The relationship of acceptance or denial of HIV-status to antiretroviral adherence among adult HIV patients in urban Botswana

https://doi.org/10.1016/j.socscimed.2008.03.042Get rights and content

Abstract

Adherence to antiretroviral therapy among HIV patients is the most important patient-enabled factor related to virological failure and can lead to drug resistance. It is important to avoid virological failure, especially in resource-limited settings where treatment options are limited and the effects of treatment failure are profound. This qualitative study aimed to identify the psycho-social factors related to adherence behaviour in Gaborone, Botswana, a high prevalence setting in southern Africa. One-to-one, in-depth interviews were conducted with adult antiretroviral patients in the private and public health sectors who had been on antiretroviral therapy for a minimum of 6 months. A grounded theory approach was adopted and patients were selected purposively and theoretical sampling determined the final sample size. Thirty-two patients were interviewed, 22 from the public-sector, the mean age was 9.5 years and 53% were women. We found that acceptance of HIV-status, the ability to avoid internalising stigmatising attitudes and identification of an encouraging confidante were key factors related to good adherence. Encouraging confidantes (including clinicians) and contributed to promoting hope and acceptance of HIV-status, enabling patients to develop a positive therapeutic relationship with their antiretrovirals and make lifestyle changes that promoted adherence. Active participation in a social network and a desire to avoid being thin and visibly identifiable as HIV-positive were also adherence-motivating factors. Conversely, participants who expressed some degree of denial about their HIV-status tended to express emotions associated with depression, and internalised stigma that inhibited the development of a relationship with a confidante. We feel it is important to identify individuals with HIV who are still in some degree of denial about their status and to identify depression among patients on antiretrovirals. This will enable more targeted, individualised support in the management of individuals' HIV disease.

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

References (48)

  • J. Stein et al.

    Hope is the pillar of the universe: health-care providers' experiences of delivering anti-retroviral therapy in primary health-care clinics in the Free State province of South Africa

    Social Science & Medicine

    (2007)
  • A. Ammarassari et al.

    Relationship between HAART adherence and adipose tissue alterations

    Journal of Acquired Immune Deficiency Syndromes

    (2002)
  • B. Arroll et al.

    Screening for depression in primary care with two verbally asked questions: cross sectional study

    British Medical Journal

    (2003)
  • D. Bangsberg et al.

    Adherence–resistance relationships for protease and non-nucleoside reverse transcriptase inhibitors explained by virological fitness

    AIDS

    (2006)
  • G.P. Bisson et al.

    Out-of-pocket cost of highly active antiretroviral therapy limits HIV treatment response in Botswana's private sector: retrospective cohort study

    AIDS

    (2006)
  • J. Byakika-Tusiime et al.

    Adherence to HIV antiretroviral therapy in HIV+ Ugandan patients purchasing therapy

    International Journal of STD & AIDS

    (2005)
  • Central Statistics Office. 2001 Population and housing census dissemination seminar. September 8–11, 2003,...
  • M.A. Chesney et al.

    Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG)

    AIDS Care

    (2000)
  • E. Collins et al.

    Psychosocial impact of the lipodystrophy syndrome on HIV infection

    AIDS Reader

    (2000)
  • DART Virology Group and Trial Team

    Virological response to a triple nucleoside/nucleotide analogue regimen over 48 weeks in HIV-1-infected adults in Africa

    AIDS

    (2006)
  • Do, N., Wester, W., Phiri, K., Bussmann, H., Foya, K., Gaolathe, T., et al. Social and cultural factors that affect ARV...
  • B. Glaser et al.

    The discovery of grounded theory: Strategies for qualitative research

    (1967)
  • L. Gras et al.

    CD4 cell counts of 800 cells/mm3 or greater after 7 years of highly active antiretroviral therapy are feasible in most patients starting with 350 cells/mm3 or greater

    Journal of Acquired Immune Deficiency Syndrome

    (2007)
  • S. Heald

    Abstain or die: the development of HIV/AIDS policy in Botswana

    Journal of Biosocial Science

    (2005)
  • Z. Hill et al.

    Patterns of adherence to antiretrovirals: why adherence has no simple measure

    AIDS Patient Care STDS

    (2003)
  • C.B. Hofer et al.

    Effectiveness of antiretroviral therapy among patients who attend public HIV clinics in Rio de Janeiro, Brazil

    Journal of Acquired Immune Deficiency Syndromes

    (2004)
  • H. Knobel et al.

    Adherence and effectiveness of highly active antiretroviral therapy

    Archives of Internal Medicine

    (1998)
  • I. Laniece et al.

    Adherence to HAART and its principal determinants in a cohort of Senegalese adults: access to antiretroviral drugs and AIDS management in Senegal. Once-a-day highly active antiretroviral therapy in treatment-naive HIV-1-infected adults in Senegal. The Senegalese government's highly active antiretroviral therapy initiative: an 18-month follow-up study antiretroviral therapy in sub-Saharan Africa: myth or reality?

    AIDS

    (2003)
  • C. Laurent et al.

    The Senegalese government's highly active antiretroviral therapy initiative: an 18-month follow-up study

    AIDS

    (2002)
  • E. Lindsey et al.

    Home-based care in Botswana: experiences of older women and young girls

    Health Care for Women International

    (2003)
  • S.J. Little et al.

    Antiretroviral-drug resistance among patients recently infected with HIV

    New England Journal of Medicine

    (2002)
  • S. Maman et al.

    High rates and positive outcomes of HIV-serostatus disclosure to sexual partners: reasons for cautious optimism from a voluntary counseling and testing clinic in Dar es Salaam, Tanzania

    AIDS and Behavior

    (2003)
  • S.B. Mannheimer et al.

    Sustained benefit from a long-term antiretroviral adherence intervention. Results of a large randomized clinical trial

    Journal of Acquired Immune Deficiency Syndrome

    (2006)
  • E. Mills et al.

    Adherence to HAART: a systematic review of developed and developing nation patient-reported barriers and facilitators

    PLoS Medicine

    (2006)
  • Cited by (0)

    1

    The ART-LINC Collaboration of the International epidemiological Databases to Evaluate AIDS (IeDEA).

    View full text