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Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia
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Contents lists available at ScienceDirect
HIV & AIDS Review journal homepage: www.elsevier.com/locate/hivar
Original Research Article
Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia Efrem Negash a, Negash Wakgari b,*, Belaynew Wasie c, Melkie Edris d, Gezahegn Bekele b a
Public Health Department, Health Science and Medical Faculty, Mettu University, Mettu, Ethiopia School of Nursing and Midwifery, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia Department of Epidemiology and Biostatics, Institute of Public Health, University of Gondar, Gondar, Ethiopia d Department of Human Nutrition, Institute of Public Health, University of Gondar, Gondar, Ethiopia b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 September 2015 Received in revised form 13 April 2016 Accepted 18 April 2016 Available online xxx
Background: Adherence to antiretroviral therapy is a powerful predictor of survival of HIV positive patients. The rate of non-adherence to antiretroviral therapy remains high in developing countries, even though it is not well documented in the study area. Hence, this study aimed to assess the level of adherence to antiretroviral therapy and associated factors among HIV positive patients. Materials and methods: An institution based cross-sectional study was conducted among 383 HIV positive patients. Respondents were selected by systematic random sampling technique. A pre-tested and structured questionnaire was used to collect data. The data were entered to Epi-Info and exported to SPSS for further analysis. Results: The self-reported adherence level in this study was 89.3%. Common reasons of being nonadherent were: being busy [2.6%], simply forgetting [7.3%], and being away from home [4.7%]. Adherence was more likely common among patients who lived 30 km far from health care facilities [AOR = 16.031, 95% CI: 2.428, 11.483], had normal mood [AOR = 5.722, 95% CI: 1.492, 21.945], had not an opportunistic infection [AOR = 6.910, 95% CI: 1.980, 24.112], whereas less likely among those who had college and above education [AOR = 0.10, 95% CI: 0.013, 0.348] and malnutrition [AOR = 0.270, 95% CI: 0.079, 0.919]. Conclusions: Self-reported adherence in this study was higher than that seen in developing countries. Management of depression and opportunistic infections using an alarm clock, nutrition education, encouragement of social support and counseling of the patient to attend their follow up at nearer health care facilities are recommended to improve the adherence level. ß 2016 Polish AIDS Research Society. Published by Elsevier Sp. z o.o. All rights reserved.
Keywords: Adherence Antiretroviral therapy West Ethiopia
1. Introduction Non-adherence to antiretroviral therapy (ART) is a powerful predictor of survival for individuals living with HIV/AIDS [1]. On the other hand, adherence to ART is critical for optimal virologic suppression and improved number of CD4+ cell [1,2]. The rate of non-adherence to ART remains high and key challenges to the programs in many countries of the world [3–7]. Patients were considered highly adherent if they reported taking 95.0% of their medication as prescribed [2]. In several studies, non-adherence of patients on ART was the strongest indicator of failure to achieve
* Corresponding author. Tel.: +251 917093718; fax: +251 0462208755. E-mail address: [email protected] (N. Wakgari).
viral suppression below the level of detection [8]. It is also an important factor in treatment failure and development of drug resistance as well as progression to AIDS and death [1,2]. The measurement of adherence of patients to treatment has been a major challenge because of the subjective and private nature of pill taking behavior in ambulatory patients. These challenges are compounded by the fact that adherence is not only affected by patient behavior alone. The ideal adherence measurement tool should be non-invasive, simple to use, sensitive, specific, and predictive of non-adherence [7,8]. Currently, there is no adherence measurement tool with all of the above attributes. This has led the recommendation to use a multi-method approach (self report, visual analogue scale, and pill identification test and pill count) that combines feasible self-reporting and reasonable objective measures [8].
http://dx.doi.org/10.1016/j.hivar.2016.04.004 1730-1270/ß 2016 Polish AIDS Research Society. Published by Elsevier Sp. z o.o. All rights reserved.
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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Even though the effectiveness of ART is highly influenced by the patient adherence, which in turn is affected by different factors [2,9,10]; the adherence level of patients to ART and its associated factors are not well determined in the study area. Therefore, this study will provide information on the level of adherence to antiretroviral therapy and its associated factors among HIVpositive patients. 2. Materials and methods 2.1. Study design and settings An institution based cross-sectional study design was conducted to assess the level of adherence to ART and its associated factors among adult HIV positive patients in Nekemte public health institutions, west Ethiopia. The Nekemte town administration is found in the east Wallaga zone. The town is 331 km far away from capital city of the country, Addis Ababa and divided into six sub cities with a total population of 91,957. There were one hospital and one health center functioning in the town during the study period. A total of 1790 and 420 adult patients were on ART in hospital and health center ART clinic, respectively during the study. The study period was from August 2012 to November 2012. 2.2. Population All adult registered patients who are on ART in Nekemte hospital and health center were considered as a source population. Eligible people living with HIV/AIDS on ART were those above 18 years of age and who had been on ART for at least a month. However, those who were critically ill, had kyphoscoliosis (for height measurement) and pregnant women were excluded from the study. 2.3. Sample size and sampling procedures The sample size was calculated using single population proportion formula: n ¼ ðZ a=2Þ2 pð1pÞ=w2 , considering the following assumptions: the proportion (p) of the prevalence of adherence to ART among people living with HIV/AIDS = 72.4%, based on previous study [11], 95% confidence interval, 5% of absolute precision, and 5% non-response rate. Hence, the total sample size was 383. Each patient was sampled by a systematic random sampling technique using patient’s unique ART number as a frame. Then study subjects were selected by proportional allocation based on the number of patients that the respective health facilities contain in their ART clinic and K number of patients was drawn. Thus: 1. Nekemte hospital = 1790 patients were on ART. Then: K¼
3831790 2210
¼ 310 patients had been taken from the hospital
Therefore, patients were selected systematically every 6 patients by using patient unique ART numbers from their registration book. 2.4. Data collection tools and procedures Literatures were reviewed to develop the tool and to include all the possible variables that address the objective of the study [1,4,5,11–14]. The instrument was pre-tested on 5% of similar study participants in the other health facility. Findings from the pre-test were used to modify the instrument. The questionnaire was designed to obtain information on the socio-demographic characteristics, psychosocial, behavioral, nutritional, disease, and health care factors. To secure the privacy and maintain the confidentiality of the study participants, five nurses who have been working in the respective health facilities rather than ART unit were used as data collectors. Two health officers were recruited as supervisors. The English version questionnaire was translated into the local language (Afan Oromo) to obtain data from the study participants and to ensure understandability and clarity of its content. Then Afan Oromo version was translated back to English version to ensure consistency. Document review was used for patient unique ART numbers. Measuring instruments including number of doses missed during the past month, weighing scale and height measuring board were used to assess the nutritional status of patients on ART, while standard mood or depression assessment questionnaire, which cover the major dimensions of depression (depressed mood, feelings of worthlessness, helplessness, psychomotor retardation and sleep disturbance), were used to assess depression. Respondents’ attitude toward ART was assessed by using a 5-point Likert scale. Dose adherence was assessed by asking participants to report on how many doses they had missed taking during the past month. Psychological distress and social support were measured by asking participants on how satisfied they are with the support they get from friends and family members with the help of 4-point scale [very dissatisfied to very satisfied] and to what extent friends and family members help them remember to take their medication [not at all to a lot]. Similarly, attitude of participants toward ART was determined by using a 5-point Likert scale, as individuals who said strongly agree score 5 while who said strongly disagree score 1 for positive attitude and this value was reversed for negative attitude questions. Finally, all values for attitude related questions were computed to get their mean value. Similarly, knowledge of the respondent for ART were assessed by yes or no formatted questions and individuals who responded as yes score 1 while those who responded as no score 0 values and lastly, the values of knowledge related questions were computed to get their mean value. Mood of patient on ART was also measured by yes or no formatted questions. 2.5. Data processing and analysis
2. Nekemte health center = 420 patients were on ART. Then: 383420 2210 ¼ 73 patients had been taken from the health center
K¼
Thus, the sampling interval for each health facility was calculated as follows:
1790 420 ¼ 6 for hospital and ¼ 6 for health center 310 73
Collected data were entered to Epi-Info version 3.5.1 and exported to SPSS version 20.0 for further analysis. Analyses of variables were made using descriptive statistics and bivariate logistic regression analysis to look into the association between exposure variables and adherence to ART. Finally, multivariable logistic regression analysis was also applied to adjust the values of the dependent variable for the influence of the likelihood of the confounding or intervening variables. Also, Adjusted Odds Ratios [AOR] and their 95% CI were used to look into the association between the dependent and independent variables.
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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2.6. Ethical consideration An ethical approval was secured from an ethical review board committee of institute of public health, college of medicine and health science, university of Gondar. Next, official letters were submitted to the Oromia regional health bureau. Then written permission was obtained from the Oromia regional health bureau and Nekemte health department to the respective health institution in the town. In addition, a letter of support from organization of social service for AIDS [an association of people living with HIV/ AIDS in Nekemte town administration that works for the rights and well-being of its member] was taken before commencing the data collection process. During the data collection process the data collectors have informed each study participant about the purpose and anticipated benefits of the research project. Finally, they were asked for their informed written consent to participate or not in the study and for their willingness to use of their files and records for the study. Assessments and measurements were conducted in a quiet, ventilated and lighted room to increase the participants’ confidence in the study. 3. Results 3.1. Socio-demographic characteristics A total of 383 adult patients on ART were involved in the study with a response rate of 100%. The mean age of the respondents was 33.12 with 7.83 standard deviation. More than half, 229 [59.8%] and 208 [54.3%] of the participants were females and married, respectively. One hundred seventy [44.4%] of the respondents were categorized in the age group of 30–39 years. Nearly half, about 167 [43.6%] of respondents were orthodox Christianity by religion. Concerning occupational status of the respondents, 102 [26.6%] were day laborer. Regarding the educational status of the respondents; only 151 [39.4%] of them were attending primary school. Nearly twothirds 277 [72.3%] of them had 400 Ethiopian birr monthly income (Table 1). 3.2. Medical and other characters of the respondents Most of the respondents 342 [89.3%] were disclosed their status to others. Regarding social support, more than half, 233 [60.8%] of them got social support. Of these, 224 [58.5%] and 9 [2.3%] were getting support from families or parents and friends, respectively. Of the total respondents who got social support, 132 [34.5%] and 82 [21.4%] of them were very satisfied and satisfied with social support they received, respectively. Almost all, 381 [99.4%] of the respondents had a good knowledge about ART. Concerning the attitude of the respondents toward ART 376 [98.2%] of them had a good attitude toward ART. Similarly, 380 [99.2%], 382 [99.7%] and 380 [99.2%] of the participants of the study replied as they had informed about the next visit, as their privacy were protected during consultation and as they had open communication with the health care providers, respectively. Three hundred eighty [99.2%] of the respondents were counseled during treatment. Participants’ response to the standard mood or depression questionnaire indicated that, 322 [84.1%] of them had normal mood (Table 2). Concerning the distance of the respondent’s residence from the health care facilities, 313 [81.7%] was coming from a distance of 30 km. The cross tabulation result of the distance of the respondent’s residence from the health care facilities versus patient adherence to ART indicated that, out of 313 respondents who came from a distance of 30 km, 290 [92.7%] of them had a good adherence. Likewise, out of 42 respondents who came from a distance of 31–60 km, 39 [92.9%] of them had a good adherence. In contrast to this, out of 21 respondents who came from a distance
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Table 1 Socio-demographic characteristics of HIV positive adult patients in Nekemte health institutions, West Ethiopia, August 2012 (n = 383). Variables
Frequency [%]
Sex Male Female
154 [40.2] 229 [59.8]
Age in years [mean: 33.12 years] 18–29 30–39 40–64 65
113 170 99 1
[29.5] [44.4] [25.8] [0.3]
Marital status Single Married Divorced Widowed Separated
52 208 55 60 8
[13.6] [54.3] [14.4] [15.7] [2.1]
Educational status Not able to read Primary school Secondary school College and above
72 151 100 60
[18.8] [39.4] [26.1] [15.7]
Monthly income [Birr] 400 401–800 801–1200 >1200
277 [72.3] 49 [12.8] 27 [7] 30 [7.8]
Occupational status Farmer Merchant Govern. employee Student Day laborer House wife No jobs a Other
21 [5.5] 72 [18.8] 68 [17.8] 3 [0.8] 102 [26.6] 63 [16.4] 36 [9.4] 18 [4.7]
a
Other = Non-Governmental Organizations.
of 91 km, only 7 [33.3%] of them had a good adherence, while more than half, 14 [66.7%] of them had a poor adherence to ART. 3.3. Missed doses and reasons All of the respondents were asked about the number of doses they missed in the previous day, previous three days, previous week and in the previous month with the respective reasons. Accordingly, 41 [10.7%] of the respondents missed 45 doses and 38 [9.9%] of them missed 11 doses of ART in the month and week prior to the interview respectively, while only 1 dose was missed by one respondent on the previous day. Patient self-report in the month prior to the interview showed that, 342 [89.3%] had a good adherence (Table 3). Regarding the reasons for missing of ART doses 28 [7.3%] and 18 [4.7%] of the respondents stated, simply forgot and away from home as a reason for missing doses of ART, respectively, while only 5 [1.3%] of the respondents stated as they felt like the drug was toxic or harmful (Fig. 1). 3.4. ART adherence level and associated factors Adherence level in the month before the assessment indicated that, 89.3% of the respondents had a good adherence. Bivariate logistic regression analysis was performed to check whether each independent predictor had a significant association with the outcome variable after the fitness of the model for the variable was checked by Hosmer and Lemeshow test. Finally, those predictors
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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Table 2 Medical characters of the respondents, Nekemte public health institutions, West Ethiopia, August 2012 (n = 383). Variables
Category
Frequency [%]
Substance use
Alcohol Cigarettes Chat None of them
31 [8.1] 5 [1.3] 4 [1.0] 343 [89.6]
Eating problem
Yes No
54 [14.1] 329 [85.9]
Types of eating problem
Difficult in swallowing Loss of appetite Others
BMI [kg/m2]
<18.5 18.5–24.9 25–29.9 30
112 [29.2] 263 [68.7] 6 [1.6] 2 [.5]
Nutritional status
Well nourished Malnourished
263 [68.7] 120 [31.3]
Social support
Yes No
233 [60.8] 150 [39.2]
Degree of patient satisfaction to support
Very dissatisfied Dissatisfied Satisfied Very satisfied
15 [3.9] 4 [1.0] 82 [21.4] 132 [34.5]
Disclosure
Yes No
342 [89.3] 41 [10.7]
Knowledge of ART
Good knowledge Poor knowledge
381 [99.5] 2 [.5]
Attitude toward ART
Good attitude Poor attitude
376 [98.2] 7 [1.8]
Open communication to health care providers
Yes No
380 [99.2] 3 [.8]
Counseling
Yes No
380 [99.2] 3 [.8]
WHO clinical stage
Stage Stage Stage Stage
Opportunistic infections
Yes No
61 [15.9] 322 [84.1]
Mood of the patient
Normal mood Depressed mood
322 [84.1] 61 [15.9]
Accessibility to health facilities
Yes No
355 [92.7] 28 [7.3]
1 2 3 4
4 [1.0] 42 [11.0] 7 [1.8]
54 [14.1] 111 [29.0] 214 [55.9] 4 [1.0]
that were identified by bivariate analysis of backward stepwise logistic regression as significant was entered in to multivariable logistic regression analysis. Accordingly, those who were taught college and above were 10 times less likely to be adherent than those who were unable to read and write [AOR = 0.100, 95% CI: 0.013, 0.348], while those who came from a distance of 30 km were 16 times more likely to be adherent than those who came Table 3 Patients’ who missed a dose by self-report in Nekemte public health institutions, West Ethiopia, August 2012. Number of days
Previous Previous Previous Previous
day three days week month
Missed doses
Total
Yes
No
Number [%]
Number [%]
1 [0.3] 3 [0.8] 38 [9.9] 41 [10.7]
382 380 345 342
Number [%]
[99.7] [99.2] [90.1] [89.3]
383 383 383 383
[100] [100] [100] [100]
Fig. 1. Reasons for missed doses of ART reported by respondents, Nekemte public health institutions, west Ethiopia, August 2012. Others: Run out of medications.
from 90 km far away from health care facilities [AOR = 16.031, 95% CI: 2.428, 11.483]. Regarding the mood of the patient and their nutritional status, those who had a normal mood were about 6 times more likely to be adherent than those who had depressed mood [AOR = 5.722, 95% CI: 1.492, 21.945], while those who were well nourished were 4 times more likely to be adherent than who were malnourished [AOR = 0.270, 95% CI: 0.079, 0.919]. Concerning the presence or absence opportunistic infections, those who did not have opportunistic infections were about 7 times more likely to be adherent than their counterparts [AOR = 6.910, 95% CI: 1.980, 24.112] (Table 4). 4. Discussions This study assessed the level of adherence to ART and associated factors in public health institution of Nekemte town, west Ethiopia. The self-reported adherence level in this study was 89.3%. The present study is consistent with the study done in Togo (78.4%) [15]. This finding is higher than the study conducted in Uganda (86.4%) [16]. However, it was lower than the study conducted in Jimma (94.3%) [17]. This is possibly due to that almost all, [99.5% and 98.2%] of the respondents of this study had a good knowledge about ART and good attitude toward ART respectively. In addition, 99.2% of the respondents counseled about the drug instructions and benefits of adherence to ART during the treatment. The other possible reasons for these differences could be differences in the study population as well as different methods used [2,16]. Tertiary education, distance of 30 km, malnutrition, depressed mood and presence of opportunistic infection were statistically significant predictors of adherence in multivariable logistic regression analysis. This finding is consistent with the studies done in developing countries [18], South Africa [19], Nigeria [20,23], and Ethiopia [11,21]. Based on the symptoms of depression reported by the respondents; the findings of this study indicated that, out of 61 [15.9%] participants who had depressed mood, almost half, 23 [6.0%] of them had a poor adherence to ART as compared to18 [4.7%] of participants with normal mood. The odds of adherence among depressed mood and normal mood indicated that, those who had normal mood were about six times more likely to be adherent than those of depressed mood. This is in line with the studies done in Atlanta [18] and Nigeria [20]. The current study showed that, the mood of the patient was a highly significant factor correlated with ART adherence. This might be due to that depressed patients had a poor attention and concentration to regularly follow their medication or probably they missed their doses due to forgetting fullness. As stated in another study, the expression of depressive symptoms such as loss of interest,
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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Table 4 Bivariate and multivariate analyses of factors associated with adherence to ART, Nekemte public health institutions, West Ethiopia, August 2012 (n = 383). Variables
Adherence Good
Odds ratio [95% CI] Poor
Crude
p-Value Adjusted
Educational status Not able to read and write Primary school Secondary school College and above
60 149 96 37
12 2 4 23
1 14.90 [3.24, 68.58] 4.80 [1.48, 15.57] 0.32 [0.14, 0.72]
1 7.97 [0.79, 80.33] 1.47 [0.24, 9.13] 0.10 [0.01, 0.35]
Disclosure Yes No
320 22
22 19
12.56 [5.93, 26.61] 1
3.79 [0.87, 16.95] 1
Distance 30 km 61–90 km 91 km
290 6 7
23 1 14
25.22 [9.26, 8.67] 12.00 [1.19, 120.08]
16.03 [2.43, 11.48] 8.96 [0.23, 343.56] 1
0.004** 0.239
Mood of the patient Normal mood Depressed
304 38
18 23
10.22 [5.06, 20.65] 1
5.72 [1.49, 21.95] 1
0.011*
Nutritional status Well-nourished Malnourished
248 94
15 26
1 0.22 [0.11, 0.43]
1 0.27 [0.08, 0.92]
0.036*
Opportunistic infections Yes No
36 306
25 161
1 3.28 [6.49, 27.18]
1 6.91 [1.98, 24.11]
0.002**
WHO clinical stage Stage 1 Stage 2 Stage 3 Stage 4
53 91 195 3
11 20 19 1
1 0.09 [0.01, 0.66] 0.19 [0.03, 1.48] 0.06 [0.01, 1.14]
0.06 [0.01, 1.096] 0.24 [0.01, 3.90] 0.04 [0.00, 6.93]
0.058 0.314 0.221
0.078 0.683 0.001**
0.076
Others: Run out of medications. * p-Value <0.05. ** p-Value <0.01.
hopelessness, lack of energy, poor concentration and memory seen in depressive disorders is likely to have contributed to poor adherence to ART in the depressed participants [22]. In the current study, distance from a health institution was also found to be factor influencing adherence level of the respondents. Those who came from a distance of 91 km were 93% less adherent as compared to those who came from 30 km. This is supported by the studies done in Atlanta [18] and South Africa [14]. Probably, those who came from far distance did not follow their follow up appointments to clinics, did not easily accessible to health care facilities due to transportation cost and fatigue. Tertiary education was identified as predictor of ART adherence in this study. Accordingly, those who were unable to read and write were ten times more likely to be adherent than those who were college and above. This is comparable to the study done in southeast Nigeria [23]. The probable reasons might be as educational status increases, there may be increased income, relaxation, involvement in many activities and may become busy with other things, which may all have their contribution to miss ART doses. In addition, because those with tertiary education are more knowledgeable about the drug side effects and the fact that there is no cure for HIV/AIDS may encourage them to be nonadherent. On the other hand, those without tertiary education would tend to respect the advice of the providers and therefore be more likely to adhere to ART drugs. Regarding the nutritional status of the respondents, the finding of this study revealed that those who were well nourished were about four times more likely to be adherent than those of malnourished. This finding is in line with the studies done in Uganda [16] and sub-Saharan Africa [13]. This may be due to that, nutrition of the patients’ affects drug metabolism, absorption, and efficiency and also patients may suffer frequently from
opportunistic infection as a result of reduced immunity and then become non-adherent. This finding was supported by other findings in the sub-Saharan Africa [13], as malnutrition and food insecurity had emerged as a major barrier to medication adherence. The most common reasons reported for missing ART doses by patients in this study were, away from home, busy with other things and simply forgot. This finding is similar to the study done in Uganda [16], South Africa [14] and Ethiopia [11,21]. 4.1. Limitations This study had some limitations: First, in this study, only dose adherence of the patients was assessed. Second, since the patient adherence to ART level was assessed over the last month prior to the interview, there could be recalled bias. Also, since data collectors were health professionals in the respective institutions, response and social desirability bias could also appear. Thirdly, since infants, pregnant women and adult patients who were on ART for less than a month were excluded, these study findings could not generalized to all people living with HIV/AIDS who were on ART. However, numerous scientific procedures have been employed to minimize the possible effects. To reduce the response and social desirability, for instance, the aim of the study was discussed with respondents in order to obtain a genuine response. In addition, procedures such as pre testing, supervision and adequate training of data collectors and supervisors were utilized. 5. Conclusions In this study, patient self-reported adherence in the month before the interview was found to be high. The closeness of the
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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patient or residence to health facilities, normal mood of the patients and absence of opportunistic infections found to be predictors of a good adherence, while being malnourished and having an education of college and above of the patient were identified as predictor of poor adherence. The most common reasons for missing ART doses were: being busy, simply forgetting, and being away from home. Authors’ contributions EN and NW participated in the design of the study and data collection and analyzed the data and drafted the paper. BW, GB and ME participated in the analysis and revised subsequent drafts of the paper. All authors read and approved the final manuscript. Conflict of interest None declared. Financial disclosure We would like to thank the University of Gondar for their financial support. References [1] M.B. Cauldbeck, C. O’Connor, M.B. O’Connor, J.A. Saunders, B. Rao, V.G. Mallesh, P. Kumar, N.K. Gurushanthappa Mamtha, C. McGoldrick, B.S.R. Laing, et al., Adherence to anti-retroviral therapy among HIV patients in Bangalore, India, AIDS Res. Ther. 6 (2009) 7. [2] P. Roux, C. Kouanfack, J. Cohen, F. Marcellin, S. Boyer, E. Delaporte, P. Carrieri, C. Laurent, Adherence to antiretroviral treatment in HIV-positive patients in the Cameroon context: promoting the use of medication reminder methods, J. Acquir. Immune Defic. Syndr. 57 (Suppl. 1) (2011) 540–543. [3] R. Garcia, R. Badaro´, M.E. Netto, M. Silva, S.F. Amorin, A. Ramos, F. Vaida, C. Brites, R.T. Schooley, Cross-sectional study to evaluate factors associated with adherence to antiretroviral therapy by Brazilian HIV-infected patients, AIDS Res. Hum. Retrovir. 22 (Suppl. 12) (2006) 1248–1252. [4] E. Mills, B.J. Nachega, I. Buchan, J. Orbinski, A. Attaran, S. Singh, B. Rachlis, P. Wu, C. Cooper, L. Thabane, et al., Adherence to antiretroviral therapy in SubSaharan Africa and North America: a meta-analysis, JAMA 296 (Suppl. 6) (2006) 679–690. [5] L.F. Filho, S.A. Nogueira, E.S. Machado, T.F. Abreu, R.H. de Oliveira, L. Evangelista, C.B. Hofer, Factors associated with lack of antiretroviral adherence among adolescents in a reference centre in Rio de Janeiro, Brazil, Int. J. STD AIDS 19 (Suppl. 10) (2008) 685–688. [6] C. Ortego, T.B. Huedo-Medina, J. Llorca, L. Sevilla, P. Santos, E. Rodrı´guez, M.R. Warren, J. Vejo, Adherence to highly active antiretroviral therapy (HAART): a meta-analysis, AIDS Behav. 15 (Suppl. 7) (2011) 1381–1396.
[7] C. Serrano, R. Laporte, M. Ide, Y. Nouhou, P. de Truchis, E. Rouveix, A. Adamou, V. Pauly, J.F. Mattei, J.A. Gastaut, Family nutritional support improves survival, immune restoration and adherence in HIV patients receiving ART in developing country, Asia Pac. J. Clin. Nutr. 19 (Suppl. 1) (2010) 68–75. [8] G. Steel, J. Nwokike, P.M. Joshi, Development of a Multi-method Tool to Measure ART Adherence in Resource-Constrained Settings: The South Africa Experience, Rational Pharmaceutical Management Plus Program Center for Pharmaceutical Management, Management Sciences for Health, USA, 2007. [9] G.L. Birbeck, M.P. Kvalsund, P.A. Byers, R. Bradbury, C. Mang’ombe, N. Organek, T. Kaile, A.M. Sinyama, S.S. Sinyangwe, K. Malama, et al., Neuropsychiatric and socioeconomic status impact antiretroviral adherence and mortality in Rural Zambia, Am. J. Trop. Med. Hyg. 85 (Suppl. 4) (2011) 782–789. [10] J. Grierson, R.L. Koelmeyer, A. Smith, M. Pitts, Adherence to antiretroviral therapy: factors independently associated with reported difficulty taking antiretroviral therapy in a national sample of HIV-positive Australians, HIV Med. 12 (Suppl. 9) (2011) 562–569. [11] A. Tiyou, T. Belachew, F. Alemseged, S. Biadgilign, Predictors of adherence to antiretroviral therapy among people living with HIV/AIDS, AIDS Res. Ther. 7 (Suppl. 39) (2010). [12] D.E. Kurtyka, Adult AIDS Clinical Group, 2008 Available: https://books.google. com.et/books?isbn. [13] J.R. Koethe, B.H. Chi, K.M. Megazzini, D.C. Heimburger, J.S. Stringer, Macronutrient supplementation for malnourished HIV-infected adults: a review of the evidence in resource-adequate and resource-constrained settings, Clin. Infect. Dis. 49 (Suppl. 5) (2009) 787–798. [14] Z. El-Khatib, M.A. Ekstrom, A. Coovadia, E.J. Abrams, M. Petzold, D. Katzenstein, L.M. Kuhn, Adherence and virologic suppression during the first 24 weeks on antiretroviral therapy among women in Johannesburg, South Africa – a prospective cohort study, BMC Public Health 11 (2011) 88. [15] I. Yaya, D.E. Landoh, B. Saka, Predictors of adherence to antiretroviral therapy among people living with HIV and AIDS at the regional hospital of Sokode´, Togo, BMC Public Health 14 (2014) 1308. [16] V. Senkomago, D. Guwatudde, M. Breda, K. Khoshnood, Barriers to antiretroviral adherence in HIV-positive patients receiving free medication in Kayunga, Uganda, AIDS Care 23 (Suppl. 10) (2011) 1246–1253. [17] A. Amberbir, K. Woldemichael, S. Getachew, B. Girma, K. Deribe, Predictors of antiretroviral therapy among HIV-infected persons: a prospective study in Southwest Ethiopia, BMC Public Health 8 (Suppl. 265) (2008). [18] S.C. Kalichman, T. Grebler, Stress and poverty predictors of treatment adherence among people with low-literacy living with HIV/AIDS, Psychosom. Med. 72 (Suppl. 8) (2010) 810–816. [19] V.G. Bhat, M. Ramburuth, M. Singh, O. Titi, A.P. Antony, L. Chiya, E.M. Irusen, P.P. Mtyapi, M.E. Mofoka, A. Zibeke, et al., Factors associated with poor adherence to anti-retroviral therapy in patients attending a rural health centre in South Africa, Eur. J. Clin. Microbiol. Infect. Dis. 29 (Suppl. 8) (2010) 947–953. [20] V.O. Olisah, O. Baiyewu, T.L. Sheikh, Adherence to highly active antiretroviral therapy in depressed patients with HIV/AIDS attending a Nigerian university teaching hospital clinic, Afr. J. Psychiatry 13 (Suppl. 1) (2010) 275–279. [21] M. Endrias, A. Worku, G. Davey, Adherence to ART in PLWHA at Yirgalem Hospital, South Ethiopia, Ethiop. J. Health Dev. 22 (Suppl. 2) (2008) 174–179. [22] N.C. Talam, P. Gatongi, J. Rotich, S. Kimaiyo, Factors affecting antiretroviral drug adherence among HIV/AIDS adult patients attending HIV/AIDS clinic at Moi Teaching and Referral Hospital, Eldoret, Kenya, East Afr. J. Public Health 5 (Suppl. 2) (2008) 74–78. [23] B.S. Uzochukwu, O.E. Onwujekwe, A.C. Onoka, C. Okoli, N.P. Uguru, O.I. Chukwuogo, Determinants of non-adherence to subsidized anti-retroviral treatment, Health Policy Plan. 24 (Suppl. 3) (2009) 189–196.
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Contents lists available at ScienceDirect
HIV & AIDS Review journal homepage: www.elsevier.com/locate/hivar
Original Research Article
Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia Efrem Negash a, Negash Wakgari b,*, Belaynew Wasie c, Melkie Edris d, Gezahegn Bekele b a
Public Health Department, Health Science and Medical Faculty, Mettu University, Mettu, Ethiopia School of Nursing and Midwifery, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia Department of Epidemiology and Biostatics, Institute of Public Health, University of Gondar, Gondar, Ethiopia d Department of Human Nutrition, Institute of Public Health, University of Gondar, Gondar, Ethiopia b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 28 September 2015 Received in revised form 13 April 2016 Accepted 18 April 2016 Available online xxx
Background: Adherence to antiretroviral therapy is a powerful predictor of survival of HIV positive patients. The rate of non-adherence to antiretroviral therapy remains high in developing countries, even though it is not well documented in the study area. Hence, this study aimed to assess the level of adherence to antiretroviral therapy and associated factors among HIV positive patients. Materials and methods: An institution based cross-sectional study was conducted among 383 HIV positive patients. Respondents were selected by systematic random sampling technique. A pre-tested and structured questionnaire was used to collect data. The data were entered to Epi-Info and exported to SPSS for further analysis. Results: The self-reported adherence level in this study was 89.3%. Common reasons of being nonadherent were: being busy [2.6%], simply forgetting [7.3%], and being away from home [4.7%]. Adherence was more likely common among patients who lived 30 km far from health care facilities [AOR = 16.031, 95% CI: 2.428, 11.483], had normal mood [AOR = 5.722, 95% CI: 1.492, 21.945], had not an opportunistic infection [AOR = 6.910, 95% CI: 1.980, 24.112], whereas less likely among those who had college and above education [AOR = 0.10, 95% CI: 0.013, 0.348] and malnutrition [AOR = 0.270, 95% CI: 0.079, 0.919]. Conclusions: Self-reported adherence in this study was higher than that seen in developing countries. Management of depression and opportunistic infections using an alarm clock, nutrition education, encouragement of social support and counseling of the patient to attend their follow up at nearer health care facilities are recommended to improve the adherence level. ß 2016 Polish AIDS Research Society. Published by Elsevier Sp. z o.o. All rights reserved.
Keywords: Adherence Antiretroviral therapy West Ethiopia
1. Introduction Non-adherence to antiretroviral therapy (ART) is a powerful predictor of survival for individuals living with HIV/AIDS [1]. On the other hand, adherence to ART is critical for optimal virologic suppression and improved number of CD4+ cell [1,2]. The rate of non-adherence to ART remains high and key challenges to the programs in many countries of the world [3–7]. Patients were considered highly adherent if they reported taking 95.0% of their medication as prescribed [2]. In several studies, non-adherence of patients on ART was the strongest indicator of failure to achieve
* Corresponding author. Tel.: +251 917093718; fax: +251 0462208755. E-mail address: [email protected] (N. Wakgari).
viral suppression below the level of detection [8]. It is also an important factor in treatment failure and development of drug resistance as well as progression to AIDS and death [1,2]. The measurement of adherence of patients to treatment has been a major challenge because of the subjective and private nature of pill taking behavior in ambulatory patients. These challenges are compounded by the fact that adherence is not only affected by patient behavior alone. The ideal adherence measurement tool should be non-invasive, simple to use, sensitive, specific, and predictive of non-adherence [7,8]. Currently, there is no adherence measurement tool with all of the above attributes. This has led the recommendation to use a multi-method approach (self report, visual analogue scale, and pill identification test and pill count) that combines feasible self-reporting and reasonable objective measures [8].
http://dx.doi.org/10.1016/j.hivar.2016.04.004 1730-1270/ß 2016 Polish AIDS Research Society. Published by Elsevier Sp. z o.o. All rights reserved.
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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Even though the effectiveness of ART is highly influenced by the patient adherence, which in turn is affected by different factors [2,9,10]; the adherence level of patients to ART and its associated factors are not well determined in the study area. Therefore, this study will provide information on the level of adherence to antiretroviral therapy and its associated factors among HIVpositive patients. 2. Materials and methods 2.1. Study design and settings An institution based cross-sectional study design was conducted to assess the level of adherence to ART and its associated factors among adult HIV positive patients in Nekemte public health institutions, west Ethiopia. The Nekemte town administration is found in the east Wallaga zone. The town is 331 km far away from capital city of the country, Addis Ababa and divided into six sub cities with a total population of 91,957. There were one hospital and one health center functioning in the town during the study period. A total of 1790 and 420 adult patients were on ART in hospital and health center ART clinic, respectively during the study. The study period was from August 2012 to November 2012. 2.2. Population All adult registered patients who are on ART in Nekemte hospital and health center were considered as a source population. Eligible people living with HIV/AIDS on ART were those above 18 years of age and who had been on ART for at least a month. However, those who were critically ill, had kyphoscoliosis (for height measurement) and pregnant women were excluded from the study. 2.3. Sample size and sampling procedures The sample size was calculated using single population proportion formula: n ¼ ðZ a=2Þ2 pð1pÞ=w2 , considering the following assumptions: the proportion (p) of the prevalence of adherence to ART among people living with HIV/AIDS = 72.4%, based on previous study [11], 95% confidence interval, 5% of absolute precision, and 5% non-response rate. Hence, the total sample size was 383. Each patient was sampled by a systematic random sampling technique using patient’s unique ART number as a frame. Then study subjects were selected by proportional allocation based on the number of patients that the respective health facilities contain in their ART clinic and K number of patients was drawn. Thus: 1. Nekemte hospital = 1790 patients were on ART. Then: K¼
3831790 2210
¼ 310 patients had been taken from the hospital
Therefore, patients were selected systematically every 6 patients by using patient unique ART numbers from their registration book. 2.4. Data collection tools and procedures Literatures were reviewed to develop the tool and to include all the possible variables that address the objective of the study [1,4,5,11–14]. The instrument was pre-tested on 5% of similar study participants in the other health facility. Findings from the pre-test were used to modify the instrument. The questionnaire was designed to obtain information on the socio-demographic characteristics, psychosocial, behavioral, nutritional, disease, and health care factors. To secure the privacy and maintain the confidentiality of the study participants, five nurses who have been working in the respective health facilities rather than ART unit were used as data collectors. Two health officers were recruited as supervisors. The English version questionnaire was translated into the local language (Afan Oromo) to obtain data from the study participants and to ensure understandability and clarity of its content. Then Afan Oromo version was translated back to English version to ensure consistency. Document review was used for patient unique ART numbers. Measuring instruments including number of doses missed during the past month, weighing scale and height measuring board were used to assess the nutritional status of patients on ART, while standard mood or depression assessment questionnaire, which cover the major dimensions of depression (depressed mood, feelings of worthlessness, helplessness, psychomotor retardation and sleep disturbance), were used to assess depression. Respondents’ attitude toward ART was assessed by using a 5-point Likert scale. Dose adherence was assessed by asking participants to report on how many doses they had missed taking during the past month. Psychological distress and social support were measured by asking participants on how satisfied they are with the support they get from friends and family members with the help of 4-point scale [very dissatisfied to very satisfied] and to what extent friends and family members help them remember to take their medication [not at all to a lot]. Similarly, attitude of participants toward ART was determined by using a 5-point Likert scale, as individuals who said strongly agree score 5 while who said strongly disagree score 1 for positive attitude and this value was reversed for negative attitude questions. Finally, all values for attitude related questions were computed to get their mean value. Similarly, knowledge of the respondent for ART were assessed by yes or no formatted questions and individuals who responded as yes score 1 while those who responded as no score 0 values and lastly, the values of knowledge related questions were computed to get their mean value. Mood of patient on ART was also measured by yes or no formatted questions. 2.5. Data processing and analysis
2. Nekemte health center = 420 patients were on ART. Then: 383420 2210 ¼ 73 patients had been taken from the health center
K¼
Thus, the sampling interval for each health facility was calculated as follows:
1790 420 ¼ 6 for hospital and ¼ 6 for health center 310 73
Collected data were entered to Epi-Info version 3.5.1 and exported to SPSS version 20.0 for further analysis. Analyses of variables were made using descriptive statistics and bivariate logistic regression analysis to look into the association between exposure variables and adherence to ART. Finally, multivariable logistic regression analysis was also applied to adjust the values of the dependent variable for the influence of the likelihood of the confounding or intervening variables. Also, Adjusted Odds Ratios [AOR] and their 95% CI were used to look into the association between the dependent and independent variables.
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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2.6. Ethical consideration An ethical approval was secured from an ethical review board committee of institute of public health, college of medicine and health science, university of Gondar. Next, official letters were submitted to the Oromia regional health bureau. Then written permission was obtained from the Oromia regional health bureau and Nekemte health department to the respective health institution in the town. In addition, a letter of support from organization of social service for AIDS [an association of people living with HIV/ AIDS in Nekemte town administration that works for the rights and well-being of its member] was taken before commencing the data collection process. During the data collection process the data collectors have informed each study participant about the purpose and anticipated benefits of the research project. Finally, they were asked for their informed written consent to participate or not in the study and for their willingness to use of their files and records for the study. Assessments and measurements were conducted in a quiet, ventilated and lighted room to increase the participants’ confidence in the study. 3. Results 3.1. Socio-demographic characteristics A total of 383 adult patients on ART were involved in the study with a response rate of 100%. The mean age of the respondents was 33.12 with 7.83 standard deviation. More than half, 229 [59.8%] and 208 [54.3%] of the participants were females and married, respectively. One hundred seventy [44.4%] of the respondents were categorized in the age group of 30–39 years. Nearly half, about 167 [43.6%] of respondents were orthodox Christianity by religion. Concerning occupational status of the respondents, 102 [26.6%] were day laborer. Regarding the educational status of the respondents; only 151 [39.4%] of them were attending primary school. Nearly twothirds 277 [72.3%] of them had 400 Ethiopian birr monthly income (Table 1). 3.2. Medical and other characters of the respondents Most of the respondents 342 [89.3%] were disclosed their status to others. Regarding social support, more than half, 233 [60.8%] of them got social support. Of these, 224 [58.5%] and 9 [2.3%] were getting support from families or parents and friends, respectively. Of the total respondents who got social support, 132 [34.5%] and 82 [21.4%] of them were very satisfied and satisfied with social support they received, respectively. Almost all, 381 [99.4%] of the respondents had a good knowledge about ART. Concerning the attitude of the respondents toward ART 376 [98.2%] of them had a good attitude toward ART. Similarly, 380 [99.2%], 382 [99.7%] and 380 [99.2%] of the participants of the study replied as they had informed about the next visit, as their privacy were protected during consultation and as they had open communication with the health care providers, respectively. Three hundred eighty [99.2%] of the respondents were counseled during treatment. Participants’ response to the standard mood or depression questionnaire indicated that, 322 [84.1%] of them had normal mood (Table 2). Concerning the distance of the respondent’s residence from the health care facilities, 313 [81.7%] was coming from a distance of 30 km. The cross tabulation result of the distance of the respondent’s residence from the health care facilities versus patient adherence to ART indicated that, out of 313 respondents who came from a distance of 30 km, 290 [92.7%] of them had a good adherence. Likewise, out of 42 respondents who came from a distance of 31–60 km, 39 [92.9%] of them had a good adherence. In contrast to this, out of 21 respondents who came from a distance
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Table 1 Socio-demographic characteristics of HIV positive adult patients in Nekemte health institutions, West Ethiopia, August 2012 (n = 383). Variables
Frequency [%]
Sex Male Female
154 [40.2] 229 [59.8]
Age in years [mean: 33.12 years] 18–29 30–39 40–64 65
113 170 99 1
[29.5] [44.4] [25.8] [0.3]
Marital status Single Married Divorced Widowed Separated
52 208 55 60 8
[13.6] [54.3] [14.4] [15.7] [2.1]
Educational status Not able to read Primary school Secondary school College and above
72 151 100 60
[18.8] [39.4] [26.1] [15.7]
Monthly income [Birr] 400 401–800 801–1200 >1200
277 [72.3] 49 [12.8] 27 [7] 30 [7.8]
Occupational status Farmer Merchant Govern. employee Student Day laborer House wife No jobs a Other
21 [5.5] 72 [18.8] 68 [17.8] 3 [0.8] 102 [26.6] 63 [16.4] 36 [9.4] 18 [4.7]
a
Other = Non-Governmental Organizations.
of 91 km, only 7 [33.3%] of them had a good adherence, while more than half, 14 [66.7%] of them had a poor adherence to ART. 3.3. Missed doses and reasons All of the respondents were asked about the number of doses they missed in the previous day, previous three days, previous week and in the previous month with the respective reasons. Accordingly, 41 [10.7%] of the respondents missed 45 doses and 38 [9.9%] of them missed 11 doses of ART in the month and week prior to the interview respectively, while only 1 dose was missed by one respondent on the previous day. Patient self-report in the month prior to the interview showed that, 342 [89.3%] had a good adherence (Table 3). Regarding the reasons for missing of ART doses 28 [7.3%] and 18 [4.7%] of the respondents stated, simply forgot and away from home as a reason for missing doses of ART, respectively, while only 5 [1.3%] of the respondents stated as they felt like the drug was toxic or harmful (Fig. 1). 3.4. ART adherence level and associated factors Adherence level in the month before the assessment indicated that, 89.3% of the respondents had a good adherence. Bivariate logistic regression analysis was performed to check whether each independent predictor had a significant association with the outcome variable after the fitness of the model for the variable was checked by Hosmer and Lemeshow test. Finally, those predictors
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Table 2 Medical characters of the respondents, Nekemte public health institutions, West Ethiopia, August 2012 (n = 383). Variables
Category
Frequency [%]
Substance use
Alcohol Cigarettes Chat None of them
31 [8.1] 5 [1.3] 4 [1.0] 343 [89.6]
Eating problem
Yes No
54 [14.1] 329 [85.9]
Types of eating problem
Difficult in swallowing Loss of appetite Others
BMI [kg/m2]
<18.5 18.5–24.9 25–29.9 30
112 [29.2] 263 [68.7] 6 [1.6] 2 [.5]
Nutritional status
Well nourished Malnourished
263 [68.7] 120 [31.3]
Social support
Yes No
233 [60.8] 150 [39.2]
Degree of patient satisfaction to support
Very dissatisfied Dissatisfied Satisfied Very satisfied
15 [3.9] 4 [1.0] 82 [21.4] 132 [34.5]
Disclosure
Yes No
342 [89.3] 41 [10.7]
Knowledge of ART
Good knowledge Poor knowledge
381 [99.5] 2 [.5]
Attitude toward ART
Good attitude Poor attitude
376 [98.2] 7 [1.8]
Open communication to health care providers
Yes No
380 [99.2] 3 [.8]
Counseling
Yes No
380 [99.2] 3 [.8]
WHO clinical stage
Stage Stage Stage Stage
Opportunistic infections
Yes No
61 [15.9] 322 [84.1]
Mood of the patient
Normal mood Depressed mood
322 [84.1] 61 [15.9]
Accessibility to health facilities
Yes No
355 [92.7] 28 [7.3]
1 2 3 4
4 [1.0] 42 [11.0] 7 [1.8]
54 [14.1] 111 [29.0] 214 [55.9] 4 [1.0]
that were identified by bivariate analysis of backward stepwise logistic regression as significant was entered in to multivariable logistic regression analysis. Accordingly, those who were taught college and above were 10 times less likely to be adherent than those who were unable to read and write [AOR = 0.100, 95% CI: 0.013, 0.348], while those who came from a distance of 30 km were 16 times more likely to be adherent than those who came Table 3 Patients’ who missed a dose by self-report in Nekemte public health institutions, West Ethiopia, August 2012. Number of days
Previous Previous Previous Previous
day three days week month
Missed doses
Total
Yes
No
Number [%]
Number [%]
1 [0.3] 3 [0.8] 38 [9.9] 41 [10.7]
382 380 345 342
Number [%]
[99.7] [99.2] [90.1] [89.3]
383 383 383 383
[100] [100] [100] [100]
Fig. 1. Reasons for missed doses of ART reported by respondents, Nekemte public health institutions, west Ethiopia, August 2012. Others: Run out of medications.
from 90 km far away from health care facilities [AOR = 16.031, 95% CI: 2.428, 11.483]. Regarding the mood of the patient and their nutritional status, those who had a normal mood were about 6 times more likely to be adherent than those who had depressed mood [AOR = 5.722, 95% CI: 1.492, 21.945], while those who were well nourished were 4 times more likely to be adherent than who were malnourished [AOR = 0.270, 95% CI: 0.079, 0.919]. Concerning the presence or absence opportunistic infections, those who did not have opportunistic infections were about 7 times more likely to be adherent than their counterparts [AOR = 6.910, 95% CI: 1.980, 24.112] (Table 4). 4. Discussions This study assessed the level of adherence to ART and associated factors in public health institution of Nekemte town, west Ethiopia. The self-reported adherence level in this study was 89.3%. The present study is consistent with the study done in Togo (78.4%) [15]. This finding is higher than the study conducted in Uganda (86.4%) [16]. However, it was lower than the study conducted in Jimma (94.3%) [17]. This is possibly due to that almost all, [99.5% and 98.2%] of the respondents of this study had a good knowledge about ART and good attitude toward ART respectively. In addition, 99.2% of the respondents counseled about the drug instructions and benefits of adherence to ART during the treatment. The other possible reasons for these differences could be differences in the study population as well as different methods used [2,16]. Tertiary education, distance of 30 km, malnutrition, depressed mood and presence of opportunistic infection were statistically significant predictors of adherence in multivariable logistic regression analysis. This finding is consistent with the studies done in developing countries [18], South Africa [19], Nigeria [20,23], and Ethiopia [11,21]. Based on the symptoms of depression reported by the respondents; the findings of this study indicated that, out of 61 [15.9%] participants who had depressed mood, almost half, 23 [6.0%] of them had a poor adherence to ART as compared to18 [4.7%] of participants with normal mood. The odds of adherence among depressed mood and normal mood indicated that, those who had normal mood were about six times more likely to be adherent than those of depressed mood. This is in line with the studies done in Atlanta [18] and Nigeria [20]. The current study showed that, the mood of the patient was a highly significant factor correlated with ART adherence. This might be due to that depressed patients had a poor attention and concentration to regularly follow their medication or probably they missed their doses due to forgetting fullness. As stated in another study, the expression of depressive symptoms such as loss of interest,
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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Table 4 Bivariate and multivariate analyses of factors associated with adherence to ART, Nekemte public health institutions, West Ethiopia, August 2012 (n = 383). Variables
Adherence Good
Odds ratio [95% CI] Poor
Crude
p-Value Adjusted
Educational status Not able to read and write Primary school Secondary school College and above
60 149 96 37
12 2 4 23
1 14.90 [3.24, 68.58] 4.80 [1.48, 15.57] 0.32 [0.14, 0.72]
1 7.97 [0.79, 80.33] 1.47 [0.24, 9.13] 0.10 [0.01, 0.35]
Disclosure Yes No
320 22
22 19
12.56 [5.93, 26.61] 1
3.79 [0.87, 16.95] 1
Distance 30 km 61–90 km 91 km
290 6 7
23 1 14
25.22 [9.26, 8.67] 12.00 [1.19, 120.08]
16.03 [2.43, 11.48] 8.96 [0.23, 343.56] 1
0.004** 0.239
Mood of the patient Normal mood Depressed
304 38
18 23
10.22 [5.06, 20.65] 1
5.72 [1.49, 21.95] 1
0.011*
Nutritional status Well-nourished Malnourished
248 94
15 26
1 0.22 [0.11, 0.43]
1 0.27 [0.08, 0.92]
0.036*
Opportunistic infections Yes No
36 306
25 161
1 3.28 [6.49, 27.18]
1 6.91 [1.98, 24.11]
0.002**
WHO clinical stage Stage 1 Stage 2 Stage 3 Stage 4
53 91 195 3
11 20 19 1
1 0.09 [0.01, 0.66] 0.19 [0.03, 1.48] 0.06 [0.01, 1.14]
0.06 [0.01, 1.096] 0.24 [0.01, 3.90] 0.04 [0.00, 6.93]
0.058 0.314 0.221
0.078 0.683 0.001**
0.076
Others: Run out of medications. * p-Value <0.05. ** p-Value <0.01.
hopelessness, lack of energy, poor concentration and memory seen in depressive disorders is likely to have contributed to poor adherence to ART in the depressed participants [22]. In the current study, distance from a health institution was also found to be factor influencing adherence level of the respondents. Those who came from a distance of 91 km were 93% less adherent as compared to those who came from 30 km. This is supported by the studies done in Atlanta [18] and South Africa [14]. Probably, those who came from far distance did not follow their follow up appointments to clinics, did not easily accessible to health care facilities due to transportation cost and fatigue. Tertiary education was identified as predictor of ART adherence in this study. Accordingly, those who were unable to read and write were ten times more likely to be adherent than those who were college and above. This is comparable to the study done in southeast Nigeria [23]. The probable reasons might be as educational status increases, there may be increased income, relaxation, involvement in many activities and may become busy with other things, which may all have their contribution to miss ART doses. In addition, because those with tertiary education are more knowledgeable about the drug side effects and the fact that there is no cure for HIV/AIDS may encourage them to be nonadherent. On the other hand, those without tertiary education would tend to respect the advice of the providers and therefore be more likely to adhere to ART drugs. Regarding the nutritional status of the respondents, the finding of this study revealed that those who were well nourished were about four times more likely to be adherent than those of malnourished. This finding is in line with the studies done in Uganda [16] and sub-Saharan Africa [13]. This may be due to that, nutrition of the patients’ affects drug metabolism, absorption, and efficiency and also patients may suffer frequently from
opportunistic infection as a result of reduced immunity and then become non-adherent. This finding was supported by other findings in the sub-Saharan Africa [13], as malnutrition and food insecurity had emerged as a major barrier to medication adherence. The most common reasons reported for missing ART doses by patients in this study were, away from home, busy with other things and simply forgot. This finding is similar to the study done in Uganda [16], South Africa [14] and Ethiopia [11,21]. 4.1. Limitations This study had some limitations: First, in this study, only dose adherence of the patients was assessed. Second, since the patient adherence to ART level was assessed over the last month prior to the interview, there could be recalled bias. Also, since data collectors were health professionals in the respective institutions, response and social desirability bias could also appear. Thirdly, since infants, pregnant women and adult patients who were on ART for less than a month were excluded, these study findings could not generalized to all people living with HIV/AIDS who were on ART. However, numerous scientific procedures have been employed to minimize the possible effects. To reduce the response and social desirability, for instance, the aim of the study was discussed with respondents in order to obtain a genuine response. In addition, procedures such as pre testing, supervision and adequate training of data collectors and supervisors were utilized. 5. Conclusions In this study, patient self-reported adherence in the month before the interview was found to be high. The closeness of the
Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004
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patient or residence to health facilities, normal mood of the patients and absence of opportunistic infections found to be predictors of a good adherence, while being malnourished and having an education of college and above of the patient were identified as predictor of poor adherence. The most common reasons for missing ART doses were: being busy, simply forgetting, and being away from home. Authors’ contributions EN and NW participated in the design of the study and data collection and analyzed the data and drafted the paper. BW, GB and ME participated in the analysis and revised subsequent drafts of the paper. All authors read and approved the final manuscript. Conflict of interest None declared. Financial disclosure We would like to thank the University of Gondar for their financial support. References [1] M.B. Cauldbeck, C. O’Connor, M.B. O’Connor, J.A. Saunders, B. Rao, V.G. Mallesh, P. Kumar, N.K. Gurushanthappa Mamtha, C. McGoldrick, B.S.R. Laing, et al., Adherence to anti-retroviral therapy among HIV patients in Bangalore, India, AIDS Res. Ther. 6 (2009) 7. [2] P. Roux, C. Kouanfack, J. Cohen, F. Marcellin, S. Boyer, E. Delaporte, P. Carrieri, C. Laurent, Adherence to antiretroviral treatment in HIV-positive patients in the Cameroon context: promoting the use of medication reminder methods, J. Acquir. Immune Defic. Syndr. 57 (Suppl. 1) (2011) 540–543. [3] R. Garcia, R. Badaro´, M.E. Netto, M. Silva, S.F. Amorin, A. Ramos, F. Vaida, C. Brites, R.T. Schooley, Cross-sectional study to evaluate factors associated with adherence to antiretroviral therapy by Brazilian HIV-infected patients, AIDS Res. Hum. Retrovir. 22 (Suppl. 12) (2006) 1248–1252. [4] E. Mills, B.J. Nachega, I. Buchan, J. Orbinski, A. Attaran, S. Singh, B. Rachlis, P. Wu, C. Cooper, L. Thabane, et al., Adherence to antiretroviral therapy in SubSaharan Africa and North America: a meta-analysis, JAMA 296 (Suppl. 6) (2006) 679–690. [5] L.F. Filho, S.A. Nogueira, E.S. Machado, T.F. Abreu, R.H. de Oliveira, L. Evangelista, C.B. Hofer, Factors associated with lack of antiretroviral adherence among adolescents in a reference centre in Rio de Janeiro, Brazil, Int. J. STD AIDS 19 (Suppl. 10) (2008) 685–688. [6] C. Ortego, T.B. Huedo-Medina, J. Llorca, L. Sevilla, P. Santos, E. Rodrı´guez, M.R. Warren, J. Vejo, Adherence to highly active antiretroviral therapy (HAART): a meta-analysis, AIDS Behav. 15 (Suppl. 7) (2011) 1381–1396.
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Please cite this article in press as: E. Negash, et al., Adherence to antiretroviral therapy and its associated factors among HIV positive patients in Nekemte public health institutions, West Ethiopia, HIV & AIDS Review (2016), http://dx.doi.org/10.1016/j.hivar.2016.04.004