HIV has remained a major public health problem despite huge financial resources expended by stakeholders at finding cure and mitigating the impact of the disease. With the global estimate of 34 million people living with the virus and 2.5 million new infections, Nigeria ranks second among HIV/AIDS burdened countries with a prevalence of 4.1% and estimated 3.2 million people living with the disease. In spite free HIV treatment in Nigeria, poor adherence to Antiretroviral Therapy has continued to pose a greater challenge to achieving remarkable clinical and immunological outcomes due to ARV drug resistance. This study identified factors associated with poor adherence to antiretroviral drugs among patients accessing care at Nigeria Institute of Medical Research, Lagos, Nigeria.
A cross-sectional study was conducted from January 1st to March 31st, 2014 on HIV- infected aged ≥ 15 years being on treatment with antiretroviral drugs three months prior to commencement of study. Data were collected using semi-structured questionnaires to obtain information on patients? adherence level, knowledge on ART, socio-demographics and provider-patient related factors. Data were subsequently entered and analyzed in Epi Info version 3.5.1 for descriptive statistics and to calculate odds ratios and adjusted odds ratios to identify the relative effect of explanatory variables on the dependent variable. A qualitative study was also carried out to further explore factors associated with poor adherence.
Of the 426 patients interviewed, 285 (66.9%) were female; mean age 39.3(ÂSD) of 8.9 years and out of 112 (26.3%) who had poor adherence, 70 (62.5%) were females and 40 (37.5%) were males. Poor adherence were associated with not receiving adherence counselling (OR 5.1; CI 95%: 2.1 - 13.5) unsatisfactory attitude of health workers (OR
4.8; CI 95%: 1.8 - 12.7), undergoing adherence counselling sessions of less than three times (OR 2.1; CI 95%: 1.2 - 3.9), and receiving counselling from non-health workers (OR 11.1; CI 95%: 1.2 - 100.2). Major reasons for poor adherence were forgetfulness (47.7%), and frequent travelling (9.2%). FGD revealed poor attitude of the health workers
and stigma and discrimination as barriers to adherence to treatment. Multivariate analysis revealed unsatisfactory attitude of health workers (AOR 4.8, p-value 0.01), undergoing adherence counselling sessions of less than three times (AOR 2.1, p-value 0.01) and receiving adherence counselling from non-health workers (AOR 10.9, p-value 0.03) as independent factors associated with poor adherence to ART.
The study revealed receiving adherence counselling, attitude of health workers, number of counselling sessions received and whether counselling was given by health worker as the major determinants of adherence to anti-retroviral treatment. On-the-job training for Health workers on attitudinal change and improving adherence by providing regular follow-up, increasing patients? awareness of the ART treatment, including its benefits and side-effects, eliminating problems of access and alleviating the impact of cost by making all drugs available was included in the routine supportive supervision.
Key words: Adherence factors, Adherence level, counselling, Human Immunodefiency Virus.
TABLE OF CONTENTS
Title page - - - - - - - - - i
Attestation - - - - - - - - - ii
Certification - - - - - - - - - iii
Dedication - - - - - - - - - iv
Acknowledgement - - - - - - - - v
Summary - - - - - - - - - vii
Table of contents - - - - - - - - ix
List of tables - - - - - - - - - xii
List of figures - - - - - - - - - xiii
List of appendices - - - - - - - - xv
List of acronyms - - - - - - - - xvi
Chapter One - Introduction
1.1 Background - - - - - - - - 1
1.2 Problem Statement - - - - - - - 5
1.3 Rational/Justification - - - - - - - 6
1.4 Research Question - - - - - - - 8
1.5 Objectives - - - - - - - - 8
Chapter Two - Literature Review
2.1 Conceptual framework - - - - - - 13
2.2 Proportion of HIV patients with poor adherence - - - 16
2.3 Knowledge about ART among HIV/AIDS patients - - - 20
2.4 Socio-demographic factors that influence adherence to ART - 21
2.5 Patient-provider related factors - - - - - 27
2.6 Method/design in previous adherence studies - - - 34
2.7 Gaps in knowledge and further justification - - - - 41
Chapter Three - Methodology
3.1 Study area - - - - - - - - 43
3.2 Study design - - - - - - - - 45
3.3 Study period - - - - - - - - 45
3.4 Study population - - - - - - - 45
3.5 Sampling size determination - - - - - - 45
3.6 Sampling techniques - - - - - - - 46
3.7 Study instruments - - - - - - - 47
3.8 Data collection methods - - - - - - 49
3.9 Data management and analysis - - - - - 50
3.10 Ethical clearance - - - - - - - 54
3.11 Limitations - - - - - - - - 56
3.12 Scope of the study - - - - - - - 57
Chapter Four - Results
4.1 Socio-demographic characteristic of study population - - 58
4.2 Proportion of poor adherence - - - - - - 69
4.3 Knowledge on anti-retroviral drugs (ART) - - - - 73
4.4 Patient-provider related factors - - - - - 75
Chapter Five - Discussion
Discussion - - - - - - - - - 98
Chapter Six - Conclusion and Recommendations
6.1 Conclusion - - - - - - - - 108
6.2 Recommendations - - - - - - - 109
References - - - - - - - - - 111
Appendices - - - - - - - - - 120
LIST OF TABLES
Table 3.1 Criteria for grading attitude of health workers - - - 52
Table 3.2 Criteria for grading knowledge about ART by study participants 53
Table 4.1: Presents socio-demographic characteristics of respondents, (n=426)
NIMR, Lagos ART Adherence study, 2014 - - - 59
Table 4.2: Monthly salary of respondents (n=381), NIMR, Lagos ART Adherence study, 2014 - - - - - - 61
Table 4.3: Transport fare of respondents (n=381), NIMR, Lagos ART Adherence study, 2014 - - - - - - 66
Table 4.4: Series of questions asked and responses from respondents to assess level of knowledge about ART (n=426), NIMR, Lagos ART Adherence study, 2014 - - - - - 74
Table 4.5: Presents patient related reasons for poor adherence to ART (n=426), NIMR, Lagos ART Adherence study, 2014 - - - 75
Table 4.6: Presents Patients? different reminder method for adherence to ART (n=351), NIMR, Lagos ART Adherence study, 2014 - - 78
Table 4.7: Presents number of times patients had adherence counselling sessions (n=426), NIMR, Lagos ART Adherence study, 2014 80
Table 4.8: Bivariate analysis of selected factors with poor adherence status, (n=426) NIMR, Lagos ART Adherence study, 2014 - - 86
Table 4.9: Multivariate analysis of the variables significant at p<0.05 with poor adherence as outcome, (n=426) NIMR, Lagos ART Adherence study, 2014 - - - - - - - 88
LIST OF FIGURES
Figure 2.1: Problem analysis diagram of possible factors contributing to poor adherence to ART - - - - - - 15
Figure 3.1: Map of Nigeria showing Lagos State with NIMR Yaba in Lagos
Mainland Local Government Area indicated - - - 44
Figure 4.1: Main source of household food by respondents (n=426), NIMR,
Lagos ART Adherence study, 2014 - - - - 62
Figure 4.2: Daily number of meals respondents could afford (n=426), NIMR,
Lagos ART Adherence study, 2014 - - - - 63
Figure 4.3: Distance of respondents? houses to health facility for drug pick-up
(n=426), NIMR, Lagos ART Adherence study, 2014 - - 64
Figure 4.4: Duration in hours from respondents? houses to health facility for
drug pick-up (n=426), NIMR, Lagos ART Adherence study, 2014 65
Figure 4.5: Average numbers of clinic visit in a month by respondents? for drug
pick-ups and follow up (n=426), NIMR, Lagos ART Adherence
study, 2014 - - - - - - - 67
Figure 4.6: Average waiting time of respondents for drug pick up during clinic
visit (n=426), NIMR, Lagos ART Adherence study, 2014 - 68
Figure 4.7: Proportion of respondents with poor adherence (n=426), NIMR,
Lagos ART Adherence study, 2014 - - - - 69
Figure 4.8: Gender distribution of respondents with their adherence status
(n=426), NIMR, Lagos ART Adherence study, 2014 - - 70
Figure 4.9: Daily dosage of ARV drugs of respondents with their adherence
status (n=426), NIMR, Lagos ART Adherence study, 2014 - 71
Figure 4.10: Proportion of respondents who missed dose (s) of ARV drug combination in a month (n=426), NIMR, Lagos ART Adherence
study, 2014 - - - - - - - 72
Figure 4.11: Proportion of respondents with level of knowledge about ART
(n=426), NIMR, Lagos ART Adherence study, 2014 - - 73
Figure 4.12: Proportion of respondents with reminder methods for adhering to
ART (n=426), NIMR, Lagos ART Adherence study, 2014 - 77
Figure 4.13: Adherence counselling on ART by respondents (n=426), NIMR,
Lagos ART Adherence study, 2014 - - - - 79
Figure 4.14: Proportion of respondents who received important counselling messages from counsellors (n=426), NIMR, Lagos ART Adherence study, 2014 - - - - - - - 81
Figure 4.15: Perception of respondents about health workers? attitude (n=426),
NIMR, Lagos ART Adherence study, 2014 - - - 82
Figure 4.16: Perception of respondents about health workers? attitude based on
level of adherence (n=426), NIMR, Lagos ART Adherence study,
2014 - - - - - - - - 83
Figure 4.17: Perception of respondents about positive attitude of health workers
(n=426), NIMR, Lagos ART Adherence study, 2014 - - 84
Figure 4.18: Perception of respondents about negative attitude of health workers
(n=426), NIMR, Lagos ART Adherence study, 2014 - - 85
LIST OF APPENDICES
Appendix 1: Questionnaire - - - - - - - 120
Appendix 2: Patient information and consent form- - - - 125
Appendix 3: Focus group guide - - - - - 128
Appendix 4: Key informant interview guide - - - - 132
Appendix 5: Ethical approval - - - - - - 134
Appendix 6: Workplan - - - - - - - 136
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