Barriers To Antiretroviral Adherence ForAdolescents Living With HIV Infection And

AIDs Reporting At Chitungwiza Central Hospital’s OIC.

P Ndarukwa Dr O Moyo

Prof A Chideme-Munodawafa E. Chadambuka

Introduction

• Establishing and maintaining adherence to medication is a difficult goal for an individual with chronic illness even when

treatment regime is simple and the patient is clearly symptomatic (UNAIDS, 2008).

• Adherence is particularly problematic in adolescents (Guidelines for Antiretroviral for the Prevention and Treatment

of HIV in Zimbabwe (GATPT), 2013). • Particular attention should be paid to assessing adherence at

every visit and to providing adherence support (GATPT, 2013). Counselling on adherence should include exploring specific

reasons that may contribute to poor adherence (GATPT, 2013).

Intro….

• Adolescents face many psychosocial issues that affect their adherence and those should be assessed (GATPT, 2013).

• Nearly perfect compliance seems to be indispensable to obtain the maximum benefit from highly active antiretroviral treatment (HAART)

(Rao, et al., 2007) and prophylactic medications and is therefore crucial to their success (Tapper, et al., 2004).

• Non-adherence to HAART is a major cause of viral resistance to medication. Blood levels of medication can quickly drop below the

therapeutic threshold, due to the limited half-life of many ART agents, giving the virus an opportunity to develop resistance (Moatti and Spire, 2003). Designing interventions to optimize the management of HIV by

improving adherence is of major clinical importance (Tapper, et al., 2004).

Intro…

• A news article in the Newsday (9/09/2011) on health issues indicated that Zimbabwe had over 100000 adolescents who were registered with HIV care

services whose adherence was dependent on caregivers. • The article further indicated orphanhood as a barrier to adherence to ART, stigma,

lack of support of by family and lack of disclosure to the adolescents the reasons for continued taking of medication as also barriers to adherence.

• Ministry of Health and Child Care (2013) identified lack of knowledge of HIV status as a leading factor to poor adherence to ART and suggested that adolescents should be involved in the discussion about HIV testing and their HIV status should be disclosed to them. Disclosure is recommended as a gradual process that should be carried out with the involvement of the guardian, a counsellor and the doctor if

adherence is to be maintained (MOHCC, 2013). • All these possible solutions to effective adherence are not conclusive to barriers to

antiretroviral adherence for adolescents living with HIV infection and AIDs, hence the need to determine such barriers to antiretroviral adherence for adolescents.

Problem Statement

• Despite government’s effort of making availability antiretroviral drugs, through AIDS and TB programme in the Ministry of Health

and Child Care there is a high level of non-adherence by adolescence at Chitungwiza Central Hospital’s OIC.

• There is 60% non adherence rate among the adolescents at Chitungwiza Central Hospital. According to Chitungwiza Central

Hospital’s OIC annual Report of 2013, non adherence rate is 3adolescence per 5 adolescences.

• This is unacceptable given the benefits of antiretroviral therapy which has had a good survival rate among those who are taking

antiretroviral therapy. Therefore, this study would wish to identify the possible barriers to antiretroviral therapy among adolescence

taking antiretroviral medications at Chitungwiza Central Hospital’s Opportunistic Infection Clinic in 2014

BROAD OBJECTIVETo determine barriers to antiretroviral adherence for

adolescence living with HIV infection and AIDs reporting at Chitungwiza Central Hospital’s OIC.

SPECIFIC OBJECTIVES• To determine the adolescents’ knowledge on the use of ARVs• To determine adolescents’ attitudes on the use of ARVs.

• To describe the practices of adolescents that affect adherence to ARVs.

• To identify the type of services delivered to adolescences receiving ARVs at the OIC.

• To describe the kind of the social support given to adolescences taking ARVs.

• To come up with recommendations for policy, practice & education

STUDY DESIGN

• The researcher used triangulated cross-sectional descriptive and correlational analytic

designs

STUDY SETTING• Chitungwiza Central Hospital’s OIC.

STUDY POPULATION

The researcher made use of the following populations;• The Adolescents who are aged 12-19years who were

coming to collect their antiretroviral therapy medications.

• Medical records of adolescents attending scheduled reviews were reviewed for adherence to ART

medications.• Health care providers who are working in the OIC department were interviewed in order to establish the

type of services provided for adolescents receiving ARVs.

SAMPLE SIZE

• This study estimated levels of non-adherence among the adolescence with HIV infection and

AIDS. The sample size was calculated using one proportion formula using the WHO

sample Size determination for Health Studies version.

Barriers To Antiretroviral Adherence For Adolescents Living With HIV Infection And

AIDs Reporting At Chitungwiza Central Hospital’s OIC.

P Ndarukwa Dr O Moyo

Prof A Chideme-Munodawafa

SAMPLE SIZE CONTI....

• The following parameters were used to calculate the sample size: proportion of adherence (P) among the HIV/AIDS

adolescents at CCH‘s OIC is 60%, the absolute precision (d) is 5% and the confidence level is 95%. This gives a sample size

of 368. The selected sample size was increased by 5% (19 cases) to allow for incomplete interviews. The minimum

survey sample was 387.

SAMPLE SELECTION• Maximum variation which is a strategy of purposive sampling

was used to identify participants for the study. Those adolescents who are aged 12-19years and registered at

Chitungwiza Central Hospital were selected purposively between March 2014 and Mid April 2014. Every adolescent who come for collection of ART supplies were interviewed

either individually or in a group.

ResultsSocio-demographic characteristics of respondents N=136

Characteristics (N=136) Adolescent patient (ARV Users) N=100(73.5%) Health Care ProvidersN=36 (26.5%)

GenderFemaleMale

6139

2313

Age(years)12-1415-1718-19

174340

N/AN/AN/A

Education levelPrimarySecondaryCollegeUniversity

2751139

N/AN/A2511

Employment StatusNot employedEmployed

8317

N/A

Time since onset ofART<1year>or =1year

3466

N/A

Location of Adolescent to ART services.UrbanRural

6337

N/A

Adolescent living withParentsGrandparentsChild headed familyOthers

3150290

N/A

Qualitative Data Analysis Framework

The following themes and sub-themes were indentified during the qualitative data analysis process.

How do ARV adolescents adhere to their regimen?• Knowledge, belief and perception of ART• Fear of consequences of non-adherence• Benefits of ART• Contrary conception between health care providers and

patients• Drug holidays/ feeling better

Which strategies ARV users applied to help them adhere to their ART?

• Adherence aid• Personnel appropriate time to take medication• Chewing medications• Borrowing medications from others

Personal factors• Age• Gender• Personal characteristics,health locus of control, self-efficacy• Alcohol use• Illicit drug use

Disclosure and Stigma as threats to ART adherence• Influence on ART adherence• Discrimination of the adolescent on ART• Reasons for non-disclosure• Examples of HIV/AIDS disclosure• Importance of HIV status and ART discrimination among

adolescents

Treatment-related factors• Complexity of regimen• Side effects• Cost and travel to clinics• Health service issues

Family and Social support• Poor support from family• Self help groups

Quantitative Data Analysis Framework Sociodemographic Data Number of

respondents

Percentage

Sample (%)Sex Females

Males

143

108

57

43

Age (Min 12; Max 19; Mean: 16.0±2.1 12-14

15-17

18-19

63

112

76

25.1

44.6

30.3

Education level : Primary

Secondary

College

University

44

161

35

11

17.6

64.1

13.9

4.4

Employment History Not employed

Employed (Formal)

Employed (Informal)

200

16

35

79.7

6.4

13.9

Number of years Since HIV first detected (Min: 1; Max 16years; Mean 6.0±3.99): <1year

1-4years

4-7years

7-12years

>12years

17

73

80

62

19

6.8

29.1

31.9

24.7

7.5

Self-reported mode of HIV acquisition At birth

Sexual Intercourse

Shared needles

154

90

7

61.3

35.9

2.8

Treatment Characteristics of the AdolescentsTreatment and clinical characteristics Number of respondents Percentage of Sample (%)

ART regimena. (AZT+3TC+NVP)b. (AZT+3TC+EFV)c. (TDF+3TC+NVP)d. (TDF+3TC+EFV)e. Other

5043134177

19.917.153.46.82.8

Duration of ART(Min:1; Max:12years;Mean:9.6±3.04)<=2years2-10years10-12years

1734200

6.813.579.7

CD4 count at baseline(Min:21;Max:731;Mean:168.9±127.6)<=100cells/µl101-200cells/µl>200cells/µlMissing

81121409

32.348.215.93.6

Tuberculosis treatmentCurrentIn the pastNever

3716198

14.76.478.9

Cotrimoxazole prophylaxis useCurrentIn the pastNever

1099151

43.436.320.3

The Use of Adherence Aids (N=251)

characteristics Number of Percentage of Sample respondents (%)

Use of adherence aids 202 80.5%

Kind of adherence aids Clock alarm

Mobile phone alarm

Calendar

TV/Radio program

Pill box

Other

103

123

43

11

190

19

41%

49%

17.1%

4.4%

75.7%

7.6%

Useful level of adherence aids Not at all

A little

Somewhat

A lot

18

45

13

175

7.2%

17.9%

5.2%

69.7%

Univariate Analysis of Socio-demographic Factors by Dose Non-adherence N=251.Socio-demographic factor Adherence Non-adherence Unadjusted OR

(95% CI)P-value

Sex Female Male

10180

4228

10.84(0.48-1.47) 0.55

Age 12-14 15-17 18-19

529039

112237

11.16(0.52-2.57)3.88(2.03-7.42)

0.72>0.001

EducationPrimarySecondaryCollegeUniversity

27117307

174454

10.60(0.30-1.20)0.44(0.16-1.21)3.43(0.73-16.17)

0.150.110.11

Current jobNot employedEmployed (formal)Employed (informal)

161119

39526

11.88(0.62-5.71)6.36(1.73-23.34)

0.260.003

No of years since HIV first detected <1yr1-4yrs4-7yrs7-12yrs>12years

1151634313

62217216

10.79(0.26-2.41)0.63(0.30-1.30)1.81(0.86-3.82)0.95(0.31-2.84)

0.680.210.120.92

Univariate Analysis of Clinical and treatment factors by dose Non-adherence N=251.Socio-demographic factor

Adherence Non-adherence Unadjusted OR (95% CI)

P-value

Sex Female Male

10180

4228

10.84(0.48-1.47) 0.55

Age 12-14 15-17 18-19

529039

112237

11.16(0.52-2.57)3.88(2.03-7.42)

0.72>0.001

EducationPrimarySecondaryCollegeUniversity

27117307

174454

10.60(0.30-1.20)0.44(0.16-1.21)3.43(0.73-16.17)

0.150.110.11

Current jobNot employedEmployed (formal)Employed (informal)

161119

39526

11.88(0.62-5.71)6.36(1.73-23.34)

0.260.003

No of years since HIV first detected <1yr1-4yrs4-7yrs7-12yrs>12years

1151634313

62217216

10.79(0.26-2.41)0.63(0.30-1.30)1.81(0.86-3.82)0.95(0.31-2.84)

0.680.210.120.92

Self reported mode of HIV acquisitionAt birthSexual intercourseShared needles

120565

34342

12.14(1.21-3.79)0.66(0.12-3.59)

0.0080.63

Conti...Treatment and Clinical characteristics

Adherence Non-adherence Unadjusted OR(95% CI) p-value

ART regimena. (AZT+3TC+NVP)b. (AZT+3TC+EFV)**c. (TDF+3TC+NVP)d. (TDF+3TC+EFV)**e. Other

313210394

29113183

10.37(0.16-0.86)0.88(0.40-1.94)2.95(1.05-8.30)0.84(0.14-4.97)

0.020.740.030.85

Duration of ART<=2years2-10years10-12years*

1023161

71139

10.68(0.21-2.28)0.51(0.23-1.13)

0.530.09

Distance from residence to clinic<=5km5-10km**>10km*

189287

142713

10.38(0.17-0.86)0.51(0.25-1.05)

0.020.06

Tuberculosis treatmentCurrentIn the past**Never

319132

6766

14.02(1.07-15.03)0.64(0.23-1.80)

0.030.40

Cotrimoxazole prophylaxis useCurrentIn the pastNever *

807233

291918

10.73(0.38-1.41)2.07(096-4.44)

0.350.06

Univariate Analysis of Alcohol and Drug Use by Dose Non-adherence N=251.

Alcohol and drug use Adherence N=161 Non-adherenceN=90 Unadjusted OR(95% CI)

p-value

Alcohol use (last month)Noyes

9071

3159

12.41(1.41-4.12) 0.001

Heavy alcohol use (≥5 drinks within two hours)NoYes

13724

4149

16.82(3.74-12.43) <0.001

Ever used illicit drugNoYes

10061

3555

12.58(1.52-4.38) <0.001

Illicit drug use (last month)NoYes

11447

4446

12.54(0.96-2.82) <0.001

Multivariate Analysis of factors associated with dose non-adherence N=251.

Factors No. of adolescent Crude OR Adjusted OR (95% CI) P-value

Sex FemaleMale

143108

10.84 3.10(1.37-7.03) 0.007

Age 12-1415-1718-19

6311276

11.163.88

11.16(0.37-3.56)3.88(1.56-9.92)

0.720.003

EducationPrimarySecondary CollegeUniversity

441613511

10.600.443.43

0.55(0.20-2.56)1.87(0.65-5.60)2.26(0.62-23.77)

0.160.110.16

Clinical factors

Distance from residence to clinic<5km5-10km>10km

32119100

10.380.51

12.48(0.68-13.31)8.17(2.49-57.61)

0.090.002

Conti...Alcohol use and drug use

Heavy alcohol use (last month)NoYes

17873

16.82

10.80(0.25-2.51) 0.002

Illict drug use (last month)NoYes

16685

11.64

10.48(0.21-1.11) 0.01

Use of adherence Aids No Yes

76175

10.69

14.26(1.76-10.14) 0.002

Multivariate analysis of factors Associated with ART Dose non-adherence N=251

Factor Mean of adherent group

Mean of non-adherent group

Crude OR Adjusted OR (95% CI)

P-value

Side-effects experienced

20.64 27.19 1.02 1.04(1.02-1.05) <0.001

Chance health locus of control

16.6 18.69 1.06 1.06(1.02-1.10) <0.001

Social related factors

Perceived quality of information from HCPs

23.32 22.16 0.91 0.94(0.88-0.99) 0.04

Satisfaction with received support

8.49 7.73 0.88 0.92(0.84-1.00) 0.06

Social connectedness

10.89 9.65 0.90 0.94(0.88-0.99) 0.04

Social isolation 4.68 5.20 1.08 1.00(0.91-1.10) 0.96

Univariate Analysis of Sociodemographic Factors by Time Non-adherence N=251.

Socio-demographic factor

Adherence N=180 Non-adherence N=71 Unadjusted OR (95% CI)

P-value

Sex Female Male

9783

4625

10.64(0.36-1.12) 0.12

Age 12-14 15-17* 18-19*

578241

63035

13.48(1.36-8.89)2.33(1.26-4.32)

0.0070.006

EducationPrimarySecondaryCollegeUniversity*

28114344

164195

10.63(0.31-1.28)0.74(0.33-1.67)4.72(1.05-21.29)

0.200.460.03

Current jobNot employedEmployed (formal)Employed (informal)*

1591011

41624

12.33(0.80-6.78)3.64(1.05-12.55)

0.110.04

No of years since HIV first detected <1yr1-4yrs4-7yrs7-12yrs>12years

1050644412

72316187

10.66(0.22-1.94)0.54(0.26-1.14)1.64(0.75-3.55)1.43(0.48-4.21)

0.450.100.210.52

Self reported mode of HIV acquisitionAt birthSexual intercourse*Shared needles

119583

34334

11.99(1.12-3.53)2.34(0.49-11.12)

0.020.27

Univariate Analysis of Clinical and treatment factors by Time dose Non-adherence N=251

Treatment and Clinical characteristics

Adherence N=180 Non-adherence N=71 Unadjusted OR(95% CI) p-value

ART regimena. (AZT+3TC+NVP)b. (AZT+3TC+EFV)**c. (TDF+3TC+NVP)d. (TDF+3TC+EFV)**e. Other

3034101105

2982743

10.24(0.10-0.61)1.14(0.47-2.74)1.50(0.44-5.14)1.50(0.24-9.46)

0.0020.780.520.67

Duration of ART<=2years2-10years*10-12years

928143

81647

10.64(0.21-2.00)0.58(0.29-1.15)

0.060.12

Distance from residence to clinic<=5km5-10km*>10km

1510065

113228

10.44(0.18-1.05)1.35(0.74-2.44)

0.020.33

Tuberculosis treatmentCurrentIn the pastNever*

2613141

121445

12.33(0.84-6.46)0.30(0.13-0.68)

0.100.003

Cotrimoxazole prophylaxis useCurrentIn the pastNever

847026

312317

10.89(0.48-1.66)1.99(0.92-4.31)

0.720.08

Univariate Analysis of Social Factors by Time Non-adherence N=251.

Adherence n=180 Non-adherence n=71t-test/Mann-Whitney

M SD M SD t DF P

Disclosure of ART treatment status

5.57 3.52 5.00 3.36 1. 85 249 0.07

Family support 9.33 2.86 8.81 2.99 2.01 249 0.05

Friend support 4.80 3.60 4.69 3.56 0.36 249 0.72

Social organisation support

4.51 3.72 4.47 3.79 0.11 249 0.91

Satisfaction with received support

8.40 2.48 8.06 2.38 1.59 249 0.11

Social connectedness

10.89 3.49 9.83 3.37 3.44 249 0.001

Social isolation 4.63 2.48 5.23 2.48 -2.71 249 0.007

Perceived quality of information from health care provider

23.23 3.11 22.55 3.52 2.385 249 0.02

Ability to initiate communication with health care provider

12.37 6.66 13.55 6.47 2.014 249 0.04

Multivariate Analysis of factors associated with time non-adherence N=251.Factors No. of adolescent Crude OR Adjusted OR (95% CI) P-value

Sex FemaleMale

143108

10.64 3.10(1.37-7.03) 0.007

Age 12-1415-1718-19

6311276

13.482.33

11.16(0.37-3.56)3.88(1.56-9.92)

0.720.003

EducationPrimarySecondary CollegeUniversity

441613511

10.630.744.72

0.55(0.20-2.56)1.87(0.65-5.60)2.26(0.62-23.77)

0.160.110.16

Clinical factorsDistance from residence to clinic<5km5-10km>10km

32119100

10.441.35

10.72(0.22-2.38)1.65(0.72-3.60)

0.450.09

Current jobNot employedFormally employedInformally employed

2001635

12.333.64

11.68(0.35-8.37)0.65(0.10-4.64)

0.360.53

Conti.....

Alcohol use and drug use

Heavy alcohol use (last month)NoYes

17873

14.88

15.38(4.14-13.61) 0.004

Illict drug use (last month)NoYes

16685

15.90

14.33(1.60-22.57) 0.007

Use of adherence Aids No Yes

71180

110.07

10.48(0.22-1.45)

0.02

Multivariate analysis of factors Associated with ART Dose non-adherence N=251

Factor Mean of adherent group

Mean of non-adherent group

Crude OR Adjusted OR (95% CI)

P-value

Side effects experience

20.26 27.17 1.03 1.07(1.05-1.09) <0.001

Chance health locus of control 16.69 18.18 1.04 1.04(1.00-1.09) 0.05

Social related factors

Disclosure of treatment status 5.57 5.00 0.95 0.94(0.88-1.02) 0.12

Family support 9.33 8.81 0.94 0.98(0.90-1.06) 0.53

Social connectedness

10.89 9.83 0.92 0.93(0.86-0.99) 0.04

Social isolation 4.68 5.23 1.09 1.08(0.98-1.20) 0.12

Perceived quality of information from HCPs

23.23 22.55 0.94 0.97(0.91-1.05) 0.49

Ability to initiate communication with HCPs

12.37 13.55 1.03 1.01(0.97-1.04) 0.81

Discussion

• The results of this study have shown that adolescents aged 12-19 years had challenges to adherence which included forgetfulness to take medication on time, being too busy that is being absorbed by something, special events which included weddings, parties, etc, being away from home and not taking medications with them,

oversleeping, problems with adherence reminders, bad memory (due to personal ability or side-effects of the pills).

• This study identified critical barriers to adherence as drug use, alcohol use, lack of disclosure, negative attitude and

inappropriate belief about who controls a patient’s health, medication side effects and long distance from residence to

clinics. The facilitators of adherence were identified as social and family support, disclosure of HIV status and treatment,

good interaction with people around them, high level of satisfaction with received support and good relationship

between health care providers and patients.

• In the bivariate analysis, association between the two types of ART non-adherence (i.e. dose and time) and the use of illicit drugs were strongly significantly associated. These were still

significantly associated with non adherence in the multivariate models. Literature has indicated that concurrent use of a

substance while taking ART leads to patients not adhering to their medications (Hill, Kendall and Fernandez, 2003; Laws,

Wilson, Bowser and Kerr, 2000, Remien, Hirky, Johnson, Weinhardt, Whittier and Le, 2003 and Remien, et al., 2003)• . In this study it was noted that non-adherence was significantly associated with each regimen of ART which

included effavirenz more side effects among the ART medications. This is supported by literature which said side

effects of ART have been identified to cause adherence problems in patients (Abel and Painter, 2003).

Recommendations

• There is need to improve family support system to assist in the disclosure of HIV status to adolescents, thus it

would improve adherence and reduce resistance of ART treatment

• This study found that long distance from area of residence to clinic was significantly associated with non-adherence.

It is therefore suggested that the government should increase the number of sites offering ART to adolescents as a way of working towards achieving the vision of the

health reforms of bringing health service as close to family as possible.

Recommendations Conti...

• This study also identified that side effects of the ART medicines played a significant role in barriers to ART

adherence among adolescents. Therefore, it is suggested that there is need to identify medications with less side effects to be supplied to adolescents if adherence is to be maintained.• In this study the researcher identified that family and

community support was a facilitator of ART adherence. Therefore it is suggested that families and communities should be encouraged to form support groups focused on ART to help

with adherence strategies of coping with chronic illnesses.

References

• UNAIDS: 2008 Report on the global. HIV/AIDS epidemic 2008. Geneva Switzerland; 2008. 

• Ministry of Health and Child Care, 2013, Guidelines for Antiretroviral Therapy for the Prevention and Treatment of HIV

in Zimbabwe • Abel E, Painter L. Factors that influence adherence to HIV

medications: perceptions of women and health care providers. J Assoc Nurses AIDS Care 2003 Jul; 14(4):61-9.

• Remien RH, Hirky AE, Johnson MO, Weinhardt LS, Whittier D, Le GM. Adherence to medication treatment: a qualitative study of

facilitators and barriers among a diverse sample of HIV+ men and women in four US cities. AIDS Behav 2003 Mar; 7(1):61-72.