to arise soon after initiation of therapy (DART Virology Group and Trial Team, 2006, Simon et al., 2002). It is important to avoid this particularly in countries where the prevalence of HIV is high, where tertiary drug regimens are limited and the consequences of first-line virological failures are profound. Although meta-analysis has found adherence to be better in early treatment programmes in African than American settings, this may change as treatment access and duration increase (Mills, Nachega, Buchan, et al., 2006). Adherence for regimens commonly used in developing nations (containing non-nucleoside reverse transcriptase inhibitors) is lower than originally thought (Bangsberg et al., 2006, Nachega et al., 2007). However, the linear dose–response relationship between level of adherence and virological success remains evident (Bangsberg et al., 2006, Little et al., 2002, Palella et al., 1998), and promotion of good adherence remains imperative.
Adherence barriers commonly reported in Africa include forgetfulness, suspicion of treatment, complex regimen, heavy pill burden, access to medication, and concomitant substance abuse. These factors were common in both developed and developing nations (Mills, Nachega, Bangsberg, et al., 2006). However, financial constraints among paying patients are among the leading factors associated with poor adherence in Africa (Bisson et al., 2006, Byakika-Tusiime et al., 2005, Laurent et al., 2002, Mills et al., 2006, Weiser et al., 2003).
Botswana, with an estimated HIV prevalence of 24% (UNAIDS, 2007), was the first country in Africa to establish a free national antiretroviral therapy programme in 2002. By February 2007, 83,000 people were on antiretrovirals, 9000 of those being treated through the private-sector. Anecdotally, clinicians at the central adult Infectious Diseases Control Centre (IDCC) in the capital, Gaborone, report overall adherence to be excellent among their patients. Past record reviews demonstrate low overall virological failure (4%), defined as two consecutive detectable plasma viral load measurements of <400 copies/μL (Ndwapi et al., 2003). Quantitative studies on adherence conducted to date, however, are inconsistent with this assessment, with adherence ranging from 54 to 85%. In the northern rural town of Maun in Botswana, the mean adherence level among public-sector patients was 83% (Nwokike, 2003). Forgetfulness, lack of access and lack of privacy were cited as reasons for poor adherence behaviour while pharmacy counselling and adherence partners were reported to improve adherence. At the IDCC in Gaborone, a mean self-reported adherence rate of 81% among 300 patients was reported (Do et al., 2006). Poor adherence was associated with depression, active alcohol abuse and lack of disclosure. A study conducted in the urban private-sector reported adherence levels of 54 and 56% among private-sector patients (Weiser et al., 2002); key barriers to adherence included financial constraints (among 44% of participants), travel or migration (10%), side effects (9%), and stigma (15%).
This qualitative study was conducted in order to identify other psycho-social factors associated with adherence behaviour by exploring, in-depth, some of the issues raised by previous quantitative studies, and to understand the inter-relationships between relevant factors among paying and non-paying patients in Botswana.
Section snippets
Methods
The study took place in two clinics: the public-sector adult Infectious Diseases Care Centre (IDCC) and the privately run Independence Surgery, both situated in the capital, Gaborone. The IDCC, an HIV specialist centre, has around 9500 patients on antiretrovirals who must have a CD4 cell count of <200 cells/mm3 or the presence of an AIDS defining illness to qualify for initiation on antiretrovirals. Patients are encouraged to bring an adherence partner for initial consultations. In contrast,
Patient sample and characteristics
Results presented are based on patient participant data unless otherwise stated. Thirty-two patients participated. Among the 10 private-sector participants, 4 had their treatment costs covered completely through medical insurance; among the 22 public-sector participants, half had started their HIV care in the private-sector before the free government programme had been launched. Despite this, the mean CD4 T-cell count at initiation for all public-sector participants was still lower than that
Discussion & conclusions
This study confirmed that acceptance of HIV-status is key in achieving adherence to antiretrovirals. The identification of an encouraging confidante with whom to share the burden of disease and the reality of it, and who could promote messages of hope for the future could encourage acceptance and appropriate lifestyle changes to support better adherence and faith in antiretrovirals. Once individuals had accepted their HIV-status, they were able to develop the ability to avoid the
Acknowledgements
We wish to thank the staff, the patients and staff who participated in interviews and Mpho Zwinila in data collection. Funding was provided by the ART-LINC Collaboration of the International Epidemiology Database to Evaluate AIDS (IeDEA) (who also have a representative as an advisor to this project), the DfID HIV and STI Knowledge Programme and GlaxoSmithKline, who provided the studentship fees and had a representative acting as advisor to this project. Gratitude is extended to Professors
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The ART-LINC Collaboration of the International epidemiological Databases to Evaluate AIDS (IeDEA).