Barriers and Facilitators of Adherence to Antiretroviral Drug Therapy and Retention in Care among Adult HIV-Positive Patients: A Qualitative Study from Ethiopia

Background

Antiretroviral therapy (ART) has been life saving for hundreds of thousands of Ethiopians. With increased availability of ART in recent years, achievement of optimal adherence and patient retention are becoming the greatest challenges in the management of HIV/AIDS in Ethiopia. However, few studies have explored factors influencing medication adherence to ART and retention in follow-up care among adult Ethiopian HIV-positive patients, especially in the Amhara region of the country, where almost one-third of the country’s ART is prescribed. The aim of this qualitative study was to collect such data from patients and healthcare providers in the Amhara region of Ethiopia.

Methods

Semi-structured interviews were conducted with 24 patients, of whom 11 had been lost to follow-up and were non-persistent with ART. In addition, focus group discussions were performed with 15 ART nurses and 19 case managers. All interviews and focus groups were audio-recorded, transcribed, and coded for themes and patterns in Amharic using a grounded theory approach. The emergent concepts and categories were translated into English.

Results

Economic constraints, perceived stigma and discrimination, fasting, holy water, medication side effects, and dissatisfaction with healthcare services were major reasons for patients being non-adherent and lost to follow-up. Disclosure of HIV status, social support, use of reminder aids, responsibility for raising children, improved health on ART, and receiving education and counseling emerged as facilitators of adherence to ART.

Conclusions

Improving adherence and retention requires integration of enhanced treatment access with improved job and food security. Healthcare providers need to be supported to better equip patients to cope with the issues associated with ART. Development of social policies and cooperation between various agencies are required to facilitate optimal adherence to ART, patient retention, and improved patient outcomes.     

Other issues

Other issues: HIV/AIDS in East Africa: addressing legal, ethical and human rights dilemmas facing healthcare workers; Building research ethics capacity in Haiti: leading the way in the Caribbean; Bioethics and academic freedom in Brazil; Non-consensual HIV testing and confidentiality breaches common in India     

Trauma History and Depression Predict Incomplete Adherence to Antiretroviral Therapies in a Low Income Country

Background

As antiretroviral therapy (ART) for HIV becomes increasingly available in low and middle income countries (LMICs), understanding reasons for lack of adherence is critical to stemming the tide of infections and improving health. Understanding the effect of psychosocial experiences and mental health symptomatology on ART adherence can help maximize the benefit of expanded ART programs by indicating types of services, which could be offered in combination with HIV care.

Methodology

The Coping with HIV/AIDS in Tanzania (CHAT) study is a longitudinal cohort study in the Kilimanjaro Region that included randomly selected HIV-infected (HIV+) participants from two local hospital-based HIV clinics and four free-standing voluntary HIV counselling and testing sites. Baseline data were collected in 2008 and 2009; this paper used data from 36 month follow-up interviews (N = 468). Regression analyses were used to predict factors associated with incomplete self-reported adherence to ART.

Results

Incomplete ART adherence was significantly more likely to be reported amongst participants who experienced a greater number of childhood traumatic events: sexual abuse prior to puberty and the death in childhood of an immediate family member not from suicide or homicide were significantly more likely in the non-adherent group and other negative childhood events trended toward being more likely. Those with incomplete adherence had higher depressive symptom severity and post-traumatic stress disorder (PTSD). In multivariable analyses, childhood trauma, depression, and financial sacrifice remained associated with incomplete adherence.

Discussion

This is the first study to examine the effect of childhood trauma, depression and PTSD on HIV medication adherence in a low income country facing a significant burden of HIV. Allocating spending on HIV/AIDS toward integrating mental health services with HIV care is essential to the creation of systems that enhance medication adherence and maximize the potential of expanded antiretroviral access to improve health and reduce new infections.     

Addressing the conflict between partner notification and patient confidentiality in serodiscordant relationships: How can Ubuntu help?

This study evaluates the conflict between patient confidentiality and partner notification in sero‐discordant relationships, and argues the thesis that based on a theoretical formulation of Ubuntu, a health provider is obliged to facilitate friendly relationships in which individuals are true subjects and/or objects of communal friendship. In serodiscordant relationships, the health professional can fulfil this obligation by notifying “others” (particularly a partner with whom an HIV positive patient has a “present” and “actual relationship”) of their spouse's HIV seroconversion, since without such relevant information a partner (subject) of an HIV positive patient cannot “appropriately” care for the patient's condition (object). There is a need to move away from the medical traditional emphasis that has for so long put primacy on doctor‐patient confidentiality as is the case with the Health Professions Council of South Africa Guidelines (Booklet 12) which favours patient confidentiality over partner notification. Given empirical evidence to support effectiveness of partner notification amongst sero‐discordant couples, there is thus, a need to focus emphasis on latter. This shift is necessary for achieving the United Nations’ Sustainable Development of Goal of ending HIV/AIDS epidemic by 2030. I proposed in this study that African ethics, specifically Ubuntu, will do a better job than current ethical frameworks at ensuring that partner notification receives more emphasis in the care of serodiscordant couples. If this framework is integrated into ethical guidelines and codes, it would significantly enhance the care of serodiscordant couples, as well as further boost global effort at ending HIV/AIDS epidemic by 2030.     

University students' knowledge of, and attitudes towards, hiv and AIDS, homosexuality and sexual risk behaviour: a questionnaire survey in two finnish universities

Summary This study describes Finnish university students' knowledge and attitudes towards HIV and AIDS, homosexuality and sexual risk behaviour. Finnish-speaking students were randomly selected from all registered students at two universities in Finland (N=9715, n=950). The data were collected by using a modified version of the State University of New York at Buffalo School of Nursing AIDS Study Questionnaire on sexual risk behaviour developed by Held and Chng. The total response rate was 35% (n=333). The data were analysed using quantitative statistical methods. Normally distributed data were analysed by t-test and one-way ANOVA, with Bonferroni corrections. Non-normally distributed data were analysed using the Mann-Whitney U-test and Kruskal-Wallis test, followed by a post-hoc test. The majority of students were familiar with HIV and AIDS, including its mode of transmission. However, there were still some misconceptions concerning HIV and AIDS. The oldest students and women had a more positive attitude towards people living with HIV and AIDS (PLWHA). Of patients with HIV or AIDS, intravenous drug users were perceived most negatively. Male students had more homophobic attitudes. Students who reported that religion had an important role in their lives had significantly stricter attitudes towards sexual risk behaviour. Students' knowledge correlated positively with general attitudes towards HIV and AIDS. Knowledge about HIV and AIDS will lead to more positive attitudes towards HIV and AIDS as a disease, towards those infected as well as homosexual people. There is a need to focus on preventive health care and sexual health promotion by educating young people and changing their attitudes towards sexual risk behaviour.     

Ethical and regulatory issues surrounding African traditional medicine in the context of HIV/AIDS

It has been estimated that more than 80% of people in Africa use traditional medicine (TM). With the HIV/AIDS epidemic claiming many lives in Africa, the majority of people affected rely on TM mainly because it is relatively affordable and available to the poor populations who cannot afford orthodox medicine. Whereas orthodox medicine is practiced under stringent regulations and ethical guidelines emanating from The Nuremburg Code, African TM seems to be exempt from such scrutiny. Although recently there have been calls for TM to be incorporated into the health care system, less emphasis has been placed on ethical and regulatory issues. In this paper, an overview of the use of African TM in general, and for HIV/AIDS in particular, is given, followed by a look at: (i) the relative laxity in the application of ethical standards and regulatory requirements with regards to TM; (ii) the importance of research on TM in order to improve and demystify its therapeutic qualities; (iii) the need to tailor-make intellectual property laws to protect traditional knowledge and biodiversity. A framework of partnerships involving traditional healers' associations, scientists, policy makers, patients, community leaders, members of the communities, and funding organizations is suggested as a possible method to tackle these issues. It is hoped that this paper will stimulate objective and constructive debate that could enhance the protection of patients' welfare.     

HIV/AIDS programmes should focus on improved access

This paper discusses the need for HIV/AIDS programs in sub-Saharan countries to focus more on improved access to information to empower poor people living in remote areas. It is noted that despite Glaxo Wellcome's move to reduce the cost of antiretroviral therapy, it is unlikely to have an impact on most of those infected with or affected by HIV/AIDS, since concerns regarding lack of sustainability, bureaucratic administration, and communication difficulties predominate in the country. In this regard, it is therefore recommended that national HIV/AIDS programs be balanced with the needs of both the community and the individual and in prevention and care. Health workers should be explicit in confronting traditional beliefs, such as those about gender roles and traditional medicine, in prevention campaigns. Moreover, there is also an urgent need to improve access to condoms; strengthen health programs such as directly observed treatment short-term (DOTS) courses for tuberculosis and the syndromic approach to sexually transmitted disease treatment; and improve practical support to communities caring for those who are sick and the orphans. Lastly, all partners working with prevention programs should use the more positive community attitudes towards HIV/AIDS issues seen in many sub-Saharan countries to develop evidence-based programs that focus more on improved access and less on sustainability.     

Hierarchical Bayesian inference for HIV dynamic differential equation models incorporating multiple treatment factors

Studies on HIV dynamics in AIDS research are very important in understanding the pathogenesis of HIV‐1 infection and also in assessing the effectiveness of antiretroviral (ARV) treatment. Viral dynamic models can be formulated through a system of nonlinear ordinary differential equations (ODE), but there has been only limited development of statistical methodologies for inference. This article, motivated by an AIDS clinical study, discusses a hierarchical Bayesian nonlinear mixed‐effects modeling approach to dynamic ODE models without a closed‐form solution. In this model, we fully integrate viral load, medication adherence, drug resistance, pharmacokinetics, baseline covariates and time‐dependent drug efficacy into the data analysis for characterizing long‐term virologic responses. Our method is implemented by a data set from an AIDS clinical study. The results suggest that modeling HIV dynamics and virologic responses with consideration of time‐varying clinical factors as well as baseline characteristics may be important for HIV/AIDS studies in providing quantitative guidance to better understand the virologic responses to ARV treatment and to help the evaluation of clinical trial design in response to existing therapies.     

Medication nonadherence: an unrecognized cardiovascular risk factor

Nonadherence with prescribed drug regimens is a pervasive medical problem. Multiple variables affecting physicians and patients contribute to nonadherence, which negatively affects treatment outcomes. In patients with hypertension, medication nonadherence is a significant, often unrecognized, risk factor that contributes to poor blood pressure control, thereby contributing to the development of further vascular disorders such as heart failure, coronary heart disease, renal insufficiency, and stroke. Analysis of various patient populations shows that choice of drug, use of concomitant medications, tolerability of drug, and duration of drug treatment influence the prevalence of nonadherence. Intervention is required among patients and healthcare prescribers to increase awareness of the need for improved medication adherence. Within this process, it is important to identify indicators of nonadherence within patient populations. This review examines the prevalence of nonadherence as a risk factor in the management of chronic diseases, with a specific focus on antihypertensive medications. Factors leading to increased incidence of nonadherence and the strategies needed to improve adherence are discussed. Medication nonadherence, defined as a patient's passive failure to follow a prescribed drug regimen, remains a significant concern for healthcare professionals and patients. On average, one third to one half of patients do not comply with prescribed treatment regimens.[1-3] Nonadherence rates are relatively high across disease states, treatment regimens, and age groups, with the first several months of therapy characterized by the highest rate of discontinuation.[3] In fact, it has recently been reported that low adherence to beta-blockers or statins in patients who have survived a myocardial infarction results in an increased risk of death.[4] In addition to inadequate disease control, medication nonadherence results in a significant burden to healthcare utilization - the estimated yearly cost is $396 to $792 million.[1] Additionally, between one third and two thirds of all medication-related hospital admissions are attributed to nonadherence.[5,6]Cardiovascular disease, which accounts for approximately 1 million deaths in the United States each year, remains a significant health concern.[7] Risk factors for the development of cardiovascular disease are associated with defined risk-taking behaviors (eg, smoking), inherited traits (eg, family history), or laboratory abnormalities (eg, abnormal lipid panels).[7] A significant but often unrecognized cardiovascular risk factor universal to all patient populations is medication nonadherence; if a patient does not regularly take the medication prescribed to attenuate cardiovascular disease, no potential therapeutic gain can be achieved. Barriers to medication adherence are multifactorial and include complex medication regimens, convenience factors (eg, dosing frequency), behavioral factors, and treatment of asymptomatic conditions.[2] This review highlights the significance of nonadherence in the treatment of hypertension, a silent but life-threatening disorder that affects approximately 72 million adults in the United States.[7] Hypertension often develops in a cluster with insulin resistance, obesity, and hypercholesterolemia, which contributes to the risk imposed by nonadherence with antihypertensive medications. Numerous strategies to improve medication adherence are available, from enhancing patient education to providing medication adherence information to the healthcare team and will be discussed in this article.     

Experience on healthcare utilization in seven administrative regions of Tanzania

Health care utilization in many developing countries, Tanzania included, is mainly through the use of traditional medicine (TRM) and its practitioners despite the presence of the conventional medicine. This article presents findings on the study that aimed to get an experience of health care utilization from both urban and rural areas of seven administrative regions in Tanzania. A total of 33 health facility managers were interviewed on health care provision and availability of supplies including drugs, in their respective areas. The findings revealed that the health facilities were overburden with higher population to serve than it was planned. Consequently essential drugs and other health supplies were available only in the first two weeks of the month. Conventional health practitioners considered traditional health practitioners to be more competent in mental health management, and overall, they were considered to handle more HIV/AIDS cases knowingly or unknowingly due to shear need of healthcare by this group. In general conventional health practitioners were positive towards traditional medicine utilization; and some of them admitted using traditional medicines. Traditional medicines like other medical health systems worldwide have side effects and some contentious ethical issues that need serious consideration and policy direction. Since many people will continue using traditional/alternative medicine, there is an urgent need to collaborate with traditional/alternative health practitioners through the institutionalization of basic training including hygiene in order to improved healthcare in the community and attain the Millennium Development Goals by 2015.     

Modelling viral and CD4 cellular population dynamics in HIV: approaches to evaluate intervention strategies.

Computational models, such as in epidemiology, provide a powerful tool that can be used to systematically examine an array of dynamic interactions among populations as well as to evaluate altemate disease intervention strategies. The specific objectives in this study were to: a/ examine the interaction of cellular (CD4) and HIV population dynamics and evaluate the impact of the use of combination chemotherapies on viral and CD4 populations (Experiment #1), b/ demonstrate how modelling can be used to evaluate the impact of an intervention (condom use) on reducing the rate of HIV/AIDS (Experiment #2). In this study, we used state transition models and conducted simulation experiments to evaluate various alternatives for the control and/or prevention of HIV/AIDS. The result indicated that combination therapy (double or triple drug therapies) was very effective. The HIV viral population decreased rapidly and remained suppressed for years. On the other hand, the CD4 cell population increased above 400 cells per ml and was maintained above that level for many years. Mono-therapy was not as effective; although the viral load decreased rapidly, it increased to its original levels within a few months. Since condom use is one of the key interventions of HIV/AIDS, we evaluated its use in 25%, 50% and 75% of an adult, sexually active population. Increasing condom use by 50% and 75% above an estimated baseline of 25% reduced the incidence of AIDS by 53% in Blacks, 49% in Hispanics and 43% in Whites. The study shows how a cellular/molecular level model can be incorporated within a macro-epidemiologic systems dynamics model to evaluate a variety of scientific questions such as to see if cellular/molecular level interventions reduce morbidity and mortality rates in HIV.     

Perception of risk of HIV/AIDS and sexual behaviour in Kenya

The association between perception of risk of HIV infection and sexual behaviour remains poorly understood, although perception of risk is considered to be the first stage towards behavioural change from risk-taking to safer behaviour. Using data from the 1998 Kenya Demographic and Health Survey, logistic regression models were fitted to examine the direction and the strength of the association between perceived risk of HIV/AIDS and risky sexual behaviour in the last 12 months before the survey. The findings indicate a strong positive association between perceived risk of HIV/AIDS and risky sexual behaviour for both women and men. Controlling for sociodemographic, sexual exposure and knowledge factors such as age, marital status, education, work status, residence, ethnicity, source of AIDS information, specific knowledge of AIDS, and condom use to avoid AIDS did not change the direction of the association, but altered its strength slightly. Young and unmarried women and men were more likely than older and married ones to report risky sexual behaviour. Ethnicity was significantly associated with risky sexual behaviour, suggesting a need to identify the contextual and social factors that influence behaviour among Kenyan people.     

Evidence for recent changes in sexual behaviour in homosexual men in England and Wales

Over 80% of cases of Acquired Immune Deficiency Syndrome (AIDS) in England and Wales have occurred in homosexual men. Changes in sexual behaviour in this group may have a substantial influence on the incidence of Human Immunodeficiency Virus (HIV) infection and will therefore be crucial in determining future cases of AIDS. This paper critically weighs the indirect and direct evidence for changes in behaviour in homosexual men since the advent of the AIDS epidemic. The paper reports on falling incidence of gonorrhoea, hepatitis B and syphilis in homosexual men, the changes being most marked from 1985 onwards. Data on temporal trends in HIV prevalence and incidence in homosexual men are reviewed. These suggest that the maximum incidence of HIV infection occurred in 1982-84 and may have fallen since then. Evidence for a concomitant change in sexual behaviour is reported from several sources. This points towards a recent change in sexual behaviour characterized by reduction in the numbers of partners and adoption of safer sexual practices. In some places change may have occurred as early as 1983. A change became apparent generally in 1985 and this appears to have been sustained in 1986-87. Nevertheless, a substantial proportion of homosexual men studied continue to practice high risk sexual practices, such as anal intercourse, including relationships with casual partners.     

Ethics and Rationing Access to Dialysis in Resource‐Limited Settings: The Consequences of Refusing a Renal Transplant in the South African State Sector

Resource constraints in developing countries compel policy makers to ration the provision of healthcare services. This article examines one such set of Guidelines: A patient dialysing in the state sector in South Africa may not refuse renal transplantation when a kidney becomes available. Refusal of transplantation can lead to exclusion from the state‐funded dialysis programme. This Guideline is legally acceptable as related to Constitutional stipulations which allow for rationing healthcare resources in South Africa. Evaluating the ethical merit of the Guideline, and exploring the ethical dilemma it poses, proves a more complex task. We examine the actions of healthcare professionals as constrained by the Guideline. From a best interests framework, we argue that in these circumstances directing patient decision making (pressurising a patient to undergo renal transplantation) is not necessarily unethical or unacceptably paternalistic. We then scrutinise the guideline itself through several different ethical ‘lenses’. Here, we argue that bioethics does not provide a definitive answer as to the moral merit of rationing dialysis under these circumstances, however it can be considered just in this context. We conclude by examining a potential pitfall of the Guideline: Unwilling transplant recipients may not comply with immunosuppressive medication, which raises questions for policies based on resource management and rationing.     

CULTURAL CIRCUMCISION IN EU PUBLIC HOSPITALS – AN ETHICAL DISCUSSION

The paper explores the ethical aspects of introducing cultural circumcision of children into the EU public health system.
We reject commonplace arguments against circumcision: considerations of good medical practice, justice, bodily integrity, autonomy and the analogy from female genital mutilation.
From the unique structure of patient-medicine interaction, we argue that the incorporation of cultural circumcision into EU public health services is a kind of medicalization, which does not fit the ethos of universal healthcare. However, we support a utilitarian argument that finds hospital-based circumcision safer than non-medicalized alternatives.
The argument concerning medicalization and the utilitarian argument both rely on preliminary empirical data, which depend on future validation.     

Optimal strategy for controlling the spread of HIV/AIDS disease: a case study of South Africa

HIV/AIDS disease continues to spread alarmingly despite the huge amounts of resources invested in fighting it. There is a need to integrate the series of control measures available to ensure a consistent reduction in the incidence of the disease pending the discovery of its cure. We present a deterministic model for controlling the spread of the disease using change in sexual habits and antiretroviral (ARV) therapy as control measures. We formulate a fixed time optimal control problem subject to the model dynamics with the goal of finding the optimal combination of the two control measures that will minimize the cost of the control efforts as well as the incidence of the disease. We estimate the model state initial conditions and parameter values from the demographic and HIV/AIDS data of South Africa. We use Pontryagin's maximum principle to derive the optimality system and solve the system numerically. Compared with the practice in most resource-limited settings where ARV treatment is given only to patients with full-blown AIDS, our simulation results suggest that starting the treatment as soon as the patients progress to the pre-AIDS stage of the disease coupled with appreciable change in the susceptible individuals' sexual habits reduces both the incidence and prevalence of the disease faster. In fact, the results predict that the implementation of the proposed strategy would drive new cases of the disease towards eradication in 10 years.     

Can asthma control be improved by understanding the patient's perspective?

Background

Clinical trials show that asthma can be controlled in the majority of patients, but poorly controlled asthma still imposes a considerable burden. The level of asthma control achieved reflects the behaviour of both healthcare professionals and patients. A key challenge for healthcare professionals is to help patients to engage in self-management behaviours with optimal adherence to appropriate treatment. These issues are particularly relevant in primary care, where most asthma is managed. An international panel of experts invited by the International Primary Care Respiratory Group considered the evidence and discussed the implications for primary care practice.

Discussion

Causes of poor control Clinical factors such as exposure to triggers and concomitant rhinitis are important but so are patient behavioural factors. Behaviours such as smoking and nonadherence may reduce the efficacy of treatment and patients' perceptions influence these behaviours. Perceptual barriers to adherence include doubting the need for treatment when symptoms are absent and concerns about potential adverse effects. Under-treatment may also be related to patients' underestimation of the significance of symptoms, and lack of awareness of achievable control. Implications Three key implications for healthcare professionals emerged from the debate. First, the need for simple tools to assess asthma control. Two approaches considered were the monitoring of biometric markers of control and questionnaires to record patient-reported outcomes. Second, to understand the reasons for poor control for individual patients, identifying both clinical (e.g. rhinitis) and behavioural factors (e.g. smoking and nonadherence to treatment). Third was the need to incorporate, within asthma review, an assessment of patient perspectives including their goals and aspirations and to elicit their beliefs and concerns about asthma and its treatment. This can be used as a basis for agreement between the healthcare professional and patient on a predefined target regarding asthma control and a treatment plan to achieve this.

Summary

Optimum review of asthma is essential to improve control. A key priority is the development of simple and effective tools for identifying poor control for individual patients coupled with a tailored approach to treatment to enable patients to set and achieve realistic goals for asthma control.     

Improving medication adherence in chronic obstructive pulmonary disease: a systematic review

Adherence to medication among individuals with chronic obstructive pulmonary disease (COPD) is suboptimal and has negative impacts on survival and health care costs. No systematic review has examined the effectiveness of interventions designed to improve medication adherence. Electronic databases Medline and Cochrane were searched using a combination of MeSH and keywords. Eligible studies were interventions with a primary or secondary aim to improve medication adherence among individuals with COPD published in English. Included studies were assessed for methodological quality using the Effective Practice and Organisation of Care (EPOC) criteria. Of the 1,186 papers identified, seven studies met inclusion criteria. Methodological quality of the studies was variable. Five studies identified effective interventions. Strategies included: brief counselling; monitoring and feedback about inhaler use through electronic medication delivery devices; and multi-component interventions consisting of self-management and care co-ordination delivered by pharmacists and primary care teams. Further research is needed to establish the most effective and cost effective interventions. Special attention should be given to increasing patient sample size and using a common measure of adherence to overcome methodological limitations. Interventions that involve caregivers and target the healthcare provider as well as the patient should be further explored.