- Email: [email protected]
The Effect of Psychological Distress on Medication Adherence in Persons With HIV Infection in Nigeria
The Effect of Psychological Distress on Medication Adherence in Persons With HIV Infection in Nigeria Abiodun O. Adewuya, MBChB, FWACP (Psych), Mohammed O. Afolabi, MBBS, FWACP Bola A. Ola, MBChB, FWACP (Psych), Olorunfemi A. Ogundele, MBChB Adeola O. Ajibare, MBChB, Bamidele F. Oladipo, MBChB Ibiyemi Fakande, R.N., P.H.N.
Background: A high level of adherence to prescribed antiretroviral (ARV) regimens is required to achieve and maintain suppression of human immunodeficiency virus (HIV) replication and prevent drug resistance. Objective: This study aimed to determine the possible relationship between psychopathology and ARV medication adherence in Nigeria. Method: Persons with HIV infection (N⫽182) completed various questionnaires on sociodemographic and clinical details, general psychopathology, self-esteem, and medication adherence. Results: Low medication adherence was reported in 26.9% of the participants; significant correlates included presence of psychopathology and perceived poor social support. Conclusion: The success of any intervention policy for HIV-infected persons in sub-Saharan Africa must consider both low level of medication adherence and its associated factors. (Psychosomatics 2010; 51:68 –73)
T
he introduction of several classes of antiretroviral (ARV) drugs and the use of combination of these medications, or highly active antiretroviral therapy (HAART), has led to a substantial improvement in the prognosis and quality of life of persons with HIV (human immunodeficiency virus) infection.1,2 However, a high level of adherence to prescribed ARV regimens is required to achieve and maintain suppression of HIV replication, prevent drug resistance, and derive maximal benefit from the medications.3 Studies have shown that HIV-infected individuals need to take at
Received October 19, 2007; revised November 26, 2007; accepted December 5, 2007. From the Dept. of Behavioural Medicine, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria; the Dept. of Family Medicine, College of Health, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria; the Dept. of Clinical Services, Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria; and Living Hope Care, Ilesa, Osun, Nigeria. Send correspondence an reprint requests to Dr Abiodun O. Adewuya, Dept. of Psychiatry, Lagos State University College of Medicine, Ikeja 100010, Lagos, Nigeria. e-mail: [email protected] © 2010 The Academy of Psychosomatic Medicine
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least 90% of their ARV medication before adequate suppression of viral replication is attained.4 Studies have shown that most HIV-infected persons in western cultures adhere to their medication regimen;5 however, poor adherence has been associated with male gender,6 perceived high HIV-related stigma,7,8 perceived poor social support,5,9,10 low/ poor education,5 and presence of emotional distress or psychiatric comorbidity.11–13 It is estimated that about two-thirds of the more than 40 million people infected with HIV worldwide live in sub-Saharan Africa.14 Despite the high prevalence of HIV in sub-Saharan Africa, the percentage of the HIV-infected persons on regular ARV therapy is low. This is due to a combination of factors, including poverty, ignorance and lack of proper education regarding HIV, unavailability of HAART, and intense HIV-related stigma in the region. Also, psychiatric comorbidity has been associated with HIV disease since the beginning of the AIDS epidemic,15 very particularly so in Africa.16 A search of literature revealed no study focusing on psychological distress and Psychosomatics 51:1, January-February 2010
Adewuya et al. adherence to medication among the HIV-infected population in sub-Saharan Africa. So, for persons who are on the ARV medication, it is not known whether their adherence is as good as found in western cultures. It is also not known whether their adherence is affected by their level of psychological distress. In order for any intervention policy to help HIVinfected persons to succeed in sub-Saharan Africa, background knowledge of their level of psychological distress and its association with adherence is important. The aim of the present study was to determine whether there is a relationship between psychiatric comorbidity and ARV medication adherence in Nigeria. METHOD Subjects Participants in the study were recruited from persons attending “Living Hope Care,” an HIV support/care center for persons with HIV infection located in Ilesa, Osun state, Western Nigeria. The center provides support, counseling, and free ARV drugs to about 200 HIV-infected persons in the state. All the Care attendees meeting the inclusion criteria were targeted for interview. Inclusion criteria include age over 18 years and HIV-seropositivity. Excluded were subjects who were critically ill; had significant neurological disorders, including traumatic brain injury, or had seroconverted to negative on HIV testing and were no longer on ARV drugs. Of the 198 persons approached, 182 agreed to participate in the study. There were no statistically significant differences between the sociodemographic and clinical profiles of those who refused participation and the participants. Testing Procedure Informed consent was obtained from the participants after the aims and objectives of the study were explained to them. The Ethics and Research Committee of the Obafemi Awolowo University Teaching Hospitals Complex approved the study protocol. The participants were first administered a pro forma questionnaire asking about sociodemographic details like age, sex, marital status, and level of education. A Likert-scale format was used to measure the level of social support from spouse/family (Poor, Fair, and Good social support). Socioeconomic status was derived from occupational status and income per month. Clinical details elicited from the clients included clinical stage of the disease, time of diagnosis, any Psychosomatics 51:1, January-February 2010
present medical problems, previous hospital admissions due to HIV, and duration of ARV drug use. Level of disease knowledge was assessed by asking the clients to recall their last CD4 cell count. The participants also completed the Rosenberg’s Self-Esteem Scale,17 which is a 10-item questionnaire with items answered on a 4-point Likert scale from Strongly Agree to Strongly Disagree. Higher scores on the scale reflect higher self-esteem. General psychopathology was measured with the self-report 12-item General Health Questionnaire (GHQ–12). The GHQ–1218 is an often-used instrument for diagnosing general psychopathology, with items including sleeping difficulties. Each item has a score of 0 to 1, with a total score range of 0 to 12. The English- and Yoruba-translated versions had been validated in Nigeria, with a cutoff score of 3-and-above indicating presence of clinically significant psychopathology.19 Adherence was assessed by use of the Morisky Medication Adherence Questionnaire.20 The questionnaire consists of four items (in a Yes-or-No answer format) asking about forgetting to take medication, carelessness about taking medication, and stopping medication when 1) feeling better and 2) when feeling worse. The questionnaire differentiates among “high,” “medium,” and “low” adherence, according to number of total “Yes” scores of 0, 1, or 2, and 3 or 4, respectively. This standard scoring was used in our study. However, the “careless” in Question 2 was changed to “casual” to avoid the possible pejorative meaning of “careless” in our culture. Statistical Analysis The Statistical package for the Social Sciences 11 (SPSS.11) program was used for statistical analysis. Results were grouped and calculated as frequencies (%), means, and standard deviations (SD). The chi-square test was used to calculate the differences between groups. All tests were two-tailed, and significance was set at p ⬍0.05. Significant variables were entered into a logistic-regression analysis, and odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for independent predictors. RESULTS Sociodemographic and Clinical Profiles of the Participants The mean age of the 182 participants in years was 30.9 (SD: 11.4), with a range of 18 – 62 years. Of the participants, 86 (47.3%) were men. Although only 29 (15.9%) were presently married, 24 (13.2%) were widhttp://psy.psychiatryonline.org
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TABLE 1.
Associations Between Low Adherence to Antiretroviral (ARV) Medications and Sociodemographic and Clinical Variables
Variables Age-group, years 18–25 26–35 ⬎35 Sex Male Female Marital status Married Single Separated/divorced Widowed Religion Christian Muslim Ethnicity Yoruba Other tribes Socioeconomic status Low Medium High Highest education obtained No formal education Primary school Secondary school College/university Level of social support Good Fair Poor Disease knowledge Good Poor CDC infection stage Stage A Stage B Past HIV-related hospitalization Yes No Comorbid medical problems Yes No Length of diagnosis, years ⬍2 2–5 ⬎5 Length of ARV use, years ⬍1 1–3 ⬎3 Level of self-esteem Low (Rosenberg scale score 0–10) Medium (Rosenberg scale score 11–20) High (Rosenberg scale score 21–30) General psychopathology Absent (GHQ–12 score ⬍3) Present (GHQ–12 score ⱖ3)
Total (Nⴝ182)
Low Adherence (Nⴝ49)
High/Medium Adherence (Nⴝ133)
74 59 49
22 17 10
86 96
2
df
52 42 39
1.461
2
0.482
25 21
58 75
2.631
1
0.105
29 89 40 24
2 20 17 10
27 69 23 14
14.393
3
0.002
101 81
31 18
70 63
1.639
1
0.200
152 30
38 11
114 19
1.733
1
0.188
62 79 41
20 21 8
42 58 33
2.046
2
0.359
19 52 91 20
12 16 20 1
7 36 71 19
19.087
3
<0.001
36 89 57
3 21 25
33 68 32
15.135
2
0.001
109 73
20 29
89 44
10.158
1
0.001
109 73
35 14
74 59
3.716
1
0.054
21 161
2 47
19 114
3.653
1
0.056
68 114
12 37
56 77
4.748
1
0.029
58 116 8
15 30 4
43 86 4
2.265
2
0.322
82 64 36
26 15 8
56 49 28
1.754
2
0.416
40 81 61
14 23 12
26 58 49
3.046
2
0.218
63 119
7 42
56 77
12.244
1
<0.001
p
Bolded p values indicate variables later entered into logistic-regression analysis.
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TABLE 2.
having high adherence; 57 (31.3%), as having medium adherence; and the rest (49; 26.9%) as having low adherence, respectively. For ease of analysis, the age, length of diagnosis, GHQ scores, and the Rosenberg Self-Esteem Scale scores were grouped. Univariate analysis (by chisquare method) of the associations among low adherence and the clinical and sociodemographic variables are shown in Table 1. As shown in the table, there were no statistically significant associations between low adherence to ARV and age-group, sex, religion, ethnicity, socioeconomic class, staging of infection, HIV-related hospitalization, length of HIV diagnosis, duration of ARV use, and level of self-esteem as measured by the Rosenberg Self-Esteem Scale. There were, however, significant association between low adherence and marital status, educational level, perceived level of social support, knowledge of the illness, comorbid medical problems, and general psychopathology as measured by the GHQ–12. The significant variables (marital status, educational level, level of social support, knowledge of illness, comorbid medical problems, and general psychopathology) and the variables with p values ⬍0.1 (CDC staging of infection and past HIV-related hospitalization) were then entered into a binary logistic-regression analysis to determine the predictors of low adherence. The results (Table 2) showed that only general psychopathology (as measured by the GHQ–12) and perceived level of social support remained in the analysis. The odds ratio (OR) and 95% confidence interval (95% CI) for the predicting variables are shown in Table 3.
Independent Predictors of Low Adherence to Antiretroviral (ARV) Medication by Binary Logistic-Regression Analysis Variable

Wald SE Statistic df
General psychopathology (by 3.330 0.816 16.662 GHQ–12) Perceived level of social support 1.481 0.449 10.866
p
1 ⬍0.001 1
0.001
owed. Ninety-one (50.0%) were educated to the secondary-school level, and 101 (55.5%) were Christians. The participants were mostly from the Yoruba ethnic group (83.5%, N⫽152). Sixty-two (34.1%) were of low socioeconomic status. A total of 57 participants (31.3%) reported receiving poor social support from family and friends. The mean average length of time the participants had been diagnosed with HIV was 2.13 (SD: 1.05) years, with a range of 1–7 years. Many (45.1%; N⫽82) had been receiving ARV for less than 1 year, and 21 (11.5%) had had an HIV-related hospitalization at least once. A total of 68 participants (37.4%) had a comorbid medical problem, although 109 (59.9%) belonged to the Center for Disease Control (CDC) Classification Group A (acute HIV infection, but asymptomatic), and the rest (73; 40.1%) belonged to Group B (symptomatic, but without an AIDS-defining condition). None of the participants belonged to the Group C (AIDS-defining condition) classification. The mean GHQ score was 3.28 (SD: 2.00), with a range of 0 –7; the mean Rosenberg Self-Esteem Scale score was 16.05 (SD: 6.93), with a range of 2–27. A total of 109 clients (59.9%) could reliably recall their last CD4 count test result, and their knowledge of the disease were classified as “good.”
DISCUSSION Rate of Adherence and Correlates of Low Adherence to ARV Medications
To our knowledge, our study is the first in sub-Saharan Africa to have focused on the association between psychological distress and adherence to medication among an HIV-infected population. Our study described the status of
By use of the Morisky Medication Adherence Questionnaire, a total of 76 clients (41.8%) was classified as TABLE 3.
Odds Ratios (OR) and 95% Confidence Intervals (95% CI) for the Predictor Variables Variables
General psychopathology Absent (GHQ–12 score ⬍3) Present (GHQ–12 score ⱖ3) Perceived level of social support Good Fair Poor
Total (Nⴝ182)
Low Adherence (Nⴝ49)
Medium/High Adherence (Nⴝ133)
OR (95% CI)
63 119
7 42
56 77
1 (reference) 4.36 (1.83–10.43)
36 89 57
3 21 25
33 68 32
1 (reference) 3.40 (0.95–12.21) 8.59 (2.36–31.30)
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Medication Adherence in HIV persons with HIV infection in sub-Saharan Africa; over one-third were of low socioeconomic status; about onethird had poor social support, and over one-third had comorbid medical problems. Only about 15% were presently married, with about the same percentage already widowed. Fewer than half of our clients (41.8%) had high adherence to their medication; this is lower than the average of 60% reported in most western studies11,21 and the over80% recently reported in South-Africa.6 It should be noted that a substantial percentage of our clients (31.3%) had medium adherence to medication, with 26.9% having low adherence. Although the level of low adherence is still higher than found in studies from western cultures,11,21 medication adherence in our study may still be overestimated. This is because of the cross-sectional nature of the study, where nonadherent clients are likely to be irregular attendees of the care center and may have dropped out, and were thus not included in the sampling frame. This is a common source of bias in most compliance studies. Also, the use of self-report is known to overestimate adherence. Also, we found that over one-third of our clients with HIV infection had psychological distress sufficient to be identified as “cases” on the GHQ–12. This is below the average of 40%–50% found in most western studies.13 There are possible explanations for this. Although the GHQ may be easily used as a screening test for psychological distress, it is inadequate in distinguishing emotional symptoms and somatic symptoms that had been commonly reported in the African population.22 Although various factors were initially associated with low adherence to medication in our study, the only significant independent predictors were level of general psychopathology (as measured by the GHQ–12) and perceived level of social support. Our study supports findings of previous studies that have linked psychological distress with low adherence to ARV drugs.11–13 Psychological symptoms may predispose to pessimism and, hence, skepticism about effectiveness of ARV medication. Psycholog-
ically-distressed individuals may not adhere to their medications because of their distorted cognitive state or as a form of deliberate self-harm. Although our study highlights the association between psychological distress and adherence to medication, it is not possible, however, to infer causality because of the cross-sectional nature of our study, and it is not known whether treating patients with identifiable psychiatric disorders or psychological distress leads to improved ARV medication adherence. In keeping with other studies,5,9,10 we also found perceived poor social support to be associated with low level of ARV adherence. Beals et al.23 had earlier reported that supportive caregivers often remind HIV-infected persons to take their medication, although they also reported that high perceived adherence hassles on the part of the caregiver was also associated with low adherence. Although we did not find any significant difference between perceived Good and Fair social support, the clients who perceived their social support as Poor are significantly more likely to have low adherence than those having perceived Good social support (OR: 8.59; 95% CI: 2.36 –31.30). It has been hypothesized that Good social support was associated with less negative affect, which, in turn, was associated with self-efficacy in adhering to medication.10 The limitations of our study include its cross-sectional design, its use of a screening scale to measure psychological distress, and a self-report questionnaire to measure medication adherence. The study indicates significant poor adherence to ARV medication among persons with HIV infection in sub-Saharan Africa and confirms the association between low medication adherence and psychological distress and poor level of social support among our patients. These factors must be considered for the success of any intervention policy on HIV-infected persons in subSaharan Africa. A longitudinal study is needed to address the specific interaction of psychological distress and low adherence.
References 1. Palella FJ, Delaney KM, Moorman AC, et al: Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med 1998; 338: 853– 860 2. Gulick RM: HIV treatment strategies: planning for the long term. JAMA 1998; 279:957–958 3. De Jong MD, de Boer RJ, de Wolff F, et al: Overshoot of HIV-1 viraemia after early discontinuation of antiretroviral treatment. AIDS 1997; 11:F79 –F84 4. Bangsberg DR, Hecht FM, Charlebois ED, et al: Adherence to
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protease inhibitors, HIV-1 load, and development of drug resistance in an indigent population. AIDS 2000; 14:357–366 5. Rueda S, Park-Wyllie L, Bayoumi A, et al: Patient support and education for promoting adherence to highly active antiretroviral therapy for HIV/AIDS. Cochrane Database Syst Rev 2006; 19: 3:CD001442 6. Nachega JB, Hislop M, Dowdy DW, et al: Adherence to highly active antiretroviral therapy assessed by pharmacy claims predicts survival in HIV-infected South African adults. J Acquir Immun Defic Syndr 2006; 43:78 – 84
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Adewuya et al. 7. Rintamaki LS, Davis TC, Skripkauskas S, et al: Social stigma concerns and HIV medication adherence. AIDS Patient Care, STDs 2006; 20:359 –368 8. Vanable PA, Carey MP, Blair DC, et al: Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS Behav 2006; 10:478 – 482 9. Edwards LV: Perceived social support and HIV/AIDS medication adherence among African American women. Qual Health Res 2006; 16:679 – 691 10. Simoni JM, Frick PA, Huang B: A longitudinal evaluation of a social support model of medication adherence among HIV-positive men and women on antiretroviral therapy. Health Psychol 2006; 25:74 – 81 11. Gordillo V, del Amo J, Soriano V, et al: Sociodemographic and psychosocial variables influencing adherence to antiretroviral therapy. AIDS 1999; 13:1763–1769 12. Naar-King S, Templin T, Wright K, et al: Psychosocial factors and medication adherence in HIV-positive youth. AIDS Patient Care, STDS 2006; 20:44 – 47 13. Sternhell PS, Corr MJ: Psychiatric morbidity and adherence to antiretroviral medication in patients with HIV/AIDS. Aust N Z J Psychiatry 2002; 36:528 –533 14. UNAIDS: Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (World Health Organization): AIDS Epidemic Update. Dec, 1999 15. Evans DL, Mason K, Bauer R, et al: Neuropsychiatric manifes-
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tations of HIV-1 infection and AIDS, in Neuropsychopharmacology: The 5th Generation of Progress. Edited by Charney D, Davis K, Nemeroff C. New York, Raven, 2002, pp 102–108 16. Sebit MB, Tombe M, Siziya S, et al: Prevalence of HIV/AIDS and psychiatric disorders and their related risk factors among adults in Epworth, Zimbabwe. East Afr Med J 2003; 80:503–512 17. Rosenberg M: Society and Adolescent Self-Image. Princeton, NJ, Princeton University Press, 1965 18. Goldberg DP, Hillier VF: A scaled version of the General Health Questionnaire. Psychol Med 1979; 9:139 –145 19. Gureje O: Reliability and the factor structure of the Yoruba version of the 12-item General Health Questionnaire. Acta Psychiatr Scand 1991; 84:125–129 20. Morisky DE, Green LW, Levine DM: Concurrent and predictive validity of a self-report measure of medication adherence. Med Care 1986; 24:67–74 21. Haubrich RH, Little SJ, Currier JS, et al: The value of patientreported adherence to antiretroviral therapy in predicting virologic and immunologic response. AIDS 1999; 13:1099 –1107 22. Goldberg DP, Bridge K: Somatic presentations of psychiatric illness in primary-care setting. J Psychosom Res 1998; 32:137– 144 23. Beals KP, Wight RG, Aneshensel CS, et al: The role of family caregivers in HIV medication adherence. AIDS Care 2006; 18: 589 –596
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Background: A high level of adherence to prescribed antiretroviral (ARV) regimens is required to achieve and maintain suppression of human immunodeficiency virus (HIV) replication and prevent drug resistance. Objective: This study aimed to determine the possible relationship between psychopathology and ARV medication adherence in Nigeria. Method: Persons with HIV infection (N⫽182) completed various questionnaires on sociodemographic and clinical details, general psychopathology, self-esteem, and medication adherence. Results: Low medication adherence was reported in 26.9% of the participants; significant correlates included presence of psychopathology and perceived poor social support. Conclusion: The success of any intervention policy for HIV-infected persons in sub-Saharan Africa must consider both low level of medication adherence and its associated factors. (Psychosomatics 2010; 51:68 –73)
T
he introduction of several classes of antiretroviral (ARV) drugs and the use of combination of these medications, or highly active antiretroviral therapy (HAART), has led to a substantial improvement in the prognosis and quality of life of persons with HIV (human immunodeficiency virus) infection.1,2 However, a high level of adherence to prescribed ARV regimens is required to achieve and maintain suppression of HIV replication, prevent drug resistance, and derive maximal benefit from the medications.3 Studies have shown that HIV-infected individuals need to take at
Received October 19, 2007; revised November 26, 2007; accepted December 5, 2007. From the Dept. of Behavioural Medicine, Lagos State University College of Medicine, Ikeja, Lagos, Nigeria; the Dept. of Family Medicine, College of Health, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria; the Dept. of Clinical Services, Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria; and Living Hope Care, Ilesa, Osun, Nigeria. Send correspondence an reprint requests to Dr Abiodun O. Adewuya, Dept. of Psychiatry, Lagos State University College of Medicine, Ikeja 100010, Lagos, Nigeria. e-mail: [email protected] © 2010 The Academy of Psychosomatic Medicine
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least 90% of their ARV medication before adequate suppression of viral replication is attained.4 Studies have shown that most HIV-infected persons in western cultures adhere to their medication regimen;5 however, poor adherence has been associated with male gender,6 perceived high HIV-related stigma,7,8 perceived poor social support,5,9,10 low/ poor education,5 and presence of emotional distress or psychiatric comorbidity.11–13 It is estimated that about two-thirds of the more than 40 million people infected with HIV worldwide live in sub-Saharan Africa.14 Despite the high prevalence of HIV in sub-Saharan Africa, the percentage of the HIV-infected persons on regular ARV therapy is low. This is due to a combination of factors, including poverty, ignorance and lack of proper education regarding HIV, unavailability of HAART, and intense HIV-related stigma in the region. Also, psychiatric comorbidity has been associated with HIV disease since the beginning of the AIDS epidemic,15 very particularly so in Africa.16 A search of literature revealed no study focusing on psychological distress and Psychosomatics 51:1, January-February 2010
Adewuya et al. adherence to medication among the HIV-infected population in sub-Saharan Africa. So, for persons who are on the ARV medication, it is not known whether their adherence is as good as found in western cultures. It is also not known whether their adherence is affected by their level of psychological distress. In order for any intervention policy to help HIVinfected persons to succeed in sub-Saharan Africa, background knowledge of their level of psychological distress and its association with adherence is important. The aim of the present study was to determine whether there is a relationship between psychiatric comorbidity and ARV medication adherence in Nigeria. METHOD Subjects Participants in the study were recruited from persons attending “Living Hope Care,” an HIV support/care center for persons with HIV infection located in Ilesa, Osun state, Western Nigeria. The center provides support, counseling, and free ARV drugs to about 200 HIV-infected persons in the state. All the Care attendees meeting the inclusion criteria were targeted for interview. Inclusion criteria include age over 18 years and HIV-seropositivity. Excluded were subjects who were critically ill; had significant neurological disorders, including traumatic brain injury, or had seroconverted to negative on HIV testing and were no longer on ARV drugs. Of the 198 persons approached, 182 agreed to participate in the study. There were no statistically significant differences between the sociodemographic and clinical profiles of those who refused participation and the participants. Testing Procedure Informed consent was obtained from the participants after the aims and objectives of the study were explained to them. The Ethics and Research Committee of the Obafemi Awolowo University Teaching Hospitals Complex approved the study protocol. The participants were first administered a pro forma questionnaire asking about sociodemographic details like age, sex, marital status, and level of education. A Likert-scale format was used to measure the level of social support from spouse/family (Poor, Fair, and Good social support). Socioeconomic status was derived from occupational status and income per month. Clinical details elicited from the clients included clinical stage of the disease, time of diagnosis, any Psychosomatics 51:1, January-February 2010
present medical problems, previous hospital admissions due to HIV, and duration of ARV drug use. Level of disease knowledge was assessed by asking the clients to recall their last CD4 cell count. The participants also completed the Rosenberg’s Self-Esteem Scale,17 which is a 10-item questionnaire with items answered on a 4-point Likert scale from Strongly Agree to Strongly Disagree. Higher scores on the scale reflect higher self-esteem. General psychopathology was measured with the self-report 12-item General Health Questionnaire (GHQ–12). The GHQ–1218 is an often-used instrument for diagnosing general psychopathology, with items including sleeping difficulties. Each item has a score of 0 to 1, with a total score range of 0 to 12. The English- and Yoruba-translated versions had been validated in Nigeria, with a cutoff score of 3-and-above indicating presence of clinically significant psychopathology.19 Adherence was assessed by use of the Morisky Medication Adherence Questionnaire.20 The questionnaire consists of four items (in a Yes-or-No answer format) asking about forgetting to take medication, carelessness about taking medication, and stopping medication when 1) feeling better and 2) when feeling worse. The questionnaire differentiates among “high,” “medium,” and “low” adherence, according to number of total “Yes” scores of 0, 1, or 2, and 3 or 4, respectively. This standard scoring was used in our study. However, the “careless” in Question 2 was changed to “casual” to avoid the possible pejorative meaning of “careless” in our culture. Statistical Analysis The Statistical package for the Social Sciences 11 (SPSS.11) program was used for statistical analysis. Results were grouped and calculated as frequencies (%), means, and standard deviations (SD). The chi-square test was used to calculate the differences between groups. All tests were two-tailed, and significance was set at p ⬍0.05. Significant variables were entered into a logistic-regression analysis, and odds ratios (OR) and 95% confidence intervals (95% CI) were calculated for independent predictors. RESULTS Sociodemographic and Clinical Profiles of the Participants The mean age of the 182 participants in years was 30.9 (SD: 11.4), with a range of 18 – 62 years. Of the participants, 86 (47.3%) were men. Although only 29 (15.9%) were presently married, 24 (13.2%) were widhttp://psy.psychiatryonline.org
69
Medication Adherence in HIV
TABLE 1.
Associations Between Low Adherence to Antiretroviral (ARV) Medications and Sociodemographic and Clinical Variables
Variables Age-group, years 18–25 26–35 ⬎35 Sex Male Female Marital status Married Single Separated/divorced Widowed Religion Christian Muslim Ethnicity Yoruba Other tribes Socioeconomic status Low Medium High Highest education obtained No formal education Primary school Secondary school College/university Level of social support Good Fair Poor Disease knowledge Good Poor CDC infection stage Stage A Stage B Past HIV-related hospitalization Yes No Comorbid medical problems Yes No Length of diagnosis, years ⬍2 2–5 ⬎5 Length of ARV use, years ⬍1 1–3 ⬎3 Level of self-esteem Low (Rosenberg scale score 0–10) Medium (Rosenberg scale score 11–20) High (Rosenberg scale score 21–30) General psychopathology Absent (GHQ–12 score ⬍3) Present (GHQ–12 score ⱖ3)
Total (Nⴝ182)
Low Adherence (Nⴝ49)
High/Medium Adherence (Nⴝ133)
74 59 49
22 17 10
86 96
2
df
52 42 39
1.461
2
0.482
25 21
58 75
2.631
1
0.105
29 89 40 24
2 20 17 10
27 69 23 14
14.393
3
0.002
101 81
31 18
70 63
1.639
1
0.200
152 30
38 11
114 19
1.733
1
0.188
62 79 41
20 21 8
42 58 33
2.046
2
0.359
19 52 91 20
12 16 20 1
7 36 71 19
19.087
3
<0.001
36 89 57
3 21 25
33 68 32
15.135
2
0.001
109 73
20 29
89 44
10.158
1
0.001
109 73
35 14
74 59
3.716
1
0.054
21 161
2 47
19 114
3.653
1
0.056
68 114
12 37
56 77
4.748
1
0.029
58 116 8
15 30 4
43 86 4
2.265
2
0.322
82 64 36
26 15 8
56 49 28
1.754
2
0.416
40 81 61
14 23 12
26 58 49
3.046
2
0.218
63 119
7 42
56 77
12.244
1
<0.001
p
Bolded p values indicate variables later entered into logistic-regression analysis.
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TABLE 2.
having high adherence; 57 (31.3%), as having medium adherence; and the rest (49; 26.9%) as having low adherence, respectively. For ease of analysis, the age, length of diagnosis, GHQ scores, and the Rosenberg Self-Esteem Scale scores were grouped. Univariate analysis (by chisquare method) of the associations among low adherence and the clinical and sociodemographic variables are shown in Table 1. As shown in the table, there were no statistically significant associations between low adherence to ARV and age-group, sex, religion, ethnicity, socioeconomic class, staging of infection, HIV-related hospitalization, length of HIV diagnosis, duration of ARV use, and level of self-esteem as measured by the Rosenberg Self-Esteem Scale. There were, however, significant association between low adherence and marital status, educational level, perceived level of social support, knowledge of the illness, comorbid medical problems, and general psychopathology as measured by the GHQ–12. The significant variables (marital status, educational level, level of social support, knowledge of illness, comorbid medical problems, and general psychopathology) and the variables with p values ⬍0.1 (CDC staging of infection and past HIV-related hospitalization) were then entered into a binary logistic-regression analysis to determine the predictors of low adherence. The results (Table 2) showed that only general psychopathology (as measured by the GHQ–12) and perceived level of social support remained in the analysis. The odds ratio (OR) and 95% confidence interval (95% CI) for the predicting variables are shown in Table 3.
Independent Predictors of Low Adherence to Antiretroviral (ARV) Medication by Binary Logistic-Regression Analysis Variable

Wald SE Statistic df
General psychopathology (by 3.330 0.816 16.662 GHQ–12) Perceived level of social support 1.481 0.449 10.866
p
1 ⬍0.001 1
0.001
owed. Ninety-one (50.0%) were educated to the secondary-school level, and 101 (55.5%) were Christians. The participants were mostly from the Yoruba ethnic group (83.5%, N⫽152). Sixty-two (34.1%) were of low socioeconomic status. A total of 57 participants (31.3%) reported receiving poor social support from family and friends. The mean average length of time the participants had been diagnosed with HIV was 2.13 (SD: 1.05) years, with a range of 1–7 years. Many (45.1%; N⫽82) had been receiving ARV for less than 1 year, and 21 (11.5%) had had an HIV-related hospitalization at least once. A total of 68 participants (37.4%) had a comorbid medical problem, although 109 (59.9%) belonged to the Center for Disease Control (CDC) Classification Group A (acute HIV infection, but asymptomatic), and the rest (73; 40.1%) belonged to Group B (symptomatic, but without an AIDS-defining condition). None of the participants belonged to the Group C (AIDS-defining condition) classification. The mean GHQ score was 3.28 (SD: 2.00), with a range of 0 –7; the mean Rosenberg Self-Esteem Scale score was 16.05 (SD: 6.93), with a range of 2–27. A total of 109 clients (59.9%) could reliably recall their last CD4 count test result, and their knowledge of the disease were classified as “good.”
DISCUSSION Rate of Adherence and Correlates of Low Adherence to ARV Medications
To our knowledge, our study is the first in sub-Saharan Africa to have focused on the association between psychological distress and adherence to medication among an HIV-infected population. Our study described the status of
By use of the Morisky Medication Adherence Questionnaire, a total of 76 clients (41.8%) was classified as TABLE 3.
Odds Ratios (OR) and 95% Confidence Intervals (95% CI) for the Predictor Variables Variables
General psychopathology Absent (GHQ–12 score ⬍3) Present (GHQ–12 score ⱖ3) Perceived level of social support Good Fair Poor
Total (Nⴝ182)
Low Adherence (Nⴝ49)
Medium/High Adherence (Nⴝ133)
OR (95% CI)
63 119
7 42
56 77
1 (reference) 4.36 (1.83–10.43)
36 89 57
3 21 25
33 68 32
1 (reference) 3.40 (0.95–12.21) 8.59 (2.36–31.30)
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Medication Adherence in HIV persons with HIV infection in sub-Saharan Africa; over one-third were of low socioeconomic status; about onethird had poor social support, and over one-third had comorbid medical problems. Only about 15% were presently married, with about the same percentage already widowed. Fewer than half of our clients (41.8%) had high adherence to their medication; this is lower than the average of 60% reported in most western studies11,21 and the over80% recently reported in South-Africa.6 It should be noted that a substantial percentage of our clients (31.3%) had medium adherence to medication, with 26.9% having low adherence. Although the level of low adherence is still higher than found in studies from western cultures,11,21 medication adherence in our study may still be overestimated. This is because of the cross-sectional nature of the study, where nonadherent clients are likely to be irregular attendees of the care center and may have dropped out, and were thus not included in the sampling frame. This is a common source of bias in most compliance studies. Also, the use of self-report is known to overestimate adherence. Also, we found that over one-third of our clients with HIV infection had psychological distress sufficient to be identified as “cases” on the GHQ–12. This is below the average of 40%–50% found in most western studies.13 There are possible explanations for this. Although the GHQ may be easily used as a screening test for psychological distress, it is inadequate in distinguishing emotional symptoms and somatic symptoms that had been commonly reported in the African population.22 Although various factors were initially associated with low adherence to medication in our study, the only significant independent predictors were level of general psychopathology (as measured by the GHQ–12) and perceived level of social support. Our study supports findings of previous studies that have linked psychological distress with low adherence to ARV drugs.11–13 Psychological symptoms may predispose to pessimism and, hence, skepticism about effectiveness of ARV medication. Psycholog-
ically-distressed individuals may not adhere to their medications because of their distorted cognitive state or as a form of deliberate self-harm. Although our study highlights the association between psychological distress and adherence to medication, it is not possible, however, to infer causality because of the cross-sectional nature of our study, and it is not known whether treating patients with identifiable psychiatric disorders or psychological distress leads to improved ARV medication adherence. In keeping with other studies,5,9,10 we also found perceived poor social support to be associated with low level of ARV adherence. Beals et al.23 had earlier reported that supportive caregivers often remind HIV-infected persons to take their medication, although they also reported that high perceived adherence hassles on the part of the caregiver was also associated with low adherence. Although we did not find any significant difference between perceived Good and Fair social support, the clients who perceived their social support as Poor are significantly more likely to have low adherence than those having perceived Good social support (OR: 8.59; 95% CI: 2.36 –31.30). It has been hypothesized that Good social support was associated with less negative affect, which, in turn, was associated with self-efficacy in adhering to medication.10 The limitations of our study include its cross-sectional design, its use of a screening scale to measure psychological distress, and a self-report questionnaire to measure medication adherence. The study indicates significant poor adherence to ARV medication among persons with HIV infection in sub-Saharan Africa and confirms the association between low medication adherence and psychological distress and poor level of social support among our patients. These factors must be considered for the success of any intervention policy on HIV-infected persons in subSaharan Africa. A longitudinal study is needed to address the specific interaction of psychological distress and low adherence.
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