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AIDS in a resource-limited setting in northern Burkina Faso
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Original Research
Attitudes and practices towards HAART among people living with HIV/AIDS in a resource-limited setting in northern Burkina Faso A.K. Guiro a, A. Traore b, A. Somda c, S.-L. Huang d,* a
Ouahigouya Hospital, Ouahigouya City, Burkina Faso AMMIE, Ouahigouya City, Burkina Faso c AIDS Committee, Ministry of Health, Ouagadougou, Burkina Faso d Institute of Public Health, National Yang Ming University, 155, Sec. 2, Li-Nong Street, Taipei 112, Taiwan b
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Article history:
Objectives: To assess the perception of human immunodeficiency virus/acquired immu-
Received 22 September 2010
nodeficiency syndrome (HIV/AIDS), and attitudes and practices towards highly active
Accepted 16 September 2011
antiretroviral treatment (HAART) among patients living in a resource-poor region of
Available online 20 October 2011
northern Burkina Faso, where HAART has only become available in recent years. Study design: A clinic-based cross-sectional survey of 306 patients taking HAART and 106
Keywords:
patients not yet on HAART.
Highly active antiretroviral
Methods: Face-to-face interview with a structured questionnaire at the clinic or at partici-
treatment
pants’ homes.
Adherence
Results: Most patients were illiterate, but overall, they had adequate knowledge and positive
Attitude
attitudes towards HAART, and self-reported that their adherence was good. However, AIDS
Resource-limited setting
carried a psychological burden, as 27% of respondents were concerned that others might discover they were on HAART. The majority of respondents expressed concerns about transmitting HIV to others, but only 22% had disclosed their HIV status to their partners, and condom use was suboptimal. Approximately one-third of participants in the HAART group reported that they could no longer work in the same way as before they had AIDS. Multivariate logistic regression found that education and living with someone were positively associated with a favourable functioning status, and distance from clinic and lack of general support from family or friends were negatively associated with a favourable functioning status. Conclusions: HAART was well accepted in this resource-poor region. Community education and supportive approaches may be critical for an effective preventive programme. ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction There were approximately 130,000 people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in Burkina Faso in 2007, and the
prevalence rate in adults was 1.6%.1 With the help of multiple international agencies and initiatives, highly active antiretroviral treatment (HAART) has become more widely available in Burkina Faso. Since 2007, a total of 69 health facilities including district, regional and national hospitals, as well as
* Corresponding author. Tel.: þ886 2 28267194; fax: þ886 2 28210514. E-mail address: [email protected] (S.-L. Huang). 0033-3506/$ e see front matter ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2011.09.015
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some non-government organizations (NGOs) have provided HAART to patients with AIDS.2 Patient care in these facilities is usually provided by general practitioners who have been trained in HIV/AIDS management. The monthly treatment cost for an individual is approximately US$3, but is free for the indigents. In order to exert its beneficial effects, patients need to be aware of HAART and perceive it in a positive manner. Very few studies have assessed the knowledge, attitudes and practices of patients about HIV/AIDS in general, and HAART in particular, in west African countries. Previous studies in other parts of the world have found that patients’ perceptions of the risk of AIDS to themselves and others, knowledge of the benefits of HAART, willingness to follow medical advice, and (particularly) ability to achieve a high rate of adherence will determine the overall efficacy of a HAART regimen. Otherwise, it may not only waste precious resources, but may increase the likelihood of developing resistance to antiretroviral treatment.3e8 It has been documented that many patients find it difficult to achieve good adherence to HAART. Previous studies, mainly in developed countries, have shown that some patient characteristics, treatment regimens and institution factors were significantly associated with adherence.9 Patients in developing countries face different problems in getting adequate treatment, yet few investigations have been undertaken, particularly in resource-limited settings. A few studies conducted in sub-Saharan African countries have shown that up to 80% of participants achieved adherence rates of 95% or higher, including some studies which used pill count methods in addition to self-report.10e14 However, these observations may be setting-specific and need to be evaluated in each country. Furthermore, factors other than medicine, such as disclosure of HIV status to others and willingness to take preventive measures, are also important in evaluating the overall success of control programmes. The need for evaluation is particularly high in Burkina Faso, where HAART has only become available in recent years. The characteristics of local people may also affect AIDS prevention and treatment; residents in northern Burkina Faso do not generally have any formal education, and health education has been limited by available resources. Furthermore, many of the languages used in this region are solely spoken, making conventional methods of health communication using printed materials far more difficult. Thus, people living with HIV/AIDS may obtain information from unqualified sources, leading to misconceptions which may compromise either prevention or treatment of the disease. The aim of this study was to assess the knowledge, attitudes and practices of people living with HIV/AIDS in northern Burkina Faso about the disease and its treatment. The study also attempted to identify the sources of information. The results may help to develop behavioural intervention strategies that are appropriate for local needs.
Methods Study subjects This cross-sectional survey was conducted from August 2008 to February 2009. The study included patients who
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received their care from AMMIE, an NGO established in 1992 in Ouahigouya City, northern Burkina Faso. The region covers 6990 km2 with a population of 1.2 million. Medical charts for HIV treatment were used to identify subjects for inclusion. The study targeted all subjects who had been diagnosed as HIV positive since 2001, the year when AMMIE started to provide HIV/AIDS services. In total, 1234 patients were identified, mainly from five districts in the north region. Of these, 106 (8.2%) patients had died and 308 (25.0%) were lost to follow-up. Of the remaining 820 patients, 420 were on HAART and 400 were not yet on HAART. Those on HAART were interviewed at the clinic during a medical visit, and 306 (74%) completed the survey. The patients who were not yet on HAART and who lived within 5 km of the clinic were approached (n ¼ 157); a second appointment was arranged for those who were absent during the first visit. In total, 106 (67.5%) patients completed the interview at their homes.
Study instrument A questionnaire was developed based on previous studies assessing the knowledge, attitudes and practices towards HIV/AIDS in developing countries. The questionnaire was composed of two parts: the first part contained eight questions related to HIV and treatment characteristics of the study participants, and was completed by the researcher according to patients’ medical charts. The second part of the questionnaire was composed of demographic data, perceived benefit of and concerns about HAART, adherence and sources of information. A five-point Likert scale was used in the attitude questions. In the analysis, ‘strongly agree’ and ‘agree’ were aggregated, and ‘neutral’, ‘disagree’ and ‘strongly disagree’ were aggregated. The questionnaire was designed in English by the researchers. The validity of the questionnaire was reviewed by a panel of four experts, which included two academics and two HIV physicians, based in Taipei and Burkina Faso. The data were collected in local languages by four trained interviewers; for confidentiality reasons, the interviewers were nurses and social counsellors from the clinic. Informed consent was obtained before each interview, and efforts were made to protect the confidentiality of the information. The study was approved by the Burkina Faso National Ethics Committee.
Analytical approach Descriptive statistics was used to outline the characteristics of the participants. Chi-squared test was used to compare the distribution of the HAART and non-HAART groups. Logistic regression was used to identify factors associated with condom use and ability to work as usual. Univariate analysis was carried out to compute odd ratios (ORs) and P-values, while multivariate analysis was used to compute adjusted ORs with 95% confidence intervals (CIs) for categorical variables. All P-values were two-tailed, and the significance level was set at P < 0.05. Statistical Package for the Social Sciences Version 16.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis.
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Results Demographic characteristics Table 1 shows the general characteristics of participants who received medical care for HIV/AIDS at this NGO. Nearly threequarters (73.3%) were female, and their ages ranged from 18 to 64 years [mean 38.0 years, standard deviation (SD) 8.8 years]. More of the participants in the non-HAART group were female and they were younger than those in the HAART group. The majority of respondents (65.5%) were illiterate, and only 15% had completed primary school or higher. The majority of respondents (87.9%) did not have a formal or qualified job, 7% were qualified craftsmen and only 5% were professionals. Half of the respondents were married or cohabiting, but approximately one-quarter of respondents had been widowed.
Two-thirds (65.8%) of the respondents reported that they were still working as usual, but 34.2% said that they were too ill to work at the time of the survey. Over half of the patients (59.4%) identified sexual transmission as the cause of HIV infection, but up to 39.3% did not know how they had been infected. As blood transfusion and intravenous drug use were both rare in this region, most of those who did not know the source of infection probably acquired the disease through the sexual route.
HIV and treatment characteristics Table 2 describes the HIV status and treatment characteristics of the participants. Among the 412 respondents, 306 (74.3%) were on HAART. The clinical stages for the two groups were different: 65% of those in the HAART group were at World
Table 1 e Personal characteristics of respondents (n [ 412). HAART status
P-value
On HAART (n ¼ 306)
Not on HAART (n ¼ 106)
n
%
n
%
Sex Male Female
91 215
29.7 70.3
19 87
17.9 82.1
0.018
Age (years) 29 30e39 40
33 133 140
10.8 43.5 45.8
32 39 35
30.2 36.8 33.0
0.001
Marital status Single Married/cohabiting Divorced/separated Widowed
29 145 50 86
9.5 47.4 15.1 28.1
15 58 13 20
14.2 54.7 12.3 18.9
0.13
Education Illiterate Some school Primary school completed Secondary school not completed Secondary school completed
196 62 16 24 8
64.1 20.3 5.2 7.8 2.6
74 15 6 9 2
69.8 14.2 5.7 8.5 1.9
Distance from home to the clinic (km) <5 5e10 10e25
156 22 128
51.0 7.2 41.8
53 8 45
50.0 7.5 42.5
0.98
Profession Not employed or not qualified Qualified craftsman Professional or administrative
268 23 15
87.6 7.5 4.9
94 7 5
88.7 6.6 4.7
0.95
Working condition Too ill to work Working as usual
101 205
33.0 67.0
40 66
37.7 62.3
0.68
Route of HIV infection Sexual Transfusion Needle Unknown
176 1 3 126
57.5 0.33 0.98 41.2
69 0 1 36
65.09 0.0 0.94 33.96
0.45
HAART, highly active antiretroviral treatment; HIV, human immunodeficiency virus.
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Table 2 e Human immunodeficiency virus (HIV) and treatment characteristics of the respondents (n [ 412). HAART status On HAART (n ¼ 306)
P-value
Not on HAART (n ¼ 106)
n
%
n
%
HIV clinical assessment (WHO staging) Stage 1 Stage 2 Stage 3 Stage 4
17 90 164 35
5.6 29.4 53.6 11.4
77 23 6 0
72.6 21.7 5.7 0.0
Circumstances of HIV discovery Voluntary screening Deterioration of general state of health Gastroenteritis Shingles/dermatosis Long-lasting fever Arthralgia Tuberculosis
67 111 49 40 33 3 3
21.9 36.3 16.0 13.1 10.8 1.0 1.0
44 32 8 8 11 2 1
41.5 30.2 7.5 7.5 10.4 1.9 0.9
HIV duration (months) <12 12
62 244
20.3 79.7
46 60
43.4 56.6
<0.01
Disclosed HIV status to partner Yes No Did not answer
69 135 102
22.5 44.1 33.3
23 58 25
21.7 54.7 23.6
0.38
8
2.6
13
12.3
<0.01
Use of traditional medicine
<0.01
HAART, highly active antiretroviral treatment; WHO, World Health Organization.
Health Organization Stage 3 or 4 at the time of their registration, and most presented with some clinical symptoms when diagnosed. On the other hand, most participants in the nonHAART group were at Stage 1 or 2 when they were first diagnosed, and 41.5% were diagnosed through voluntary screening programmes. Most participants in the HAART group (99%) were on a first-line regimen. Only a minority of participants agreed that traditional medicine was beneficial for HIV; 2.6% of patients in the HAART group and 12.3% of patients in the non-HAART group reported use of traditional medicines. The mean duration of HIV infection was significantly longer in the HAART group compared with the non-HAART group [31.4 (SD 22.5) months, range 0.4e128 months vs 20.13 (19.9) months, range 0.2e93 months]. When asked whether they had disclosed their HIV status to their sexual partners, a significant proportion chose not to answer the question. Of those who did answer, 67.7% reported that they had not disclosed their status. Only 22.3% said that they had disclosed their HIV status; the rate of disclosure was not significantly different between males and females, between illiterate and educated respondents, between those who had had HIV for less than 1 year vs longer than 1 year, or between those reporting general support from family and friends vs those who did not have such support.
Attitudes about HAART Despite the high illiteracy rate, the majority of respondents showed very positive attitudes towards HAART; for example, 98% of respondents strongly agreed or agreed that HIV could be controlled by HAART, that taking HAART could slow down
disease progression, and that HAART could preserve daily function (Table 3). They also recognized the importance of taking medication regularly. Almost all of the respondents agreed that missing doses of HAART would lead to disease progression, and increase the risk of transmitting HIV to others. Also, almost all of those in the HAART group agreed that they were able to take the medication as prescribed on most days. Compared with the non-HAART group, those in the HAART group were more likely to report that HIV could be controlled by HAART, and that taking the medication regularly could be protective. Regarding participants’ concerns about HAART, the majority (86%) agreed that HAART can have side effects, especially among those in the HAART group, although only 22% of them said that HAART affected their daily activities. One-quarter of the respondents (27.4%) were worried that others might find out they were on HAART, and this concern was greater in those in the non-HAART group, although the difference was not statistically significant. A great majority of the respondents stated that they were worried about transmitting HIV to other people. However, this concern was not accompanied by preventive actions apart from HAART, since up to two-thirds did not disclose their HIV status to their sexual partners, and the use of condoms was less than optimal. When asked about whether or not they use condoms (or ask their partners to use condoms), up to 35% reported that they were not sexually active at the time of the survey, 42% reported that they always use condoms, 13% reported that they often or occasionally use condoms, and 9% reported that they rarely or never use condoms. Among those who were sexually active, males (70.2%) were more likely than
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Table 3 e Attitude towards highly active antiretroviral treatment (HAART) among respondents (n [ 412). HAART status On HAART (n ¼ 306) Agree (%) HIV can be controlled by HAART Taking HAART on schedule prevents you from being sick Taking HAART can slow down disease progression HAART can preserve daily function You can take the medicine as prescribed most days Missing doses of HAART leads to disease progression Missing doses of HAART increases the risk of transmitting HIV HAART can have side effects Side effects have affected your daily activities Worried about side effects of HAART Worried that others will find out you are on HAART Worried about transmitting the disease to others Have good support from families and friends
305 277 306 306 302 305 299 285 67
(99.3) (90.5) (100) (100) (98.7) (99.7) (97.7) (93.1) (22.0) e 77 (25.4) 263 (85.9) 198 (64.7)
P-value
Not on HAART (n ¼ 106)
Disagree (%)
Agree (%)
Disagree (%)
1 (0.3) 29 (9.5) 0 (0) 0 (0) 4 (1.3) 1 (0.3) 7 (2.3) 21 (6.9) 237 (78.0) e 226 (74.0) 43 (14.1) 108 (35.3)
100 (94.4) 82 (77.4) 106 (100) 106 (100) e 106 (100) 104 (98.1) 69 (66.3) e 41 (38.7) 36 (34.0) 97 (91.5) 58 (54.7)
6 (5.7) 24 (22.6) 0 (0) 0 (0) e 0 (0) 2 (1.9) 35 (33.7) e 65 (61.3) 70 (66.0) 9 (8.5) 48 (45.3)
<0.01 <0.01 e e e e 1.00 <0.001 e e 0.09 0.14 0.044
HIV, human immunodeficiency virus.
females (63.0%) to report that they always use condoms, but the difference was not statistically significant. Multivariate logistic analysis was used to identify factors associated with condom use among those who were sexually active. HAART status, sex and years of education were not significantly associated with condom use, whereas respondents who were married or cohabiting were less likely to use condoms than those who were single or living alone (OR 0.41, 95% CI 0.21e0.82; P ¼ 0.011).
Adherence to HAART Two questions were asked to assess adherence to HAART: (1) how many doses were missed in the week prior to the interview? and (2) had the patient ever stopped taking their medication for a period of more than 3 days? The majority (95%) of the respondents in the HAART group stated that they had not forgotten to take any of their HIV medication in the previous week. Similarly, 94% stated they had never stopped taking their medication for 3 days or more. Of the 19 participants (6%) who had ever stopped taking their medication for 3 days or more, the reasons cited were: travel (n ¼ 6), did not obtain their medication at the clinic (n ¼ 4), long distance to the clinic (n ¼ 3), depressed (n ¼ 2), did not have money (n ¼ 2), treatment was too complicated to take (n ¼ 1), and too ill to take their medication (n ¼ 1).
Sources of information and support Eighty-eight percent of the respondents cited physicians as the most important source of information for HIV and HAART. Nurses (79.1%) and radio/television (51%) were other important sources of information. Other people living with HIV/ AIDS was cited by 38.1% as an important source of information.
Adequacy of AIDS treatment As objective measurements of AIDS treatment, such as CD4þ lymphocyte count, were not available, the self-reported
answer ‘I am still working in the same way as before I had HIV’ was used to indicate the adequacy of treatment. Of the 306 participants in the HAART group, 205 said that they were working as usual and 101 said that they were too ill to work. Univariate analysis revealed that several factors were associated with the outcome of treatment; a positive association was found for female sex, and a negative association was found for lack of support from family or friends and distance from the clinic. In multivariate logistic regression considering all the variables in Table 4, two factors were found to be associated with a more favourable outcome: being educated (any schooling compared with those who were illiterate), and being married or cohabiting (compared with those who were living alone). Being female and having a qualified job were also associated with being able to work as usual, albeit with marginal statistical significance.
Discussion This paper has described the characteristics of patients undergoing HIV treatment or follow-up in an NGO in northern Burkina Faso. Patients generally had positive attitudes towards HAART, and were aware of the importance of regular treatment. The results demonstrate that HAART is well accepted by people in this region, although most of them did not have any formal education and were engaged in nonqualified jobs (e.g. subsistence farming, unskilled labour). The study also indicated that disclosure of HIV status and use of condoms were potential difficulties in AIDS control. Several characteristics of the study population deserve discussion. Among the participants, 73% were female. This is higher than the rate in the 2007 UNAIDS report for Burkina Faso (51% female) and Africa (61% female), but is similar to an unpublished study in Ouahigouya Hospital, located in the same area as this study, in which 68% of patients were female.15 HIV is more prevalent in women than men in Africa, probably because of the prematurity of sexuality and polygamy in this region. However, females are more likely to receive healthcare than males. As suggested by
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Table 4 e Factors associated with working as usual among participants on highly active antiretroviral treatment (HAART) (n [ 306). OR
P
adjOR
95% CI
P
Sex (female vs male)
1.38
0.02
1.76
0.97e3.18
0.06
Age 30e39 vs 29 40 vs 29
0.91 1.13
0.82 0.64
0.73 0.96
0.31e1.71 0.56e1.66
0.47 0.89
Literate (vs illiterate) Married or cohabiting (vs living alone) Job type (qualified vs unqualified job) HIV duration (12 vs 11 months) Longer distance to the clinic (5 vs <5 km) Lack of support from family and friends Regular visits to physicians HAART side effects affected activities
1.69 1.55 1.46 0.84 0.57 0.50 1.14 1.15
0.10 0.08 0.33 0.50 0.02 0.01 0.60 0.64
2.16 2.08 2.28 0.98 0.49 0.40 1.36 1.24
1.04e4.48 1.19e3.62 0.95e5.47 0.52e1.85 0.29e0.83 0.23e0.71 0.78e2.37 0.66e2.32
0.04 0.01 0.06 0.94 0.01 0.002 0.28 0.51
OR, odds ratio; adjOR, adjusted odds ratio; CI, confidence interval; HIV, human immunodeficiency virus.
anthropological studies, social values attached to femininity, maternity and the status of wife create conditions for women that favour their attendance at care facilities.16 The majority of participants were illiterate and did not have a formal job; these observations were in accordance with the census results in this country.17
Treatment In addition to having a positive attitude towards HAART, the participants reported high adherence; 95% of participants claimed that they had not missed any doses of medication during the week prior to the interview, and 94% claimed that they had never stopped taking their medication for more than 3 days in the past. Although it was not possible to ascertain the accuracy of these results, and social desirability bias could not be ruled out, the results did indicate that most patients were aware that a high adherence rate was a desirable goal. Many studies conducted in sub-Saharan African countries have shown that up to 80% of participants could achieve adherence rates of 95% or higher, including some studies which used pill count methods in addition to self-report.10e14 A qualitative study in three African countries also revealed that patients routinely overcame economic obstacles through a number of deliberate strategies aimed at prioritizing HAART adherence, including financial arrangements.18 However, it has been proven that adherence is a dynamic phenomenon that varies over time,9,10,19 and self-reported adherence does not always correlate with biological findings such as plasma concentrations of medication or viral load.11,12 Therefore, future studies combining at least two methods are needed to better estimate HAART adherence among patients living with HIV/AIDS in northern Burkina Faso.
Support As this study was conducted in a primarily agrarian society, working in the fields was common. As such, ‘working as usual’ was used as an indicator of being able to maintain daily activities and therefore adequacy of treatment. The fact that over one-third of patients were not able to work as usual may suggest that some respondents were in advanced clinical
stages of HIV infection before they were enrolled for HAART, or that some were not treated optimally. Education, support from family and friends, and cohabiting were found to be positively associated with a favourable functioning status. The study by Ware et al. demonstrated that resources and help from family members and friends were vital to adherence. Moreover, adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities; thus, preserving social capital in essential relationships is an important factor in continuing treatment.18,20 These results suggest the importance of community programmes that aim to enhance the self-care of patients with AIDS.
Prevention This survey showed that the most important route of HIV infection was sexual intercourse, which was consistent with the 2007 UNAIDS report. In order to prevent transmission through the sexual route, sexual partners of people with HIV would benefit from disclosure and use of condoms. However, only 22% of participants in this study said that they had disclosed their HIV status to their sexual partners. Disclosure was not related to the duration of infection, sex of the participants, or whether they had support from family and friends. The reported figure was consistent with the experience of healthcare workers at AMMIE. This may indicate that stigmatization about HIV is still an important concern for people living with HIV/ AIDS in the region. Although stigmatization has been tackled in Burkina Faso through media campaigns and community sensitization, it seems that more is needed to overcome this barrier to the successful control of AIDS. Equally worrisome was that only 42% of the respondents reported that they always use a condom when having sex with their partners. In particular, respondents who were married or cohabiting were less likely to use condoms than those who were single or living alone. This is consistent with the report that, in many African countries, condoms are more often used when having sex with someone other than a spouse, indicating that the use of condoms within marital or cohabiting partnerships needs to be advocated.21 A qualitative study in this region is needed to gain better insight into the difficulties of using condoms with a spouse.
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Limitations The present study has some limitations. Face-to-face interviews in the local language were performed because there was no written language. Although interviewers were asked to use the same translation for each question, it is possible that there were slight differences in wording between interviewers. Face-to-face interviews to assess patients’ attitudes and practices can lead to socially desirable responses, so this study may have overestimated the positive reactions of participants to HAART and adherence. Finally, this survey could not include patients lost to follow-up, and had the potential for sampling bias in patient recruitment. For the HAART group, although the response rate was satisfactory, it is possible that those who did not come to the clinic during the study period were less adherent. For the non-HAART group, there could be another type of sampling bias as, for practical reasons, only patients living within 5 km of the clinic were included in this study. These patients may have had different characteristics from patients living further away from the clinic. Despite the aforementioned limitations, this study provided an insight into patients’ attitudes and practices in a resourcelimited setting in Burkina Faso. It demonstrated that the study population, particularly the HAART group, had a generally positive attitude towards HAART, good adherence and made regular visit to the clinic. It is encouraging that HAART is well accepted by the population. Nevertheless, an appropriate intervention is necessary to reinforce education messages, especially for those not yet on HAART. In addition, most respondents in the non-HAART group were in the early stages of disease. A minor proportion of these patients, particularly among those who claimed that they were not able to work as usual, should be assessed carefully for HAART. Finally, an outreach programme may be necessary to take care of those who do not visit the clinic regularly and those who were lost to follow-up.
Ethical approval Burkina Faso National Ethics Committee.
Funding The study was funded, in part, by the International Cooperation and Development Fund (Taiwan), and Student Travelling Grant, National Yang Ming University, Taiwan.
Competing interests None declared.
references
1. UNAIDS. Report on the global HIV/AIDS epidemic 2008. UNAIDS/08.25E/JC1510E. WHO Library Cataloguing-inPublication Data; 2008. 2. UNGASS report. Burkina Faso: Ministry of Health; 2008. 3. Chesney MA. Factors affecting adherence to antiretroviral therapy. Clin Infect Dis 2000;30(Suppl. 2):S171e6.
4. Soria A, Porten K, Fampou-Toundji JC, Galli L, Mougnutou R, Buard V, et al. Resistance profiles after different periods of exposure to a first-line antiretroviral regimen in a Cameroonian cohort of HIV type-1-infected patients. Antivir Ther 2009;14:339e47. 5. Jallow S, Alabi A, Sarge-Njie R, Peterson K, Whittle H, Corrah T, et al. Virological response to highly active antiretroviral therapy (HAART) in HIV-2 and HIV-1/HIV-2 dually infected patients in The Gambia and the emergence of drug resistant variants. J Clin Microbiol; 2009. 6. Hosseinipour MC, van Oosterhout JJ, Weigel R, Phiri S, Kamwendo D, Parkin N, et al. The public health approach to identify antiretroviral therapy failure: high-level nucleoside reverse transcriptase inhibitor resistance among Malawians failing first-line antiretroviral therapy. AIDS 2009;23:1127e34. 7. Hanson DL, Adje-Toure C, Talla-Nzussouo N, Eby P, Borget MY, Kouadio LY, et al. HIV type 1 drug resistance in adults receiving highly active antiretroviral therapy in Abidjan, Cote d’Ivoire. AIDS Res Hum Retroviruses 2009;25:489e95. 8. Meya D, Spacek LA, Tibenderana H, John L, Namugga I, Magero S, et al. Development and evaluation of a clinical algorithm to monitor patients on antiretrovirals in resourcelimited settings using adherence, clinical and CD4 cell count criteria. J Int AIDS Soc 2009;12:3. 9. Fumaz CR, Munoz-Moreno JA, Molto J, Ferrer MJ, LopezBlazquez R, Negredo E, et al. Sustained antiretroviral treatment adherence in survivors of the pre-HAART era: attitudes and beliefs. AIDS Care 2008;20:796e805. 10. Laurent C, Ngom Gueye NF, Ndour CT, Gueye PM, Diouf M, Diakhate N, et al. Long-term benefits of highly active antiretroviral therapy in Senegalese HIV-1-infected adults. J Acquir Immune Defic Syndr 2005;38:14e7. 11. Kouanfack C, Laurent C, Peytavin G, Ciaffi L, Ngolle M, Nkene YM, et al. Adherence to antiretroviral therapy assessed by drug level monitoring and self-report in Cameroon. J Acquir Immune Defic Syndr 2008;48:216e9. 12. Bell DJ, Kapitao Y, Sikwese R, van Oosterhout JJ, Lalloo DG. Adherence to antiretroviral therapy in patients receiving free treatment from a government hospital in Blantyre, Malawi. J Acquir Immune Defic Syndr 2007;45:560e3. 13. Abaasa AM, Todd J, Ekoru K, Kalyango JN, Levin J, Odeke E, et al. Good adherence to HAART and improved survival in a community HIV/AIDS treatment and care programme: the experience of The AIDS Support Organization (TASO), Kampala, Uganda. BMC Health Serv Res 2008;8:241. 14. Carlucci JG, Kamanga A, Sheneberger R, Shepherd BE, Jenkins CA, Spurrier J, et al. Predictors of adherence to antiretroviral therapy in rural Zambia. J Acquir Immune Defic Syndr 2008;47:615e22. 15. UNAIDS. AIDS epidemic update: December 2007. UNAIDS/07.27E/ JC1322E. WHO Library Cataloguing-in-Publication Data; 2007. 16. Bila B, Egrot M. Gender asymmetry in healthcare-facility attendance of people living with HIV/AIDS in Burkina Faso. Soc Sci Med 2009;69:854e61. 17. Burkina Faso. 2006 Census of general population and habitation. Ouagadoougou: Burkina Faso; 2006. 18. Ware NC, Idoko J, Kaaya S, Biraro IA, Wyatt MA, Agbaji O, et al. Explaining adherence success in sub-Saharan Africa: an ethnographic study. PLoS Med 2009;6:e11. 19. Halkitis P, Palamar J, Mukherjee P. Analysis of HIV medication adherence in relation to person and treatment characteristics using hierarchical linear modeling. AIDS Patient Care STDS 2008;22:323e35. 20. Binagwaho A, Ratnayake N. The role of social capital in successful adherence to antiretroviral therapy in Africa. PLoS Med 2009;6:e18. 21. de Walque D, Kline R. Comparing condom use with different types of partners: evidence from national HIV surveys in Africa. World Bank; 2009.
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Original Research
Attitudes and practices towards HAART among people living with HIV/AIDS in a resource-limited setting in northern Burkina Faso A.K. Guiro a, A. Traore b, A. Somda c, S.-L. Huang d,* a
Ouahigouya Hospital, Ouahigouya City, Burkina Faso AMMIE, Ouahigouya City, Burkina Faso c AIDS Committee, Ministry of Health, Ouagadougou, Burkina Faso d Institute of Public Health, National Yang Ming University, 155, Sec. 2, Li-Nong Street, Taipei 112, Taiwan b
article info
summary
Article history:
Objectives: To assess the perception of human immunodeficiency virus/acquired immu-
Received 22 September 2010
nodeficiency syndrome (HIV/AIDS), and attitudes and practices towards highly active
Accepted 16 September 2011
antiretroviral treatment (HAART) among patients living in a resource-poor region of
Available online 20 October 2011
northern Burkina Faso, where HAART has only become available in recent years. Study design: A clinic-based cross-sectional survey of 306 patients taking HAART and 106
Keywords:
patients not yet on HAART.
Highly active antiretroviral
Methods: Face-to-face interview with a structured questionnaire at the clinic or at partici-
treatment
pants’ homes.
Adherence
Results: Most patients were illiterate, but overall, they had adequate knowledge and positive
Attitude
attitudes towards HAART, and self-reported that their adherence was good. However, AIDS
Resource-limited setting
carried a psychological burden, as 27% of respondents were concerned that others might discover they were on HAART. The majority of respondents expressed concerns about transmitting HIV to others, but only 22% had disclosed their HIV status to their partners, and condom use was suboptimal. Approximately one-third of participants in the HAART group reported that they could no longer work in the same way as before they had AIDS. Multivariate logistic regression found that education and living with someone were positively associated with a favourable functioning status, and distance from clinic and lack of general support from family or friends were negatively associated with a favourable functioning status. Conclusions: HAART was well accepted in this resource-poor region. Community education and supportive approaches may be critical for an effective preventive programme. ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction There were approximately 130,000 people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in Burkina Faso in 2007, and the
prevalence rate in adults was 1.6%.1 With the help of multiple international agencies and initiatives, highly active antiretroviral treatment (HAART) has become more widely available in Burkina Faso. Since 2007, a total of 69 health facilities including district, regional and national hospitals, as well as
* Corresponding author. Tel.: þ886 2 28267194; fax: þ886 2 28210514. E-mail address: [email protected] (S.-L. Huang). 0033-3506/$ e see front matter ª 2011 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2011.09.015
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some non-government organizations (NGOs) have provided HAART to patients with AIDS.2 Patient care in these facilities is usually provided by general practitioners who have been trained in HIV/AIDS management. The monthly treatment cost for an individual is approximately US$3, but is free for the indigents. In order to exert its beneficial effects, patients need to be aware of HAART and perceive it in a positive manner. Very few studies have assessed the knowledge, attitudes and practices of patients about HIV/AIDS in general, and HAART in particular, in west African countries. Previous studies in other parts of the world have found that patients’ perceptions of the risk of AIDS to themselves and others, knowledge of the benefits of HAART, willingness to follow medical advice, and (particularly) ability to achieve a high rate of adherence will determine the overall efficacy of a HAART regimen. Otherwise, it may not only waste precious resources, but may increase the likelihood of developing resistance to antiretroviral treatment.3e8 It has been documented that many patients find it difficult to achieve good adherence to HAART. Previous studies, mainly in developed countries, have shown that some patient characteristics, treatment regimens and institution factors were significantly associated with adherence.9 Patients in developing countries face different problems in getting adequate treatment, yet few investigations have been undertaken, particularly in resource-limited settings. A few studies conducted in sub-Saharan African countries have shown that up to 80% of participants achieved adherence rates of 95% or higher, including some studies which used pill count methods in addition to self-report.10e14 However, these observations may be setting-specific and need to be evaluated in each country. Furthermore, factors other than medicine, such as disclosure of HIV status to others and willingness to take preventive measures, are also important in evaluating the overall success of control programmes. The need for evaluation is particularly high in Burkina Faso, where HAART has only become available in recent years. The characteristics of local people may also affect AIDS prevention and treatment; residents in northern Burkina Faso do not generally have any formal education, and health education has been limited by available resources. Furthermore, many of the languages used in this region are solely spoken, making conventional methods of health communication using printed materials far more difficult. Thus, people living with HIV/AIDS may obtain information from unqualified sources, leading to misconceptions which may compromise either prevention or treatment of the disease. The aim of this study was to assess the knowledge, attitudes and practices of people living with HIV/AIDS in northern Burkina Faso about the disease and its treatment. The study also attempted to identify the sources of information. The results may help to develop behavioural intervention strategies that are appropriate for local needs.
Methods Study subjects This cross-sectional survey was conducted from August 2008 to February 2009. The study included patients who
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received their care from AMMIE, an NGO established in 1992 in Ouahigouya City, northern Burkina Faso. The region covers 6990 km2 with a population of 1.2 million. Medical charts for HIV treatment were used to identify subjects for inclusion. The study targeted all subjects who had been diagnosed as HIV positive since 2001, the year when AMMIE started to provide HIV/AIDS services. In total, 1234 patients were identified, mainly from five districts in the north region. Of these, 106 (8.2%) patients had died and 308 (25.0%) were lost to follow-up. Of the remaining 820 patients, 420 were on HAART and 400 were not yet on HAART. Those on HAART were interviewed at the clinic during a medical visit, and 306 (74%) completed the survey. The patients who were not yet on HAART and who lived within 5 km of the clinic were approached (n ¼ 157); a second appointment was arranged for those who were absent during the first visit. In total, 106 (67.5%) patients completed the interview at their homes.
Study instrument A questionnaire was developed based on previous studies assessing the knowledge, attitudes and practices towards HIV/AIDS in developing countries. The questionnaire was composed of two parts: the first part contained eight questions related to HIV and treatment characteristics of the study participants, and was completed by the researcher according to patients’ medical charts. The second part of the questionnaire was composed of demographic data, perceived benefit of and concerns about HAART, adherence and sources of information. A five-point Likert scale was used in the attitude questions. In the analysis, ‘strongly agree’ and ‘agree’ were aggregated, and ‘neutral’, ‘disagree’ and ‘strongly disagree’ were aggregated. The questionnaire was designed in English by the researchers. The validity of the questionnaire was reviewed by a panel of four experts, which included two academics and two HIV physicians, based in Taipei and Burkina Faso. The data were collected in local languages by four trained interviewers; for confidentiality reasons, the interviewers were nurses and social counsellors from the clinic. Informed consent was obtained before each interview, and efforts were made to protect the confidentiality of the information. The study was approved by the Burkina Faso National Ethics Committee.
Analytical approach Descriptive statistics was used to outline the characteristics of the participants. Chi-squared test was used to compare the distribution of the HAART and non-HAART groups. Logistic regression was used to identify factors associated with condom use and ability to work as usual. Univariate analysis was carried out to compute odd ratios (ORs) and P-values, while multivariate analysis was used to compute adjusted ORs with 95% confidence intervals (CIs) for categorical variables. All P-values were two-tailed, and the significance level was set at P < 0.05. Statistical Package for the Social Sciences Version 16.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis.
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Results Demographic characteristics Table 1 shows the general characteristics of participants who received medical care for HIV/AIDS at this NGO. Nearly threequarters (73.3%) were female, and their ages ranged from 18 to 64 years [mean 38.0 years, standard deviation (SD) 8.8 years]. More of the participants in the non-HAART group were female and they were younger than those in the HAART group. The majority of respondents (65.5%) were illiterate, and only 15% had completed primary school or higher. The majority of respondents (87.9%) did not have a formal or qualified job, 7% were qualified craftsmen and only 5% were professionals. Half of the respondents were married or cohabiting, but approximately one-quarter of respondents had been widowed.
Two-thirds (65.8%) of the respondents reported that they were still working as usual, but 34.2% said that they were too ill to work at the time of the survey. Over half of the patients (59.4%) identified sexual transmission as the cause of HIV infection, but up to 39.3% did not know how they had been infected. As blood transfusion and intravenous drug use were both rare in this region, most of those who did not know the source of infection probably acquired the disease through the sexual route.
HIV and treatment characteristics Table 2 describes the HIV status and treatment characteristics of the participants. Among the 412 respondents, 306 (74.3%) were on HAART. The clinical stages for the two groups were different: 65% of those in the HAART group were at World
Table 1 e Personal characteristics of respondents (n [ 412). HAART status
P-value
On HAART (n ¼ 306)
Not on HAART (n ¼ 106)
n
%
n
%
Sex Male Female
91 215
29.7 70.3
19 87
17.9 82.1
0.018
Age (years) 29 30e39 40
33 133 140
10.8 43.5 45.8
32 39 35
30.2 36.8 33.0
0.001
Marital status Single Married/cohabiting Divorced/separated Widowed
29 145 50 86
9.5 47.4 15.1 28.1
15 58 13 20
14.2 54.7 12.3 18.9
0.13
Education Illiterate Some school Primary school completed Secondary school not completed Secondary school completed
196 62 16 24 8
64.1 20.3 5.2 7.8 2.6
74 15 6 9 2
69.8 14.2 5.7 8.5 1.9
Distance from home to the clinic (km) <5 5e10 10e25
156 22 128
51.0 7.2 41.8
53 8 45
50.0 7.5 42.5
0.98
Profession Not employed or not qualified Qualified craftsman Professional or administrative
268 23 15
87.6 7.5 4.9
94 7 5
88.7 6.6 4.7
0.95
Working condition Too ill to work Working as usual
101 205
33.0 67.0
40 66
37.7 62.3
0.68
Route of HIV infection Sexual Transfusion Needle Unknown
176 1 3 126
57.5 0.33 0.98 41.2
69 0 1 36
65.09 0.0 0.94 33.96
0.45
HAART, highly active antiretroviral treatment; HIV, human immunodeficiency virus.
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Table 2 e Human immunodeficiency virus (HIV) and treatment characteristics of the respondents (n [ 412). HAART status On HAART (n ¼ 306)
P-value
Not on HAART (n ¼ 106)
n
%
n
%
HIV clinical assessment (WHO staging) Stage 1 Stage 2 Stage 3 Stage 4
17 90 164 35
5.6 29.4 53.6 11.4
77 23 6 0
72.6 21.7 5.7 0.0
Circumstances of HIV discovery Voluntary screening Deterioration of general state of health Gastroenteritis Shingles/dermatosis Long-lasting fever Arthralgia Tuberculosis
67 111 49 40 33 3 3
21.9 36.3 16.0 13.1 10.8 1.0 1.0
44 32 8 8 11 2 1
41.5 30.2 7.5 7.5 10.4 1.9 0.9
HIV duration (months) <12 12
62 244
20.3 79.7
46 60
43.4 56.6
<0.01
Disclosed HIV status to partner Yes No Did not answer
69 135 102
22.5 44.1 33.3
23 58 25
21.7 54.7 23.6
0.38
8
2.6
13
12.3
<0.01
Use of traditional medicine
<0.01
HAART, highly active antiretroviral treatment; WHO, World Health Organization.
Health Organization Stage 3 or 4 at the time of their registration, and most presented with some clinical symptoms when diagnosed. On the other hand, most participants in the nonHAART group were at Stage 1 or 2 when they were first diagnosed, and 41.5% were diagnosed through voluntary screening programmes. Most participants in the HAART group (99%) were on a first-line regimen. Only a minority of participants agreed that traditional medicine was beneficial for HIV; 2.6% of patients in the HAART group and 12.3% of patients in the non-HAART group reported use of traditional medicines. The mean duration of HIV infection was significantly longer in the HAART group compared with the non-HAART group [31.4 (SD 22.5) months, range 0.4e128 months vs 20.13 (19.9) months, range 0.2e93 months]. When asked whether they had disclosed their HIV status to their sexual partners, a significant proportion chose not to answer the question. Of those who did answer, 67.7% reported that they had not disclosed their status. Only 22.3% said that they had disclosed their HIV status; the rate of disclosure was not significantly different between males and females, between illiterate and educated respondents, between those who had had HIV for less than 1 year vs longer than 1 year, or between those reporting general support from family and friends vs those who did not have such support.
Attitudes about HAART Despite the high illiteracy rate, the majority of respondents showed very positive attitudes towards HAART; for example, 98% of respondents strongly agreed or agreed that HIV could be controlled by HAART, that taking HAART could slow down
disease progression, and that HAART could preserve daily function (Table 3). They also recognized the importance of taking medication regularly. Almost all of the respondents agreed that missing doses of HAART would lead to disease progression, and increase the risk of transmitting HIV to others. Also, almost all of those in the HAART group agreed that they were able to take the medication as prescribed on most days. Compared with the non-HAART group, those in the HAART group were more likely to report that HIV could be controlled by HAART, and that taking the medication regularly could be protective. Regarding participants’ concerns about HAART, the majority (86%) agreed that HAART can have side effects, especially among those in the HAART group, although only 22% of them said that HAART affected their daily activities. One-quarter of the respondents (27.4%) were worried that others might find out they were on HAART, and this concern was greater in those in the non-HAART group, although the difference was not statistically significant. A great majority of the respondents stated that they were worried about transmitting HIV to other people. However, this concern was not accompanied by preventive actions apart from HAART, since up to two-thirds did not disclose their HIV status to their sexual partners, and the use of condoms was less than optimal. When asked about whether or not they use condoms (or ask their partners to use condoms), up to 35% reported that they were not sexually active at the time of the survey, 42% reported that they always use condoms, 13% reported that they often or occasionally use condoms, and 9% reported that they rarely or never use condoms. Among those who were sexually active, males (70.2%) were more likely than
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Table 3 e Attitude towards highly active antiretroviral treatment (HAART) among respondents (n [ 412). HAART status On HAART (n ¼ 306) Agree (%) HIV can be controlled by HAART Taking HAART on schedule prevents you from being sick Taking HAART can slow down disease progression HAART can preserve daily function You can take the medicine as prescribed most days Missing doses of HAART leads to disease progression Missing doses of HAART increases the risk of transmitting HIV HAART can have side effects Side effects have affected your daily activities Worried about side effects of HAART Worried that others will find out you are on HAART Worried about transmitting the disease to others Have good support from families and friends
305 277 306 306 302 305 299 285 67
(99.3) (90.5) (100) (100) (98.7) (99.7) (97.7) (93.1) (22.0) e 77 (25.4) 263 (85.9) 198 (64.7)
P-value
Not on HAART (n ¼ 106)
Disagree (%)
Agree (%)
Disagree (%)
1 (0.3) 29 (9.5) 0 (0) 0 (0) 4 (1.3) 1 (0.3) 7 (2.3) 21 (6.9) 237 (78.0) e 226 (74.0) 43 (14.1) 108 (35.3)
100 (94.4) 82 (77.4) 106 (100) 106 (100) e 106 (100) 104 (98.1) 69 (66.3) e 41 (38.7) 36 (34.0) 97 (91.5) 58 (54.7)
6 (5.7) 24 (22.6) 0 (0) 0 (0) e 0 (0) 2 (1.9) 35 (33.7) e 65 (61.3) 70 (66.0) 9 (8.5) 48 (45.3)
<0.01 <0.01 e e e e 1.00 <0.001 e e 0.09 0.14 0.044
HIV, human immunodeficiency virus.
females (63.0%) to report that they always use condoms, but the difference was not statistically significant. Multivariate logistic analysis was used to identify factors associated with condom use among those who were sexually active. HAART status, sex and years of education were not significantly associated with condom use, whereas respondents who were married or cohabiting were less likely to use condoms than those who were single or living alone (OR 0.41, 95% CI 0.21e0.82; P ¼ 0.011).
Adherence to HAART Two questions were asked to assess adherence to HAART: (1) how many doses were missed in the week prior to the interview? and (2) had the patient ever stopped taking their medication for a period of more than 3 days? The majority (95%) of the respondents in the HAART group stated that they had not forgotten to take any of their HIV medication in the previous week. Similarly, 94% stated they had never stopped taking their medication for 3 days or more. Of the 19 participants (6%) who had ever stopped taking their medication for 3 days or more, the reasons cited were: travel (n ¼ 6), did not obtain their medication at the clinic (n ¼ 4), long distance to the clinic (n ¼ 3), depressed (n ¼ 2), did not have money (n ¼ 2), treatment was too complicated to take (n ¼ 1), and too ill to take their medication (n ¼ 1).
Sources of information and support Eighty-eight percent of the respondents cited physicians as the most important source of information for HIV and HAART. Nurses (79.1%) and radio/television (51%) were other important sources of information. Other people living with HIV/ AIDS was cited by 38.1% as an important source of information.
Adequacy of AIDS treatment As objective measurements of AIDS treatment, such as CD4þ lymphocyte count, were not available, the self-reported
answer ‘I am still working in the same way as before I had HIV’ was used to indicate the adequacy of treatment. Of the 306 participants in the HAART group, 205 said that they were working as usual and 101 said that they were too ill to work. Univariate analysis revealed that several factors were associated with the outcome of treatment; a positive association was found for female sex, and a negative association was found for lack of support from family or friends and distance from the clinic. In multivariate logistic regression considering all the variables in Table 4, two factors were found to be associated with a more favourable outcome: being educated (any schooling compared with those who were illiterate), and being married or cohabiting (compared with those who were living alone). Being female and having a qualified job were also associated with being able to work as usual, albeit with marginal statistical significance.
Discussion This paper has described the characteristics of patients undergoing HIV treatment or follow-up in an NGO in northern Burkina Faso. Patients generally had positive attitudes towards HAART, and were aware of the importance of regular treatment. The results demonstrate that HAART is well accepted by people in this region, although most of them did not have any formal education and were engaged in nonqualified jobs (e.g. subsistence farming, unskilled labour). The study also indicated that disclosure of HIV status and use of condoms were potential difficulties in AIDS control. Several characteristics of the study population deserve discussion. Among the participants, 73% were female. This is higher than the rate in the 2007 UNAIDS report for Burkina Faso (51% female) and Africa (61% female), but is similar to an unpublished study in Ouahigouya Hospital, located in the same area as this study, in which 68% of patients were female.15 HIV is more prevalent in women than men in Africa, probably because of the prematurity of sexuality and polygamy in this region. However, females are more likely to receive healthcare than males. As suggested by
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Table 4 e Factors associated with working as usual among participants on highly active antiretroviral treatment (HAART) (n [ 306). OR
P
adjOR
95% CI
P
Sex (female vs male)
1.38
0.02
1.76
0.97e3.18
0.06
Age 30e39 vs 29 40 vs 29
0.91 1.13
0.82 0.64
0.73 0.96
0.31e1.71 0.56e1.66
0.47 0.89
Literate (vs illiterate) Married or cohabiting (vs living alone) Job type (qualified vs unqualified job) HIV duration (12 vs 11 months) Longer distance to the clinic (5 vs <5 km) Lack of support from family and friends Regular visits to physicians HAART side effects affected activities
1.69 1.55 1.46 0.84 0.57 0.50 1.14 1.15
0.10 0.08 0.33 0.50 0.02 0.01 0.60 0.64
2.16 2.08 2.28 0.98 0.49 0.40 1.36 1.24
1.04e4.48 1.19e3.62 0.95e5.47 0.52e1.85 0.29e0.83 0.23e0.71 0.78e2.37 0.66e2.32
0.04 0.01 0.06 0.94 0.01 0.002 0.28 0.51
OR, odds ratio; adjOR, adjusted odds ratio; CI, confidence interval; HIV, human immunodeficiency virus.
anthropological studies, social values attached to femininity, maternity and the status of wife create conditions for women that favour their attendance at care facilities.16 The majority of participants were illiterate and did not have a formal job; these observations were in accordance with the census results in this country.17
Treatment In addition to having a positive attitude towards HAART, the participants reported high adherence; 95% of participants claimed that they had not missed any doses of medication during the week prior to the interview, and 94% claimed that they had never stopped taking their medication for more than 3 days in the past. Although it was not possible to ascertain the accuracy of these results, and social desirability bias could not be ruled out, the results did indicate that most patients were aware that a high adherence rate was a desirable goal. Many studies conducted in sub-Saharan African countries have shown that up to 80% of participants could achieve adherence rates of 95% or higher, including some studies which used pill count methods in addition to self-report.10e14 A qualitative study in three African countries also revealed that patients routinely overcame economic obstacles through a number of deliberate strategies aimed at prioritizing HAART adherence, including financial arrangements.18 However, it has been proven that adherence is a dynamic phenomenon that varies over time,9,10,19 and self-reported adherence does not always correlate with biological findings such as plasma concentrations of medication or viral load.11,12 Therefore, future studies combining at least two methods are needed to better estimate HAART adherence among patients living with HIV/AIDS in northern Burkina Faso.
Support As this study was conducted in a primarily agrarian society, working in the fields was common. As such, ‘working as usual’ was used as an indicator of being able to maintain daily activities and therefore adequacy of treatment. The fact that over one-third of patients were not able to work as usual may suggest that some respondents were in advanced clinical
stages of HIV infection before they were enrolled for HAART, or that some were not treated optimally. Education, support from family and friends, and cohabiting were found to be positively associated with a favourable functioning status. The study by Ware et al. demonstrated that resources and help from family members and friends were vital to adherence. Moreover, adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities; thus, preserving social capital in essential relationships is an important factor in continuing treatment.18,20 These results suggest the importance of community programmes that aim to enhance the self-care of patients with AIDS.
Prevention This survey showed that the most important route of HIV infection was sexual intercourse, which was consistent with the 2007 UNAIDS report. In order to prevent transmission through the sexual route, sexual partners of people with HIV would benefit from disclosure and use of condoms. However, only 22% of participants in this study said that they had disclosed their HIV status to their sexual partners. Disclosure was not related to the duration of infection, sex of the participants, or whether they had support from family and friends. The reported figure was consistent with the experience of healthcare workers at AMMIE. This may indicate that stigmatization about HIV is still an important concern for people living with HIV/ AIDS in the region. Although stigmatization has been tackled in Burkina Faso through media campaigns and community sensitization, it seems that more is needed to overcome this barrier to the successful control of AIDS. Equally worrisome was that only 42% of the respondents reported that they always use a condom when having sex with their partners. In particular, respondents who were married or cohabiting were less likely to use condoms than those who were single or living alone. This is consistent with the report that, in many African countries, condoms are more often used when having sex with someone other than a spouse, indicating that the use of condoms within marital or cohabiting partnerships needs to be advocated.21 A qualitative study in this region is needed to gain better insight into the difficulties of using condoms with a spouse.
790
p u b l i c h e a l t h 1 2 5 ( 2 0 1 1 ) 7 8 4 e7 9 0
Limitations The present study has some limitations. Face-to-face interviews in the local language were performed because there was no written language. Although interviewers were asked to use the same translation for each question, it is possible that there were slight differences in wording between interviewers. Face-to-face interviews to assess patients’ attitudes and practices can lead to socially desirable responses, so this study may have overestimated the positive reactions of participants to HAART and adherence. Finally, this survey could not include patients lost to follow-up, and had the potential for sampling bias in patient recruitment. For the HAART group, although the response rate was satisfactory, it is possible that those who did not come to the clinic during the study period were less adherent. For the non-HAART group, there could be another type of sampling bias as, for practical reasons, only patients living within 5 km of the clinic were included in this study. These patients may have had different characteristics from patients living further away from the clinic. Despite the aforementioned limitations, this study provided an insight into patients’ attitudes and practices in a resourcelimited setting in Burkina Faso. It demonstrated that the study population, particularly the HAART group, had a generally positive attitude towards HAART, good adherence and made regular visit to the clinic. It is encouraging that HAART is well accepted by the population. Nevertheless, an appropriate intervention is necessary to reinforce education messages, especially for those not yet on HAART. In addition, most respondents in the non-HAART group were in the early stages of disease. A minor proportion of these patients, particularly among those who claimed that they were not able to work as usual, should be assessed carefully for HAART. Finally, an outreach programme may be necessary to take care of those who do not visit the clinic regularly and those who were lost to follow-up.
Ethical approval Burkina Faso National Ethics Committee.
Funding The study was funded, in part, by the International Cooperation and Development Fund (Taiwan), and Student Travelling Grant, National Yang Ming University, Taiwan.
Competing interests None declared.
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