Factors influencing adherence to antiretroviral therapy among HIV-infected adults in Cross River State, Nigeria: a cross-sectional study

The Pan African medical journal, Volume 43, Year 2022

Interpretation

Introduction: improved access to antiretroviral therapy (ART) has significantly increased the survival and quality of life of HIV-infected persons. Strict adherence to antiretroviral therapy (ART) is crucial if viral suppression must remain optimal. We assessed predictors of adherence to ART among adult patients in Cross River State (CRS), Nigeria. Methods: a cross-sectional survey was conducted among 999 adult patients on ART in selected secondary and tertiary health facilities in CRS from January to June 2017. Respondents were recruited using multistage technique. Data were collected using a pre-tested interviewer-administered questionnaire. Adherence was defined as clients taking at least 95% of their pills in the last seven days. Multivariate analysis was performed to determine predictors of adherence at 5% level of significance. Results: majority (70.5%) of the respondents were females with a mean age of 43.7 ± 11.1 years. The self-reported adherence rate was 60.1%. The commonest reasons for non-adherence was client travelling out of home, being busy, forgetting and lack of food. The significant predictor identified in this study was being on first-line drugs (OR=3.677, 95% C.I=2.523-5.358), were 3 times more likely to have good adherence. Predictors of poor-adherence were alcohol intake (OR=0.382, 95% C.I=0.262-0.559), dosing medications (OR=0.502, 95% C.I=0.381-0.661), CD4 cell count ≥ 500 (OR=0.723, 95% C.I=0.543-0.964), poor attitude to HIV status and medication (OR=0.713, 95% C.I=0.512-0.994) and family support (OR=0.736, 95% C.I=0.544-0.995). Conclusion: adherence to ART among clients in this study was fair. Majority of the reasons for poor-adherence were client-related. There is need for targeted counselling to improve adherence. Study area and setting: the study was conducted in Cross River State located in the southern part of Nigeria [18], with Calabar as its capital city [19]. The State shares boundaries with Akwa Ibom State to the South-West, Ebonyi and Abia to the West, Benue to the North, the Republic of Cameroon to the East and the Atlantic Ocean to the West. Cross River has 18 LGAs, with an estimated population of 3,674,951 (2015 estimate), projected from the 2006 census population at a growth rate of 2.9% [19]. The State is composed of several ethnic groups, which include the Efik, Ejagham, Yakurr, Bahumono, Bette, Yala, Igede, Ukelle, Utukwang and the Bekwarra [19]. The prevalence of HIV in the State dropped from 6.6% in 2014 to 1.7% in 2018 [20,21]. Cross River State, sandwiched between Benue and Akwa Ibom States, the two States with the highest prevalence of HIV in Nigeria, is a choice tourist destination with a large influx of visitors [6]. The four study facilities provide comprehensive HIV care (paediatric, adult and prevention of maternal to child transmission of HIV services) and run clinics from Monday through Friday. University of Calabar Teaching Hospital, the only tertiary healthcare facility in the State, has 5,800 patients accessing HIV care, of which more than 3,900 were on HAART; while General Hospital Calabar, had 11,057 patients with 3,294 on HAART. Study design: a cross-sectional facility-based descriptive study. Study population: we studied 999 adult (≥18 years) HIV-infected patients receiving treatment in three general hospitals (one from each senatorial district) and the only teaching hospital in the State. Eligibility criteria: all the adult patients on HAART for at least three months prior to the study were eligible to participate. People living with HIV/AIDS (PLWHA) who were too sick, pregnant, had cognitive impairment or other disabilities like deafness, were excluded from the study. Sample size determination: using the Leslie Kish formula for determination of minimum sample size based on the assumption of ART adherence rate of 59.9% among adult HIV-infected patients from a similar study [16], 5% precision, design effect of 2.4 and adjusting for a non-response rate of 10% non-response, the desired sample size was determined to be 985 rounded to 999 participants. This sample size was proportionately allocated to the study facilities. Sampling technique: a multi-stage sampling involving three-stage was used to select participants for the study. The first stage involved selection of one local government area (LGA) each from the three senatorial districts in the State through simple random sampling (SRS). In the second stage (selection of study facilities), one general hospital was selected by SRS from each of the three selected LGA, while the only teaching hospital in the State was also included, giving a total of four selected facilities (General Hospital Calabar, General Hospital Ugep and General Hospital Obanliku representing the south, central and northern senatorial districts respectively, with University of Calabar Teaching Hospital included as the only teaching hospital in the State). Systematic random sampling was used in the third stage to recruit participants from the selected facilities based on proportionate allocation of sample size to each facility. Study instruments: a pre-tested, semi-structured, interviewer-administered questionnaire adapted from a similar study [16] was used to collect information on participants´ socio-demographic characteristics, treatment history (when treatment commenced, type of HAART regimen), adherence profile and attitude to HAART. Quantitative survey: collected data uploaded to a secure server were exported in Microsoft Excel XLS format, cleaned in Excel spreadsheet and analysed with SPSS version 23. Frequencies, percentages, mean and standard deviations were used as appropriate in descriptive statistics. Adherence to HAART in the seven days preceding the interview was measured by self-report. The questions were adapted from brief medication questionnaire self-report tool for screening adherence and barriers to adherence [16]. The degree of adherence from patient self-report was estimated using the following formula [22]. For the purpose of the study, adherence score of 95% and above represented good adherence while scores of less than 95% were rated as poor adherence. At bivariate analysis, association between HAART adherence and independent variables such as socio-demographic and treatment characteristics were determined using Chi-square tests with corresponding p-values. Variables that had a p-value of ≤ 0.2 at bivariate analysis were entered into the logistic regression model to determine the predictors of HAART adherence. The results of the logistic regression were reported using odds ratios and 95% confidence intervals. All statistical analyses were performed at 5% level of significance. Ethical considerations: ethical approval for this study was obtained from the Health Research Ethics Committees of University of Calabar Teaching Hospital (reference: UCTH/HREC/33/519) and the State Ministry of Health (reference: RP/REC/2016/422). Written informed consents were obtained from the participants after the details of the study and its voluntariness was explained to them. Safety and confidentiality of collected data was ensured throughout the study.

AI Digest

Study Justification:

This study aimed to assess the factors influencing adherence to antiretroviral therapy (ART) among HIV-infected adults in Cross River State, Nigeria. The justification for this study is based on the importance of strict adherence to ART for optimal viral suppression and improved survival and quality of life for HIV-infected individuals. By identifying predictors of adherence, this study can contribute to the development of targeted interventions and counseling strategies to improve adherence rates.

Study Highlights:

– The study was conducted among 999 adult patients on ART in selected secondary and tertiary health facilities in Cross River State, Nigeria.
– The self-reported adherence rate was 60.1%.
– The common reasons for non-adherence included client travel, being busy, forgetting, and lack of food.
– The significant predictor of good adherence was being on first-line drugs, while predictors of poor adherence included alcohol intake, dosing medications, CD4 cell count ≥ 500, poor attitude to HIV status and medication, and lack of family support.
– The study concluded that adherence to ART among clients in the study was fair and highlighted the need for targeted counseling to improve adherence.

Recommendations for Lay Reader:

– It is important for HIV-infected individuals to adhere to their antiretroviral therapy (ART) to achieve optimal viral suppression and improve their health outcomes.
– Factors such as being on first-line drugs, avoiding alcohol intake, following proper dosing instructions, having a CD4 cell count below 500, maintaining a positive attitude towards HIV status and medication, and receiving family support can contribute to better adherence.
– Clients should be provided with targeted counseling to address the common reasons for non-adherence, such as travel, busy schedules, forgetfulness, and lack of food.

Recommendations for Policy Maker:

– Develop and implement targeted counseling programs to improve adherence to ART among HIV-infected individuals.
– Strengthen adherence support services in health facilities, including counseling services and reminders for medication intake.
– Promote awareness and education campaigns to address misconceptions and stigma related to HIV status and medication.
– Enhance access to first-line drugs and ensure availability of medications in health facilities.
– Collaborate with community organizations and support groups to provide social support and family involvement in adherence promotion.

Key Role Players:

– Healthcare providers: responsible for providing counseling, support, and medication management for HIV-infected individuals.
– Community organizations: involved in awareness campaigns, support groups, and social support for adherence promotion.
– Policy makers: responsible for developing and implementing policies to improve adherence to ART.
– Researchers: contribute to the evidence base by conducting studies on adherence predictors and interventions.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers on adherence counseling.
– Development and dissemination of educational materials for awareness campaigns.
– Implementation of reminder systems for medication intake.
– Collaboration and partnership with community organizations for support services.
– Monitoring and evaluation of adherence programs.
– Research funding for further studies on adherence predictors and interventions.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is cross-sectional, which limits the ability to establish causality. However, the study population is large and representative of adult HIV-infected patients in Cross River State, Nigeria. The data collection methods are well-described, and statistical analysis was performed to determine predictors of adherence. To improve the strength of the evidence, future studies could consider using a longitudinal design to establish causality and include a control group for comparison. Additionally, collecting objective measures of adherence, such as pill counts or electronic monitoring, would provide more accurate data.

Abstract

Study area and setting: the study was conducted in Cross River State located in the southern part of Nigeria [18], with Calabar as its capital city [19]. The State shares boundaries with Akwa Ibom State to the South-West, Ebonyi and Abia to the West, Benue to the North, the Republic of Cameroon to the East and the Atlantic Ocean to the West. Cross River has 18 LGAs, with an estimated population of 3,674,951 (2015 estimate), projected from the 2006 census population at a growth rate of 2.9% [19]. The State is composed of several ethnic groups, which include the Efik, Ejagham, Yakurr, Bahumono, Bette, Yala, Igede, Ukelle, Utukwang and the Bekwarra [19]. The prevalence of HIV in the State dropped from 6.6% in 2014 to 1.7% in 2018 [20,21]. Cross River State, sandwiched between Benue and Akwa Ibom States, the two States with the highest prevalence of HIV in Nigeria, is a choice tourist destination with a large influx of visitors [6]. The four study facilities provide comprehensive HIV care (paediatric, adult and prevention of maternal to child transmission of HIV services) and run clinics from Monday through Friday. University of Calabar Teaching Hospital, the only tertiary healthcare facility in the State, has 5,800 patients accessing HIV care, of which more than 3,900 were on HAART; while General Hospital Calabar, had 11,057 patients with 3,294 on HAART. Study design: a cross-sectional facility-based descriptive study. Study population: we studied 999 adult (≥18 years) HIV-infected patients receiving treatment in three general hospitals (one from each senatorial district) and the only teaching hospital in the State. Eligibility criteria: all the adult patients on HAART for at least three months prior to the study were eligible to participate. People living with HIV/AIDS (PLWHA) who were too sick, pregnant, had cognitive impairment or other disabilities like deafness, were excluded from the study. Sample size determination: using the Leslie Kish formula for determination of minimum sample size based on the assumption of ART adherence rate of 59.9% among adult HIV-infected patients from a similar study [16], 5% precision, design effect of 2.4 and adjusting for a non-response rate of 10% non-response, the desired sample size was determined to be 985 rounded to 999 participants. This sample size was proportionately allocated to the study facilities. Sampling technique: a multi-stage sampling involving three-stage was used to select participants for the study. The first stage involved selection of one local government area (LGA) each from the three senatorial districts in the State through simple random sampling (SRS). In the second stage (selection of study facilities), one general hospital was selected by SRS from each of the three selected LGA, while the only teaching hospital in the State was also included, giving a total of four selected facilities (General Hospital Calabar, General Hospital Ugep and General Hospital Obanliku representing the south, central and northern senatorial districts respectively, with University of Calabar Teaching Hospital included as the only teaching hospital in the State). Systematic random sampling was used in the third stage to recruit participants from the selected facilities based on proportionate allocation of sample size to each facility. Study instruments: a pre-tested, semi-structured, interviewer-administered questionnaire adapted from a similar study [16] was used to collect information on participants´ socio-demographic characteristics, treatment history (when treatment commenced, type of HAART regimen), adherence profile and attitude to HAART. Quantitative survey: collected data uploaded to a secure server were exported in Microsoft Excel XLS format, cleaned in Excel spreadsheet and analysed with SPSS version 23. Frequencies, percentages, mean and standard deviations were used as appropriate in descriptive statistics. Adherence to HAART in the seven days preceding the interview was measured by self-report. The questions were adapted from brief medication questionnaire self-report tool for screening adherence and barriers to adherence [16]. The degree of adherence from patient self-report was estimated using the following formula [22]. For the purpose of the study, adherence score of 95% and above represented good adherence while scores of less than 95% were rated as poor adherence. At bivariate analysis, association between HAART adherence and independent variables such as socio-demographic and treatment characteristics were determined using Chi-square tests with corresponding p-values. Variables that had a p-value of ≤ 0.2 at bivariate analysis were entered into the logistic regression model to determine the predictors of HAART adherence. The results of the logistic regression were reported using odds ratios and 95% confidence intervals. All statistical analyses were performed at 5% level of significance. Ethical considerations: ethical approval for this study was obtained from the Health Research Ethics Committees of University of Calabar Teaching Hospital (reference: UCTH/HREC/33/519) and the State Ministry of Health (reference: RP/REC/2016/422). Written informed consents were obtained from the participants after the details of the study and its voluntariness was explained to them. Safety and confidentiality of collected data was ensured throughout the study.

Materials

N/A

Innovations

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide pregnant women with information on antenatal care, nutrition, and medication reminders. These apps can also offer access to telemedicine services for remote consultations with healthcare providers.

2. Community Health Workers: Train and deploy community health workers to provide education and support to pregnant women in rural areas. These workers can conduct home visits, provide antenatal care, and assist with referrals to healthcare facilities.

3. Telemedicine Services: Establish telemedicine services to enable pregnant women in remote areas to consult with healthcare providers through video calls. This can help overcome geographical barriers and provide timely access to medical advice.

4. Maternal Health Vouchers: Implement a voucher system that provides pregnant women with subsidized or free access to antenatal care, delivery services, and postnatal care. This can help reduce financial barriers and increase utilization of maternal health services.

5. Transportation Support: Develop transportation initiatives, such as providing free or subsidized transportation for pregnant women to healthcare facilities. This can address the challenge of distance and lack of transportation options in rural areas.

6. Maternal Health Hotlines: Establish toll-free hotlines staffed by trained healthcare professionals who can provide information, counseling, and referrals to pregnant women. This can ensure that women have access to accurate and timely support throughout their pregnancy.

7. Maternal Health Education Campaigns: Conduct targeted education campaigns to raise awareness about the importance of antenatal care, safe delivery practices, and postnatal care. These campaigns can be delivered through various channels, including radio, television, and community outreach programs.

8. Integration of Maternal Health Services: Integrate maternal health services with other healthcare programs, such as HIV/AIDS treatment and prevention programs. This can improve access to comprehensive care for pregnant women who may have multiple healthcare needs.

9. Strengthening Health Systems: Invest in strengthening healthcare infrastructure, training healthcare providers, and ensuring the availability of essential medicines and equipment for maternal health services. This can improve the quality and accessibility of care for pregnant women.

10. Public-Private Partnerships: Foster collaborations between the public and private sectors to expand access to maternal health services. This can involve leveraging private healthcare facilities and resources to complement the capacity of public healthcare systems.

It is important to note that the specific context and needs of the target population should be considered when implementing these innovations.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health is to implement targeted counseling programs to improve adherence to antiretroviral therapy (ART) among HIV-infected pregnant women. This recommendation is based on the findings of the study, which identified factors influencing adherence to ART among HIV-infected adults in Cross River State, Nigeria.

The study found that adherence to ART among clients was fair, with the self-reported adherence rate at 60.1%. The common reasons for non-adherence included clients traveling out of home, being busy, forgetting, and lack of food. The study also identified predictors of both good adherence and poor adherence. Being on first-line drugs was a significant predictor of good adherence, while alcohol intake, dosing medications, CD4 cell count ≥ 500, poor attitude to HIV status and medication, and lack of family support were predictors of poor adherence.

To improve access to maternal health, it is important to ensure that pregnant women living with HIV have optimal adherence to ART. Targeted counseling programs can be developed to address the specific reasons for non-adherence identified in the study, such as providing support for clients who need to travel or are busy, implementing reminder systems to help clients remember to take their medication, and addressing issues related to food insecurity. These counseling programs should also address the predictors of poor adherence, such as alcohol intake, dosing medications, and lack of family support, by providing education and support to help clients overcome these barriers.

By implementing targeted counseling programs to improve adherence to ART among HIV-infected pregnant women, access to maternal health can be improved by ensuring that these women receive the necessary treatment and support to prevent mother-to-child transmission of HIV and promote the health and well-being of both the mother and the child.

AI Innovations Methodology

To improve access to maternal health, here are some potential recommendations:

1. Mobile clinics: Implementing mobile clinics that travel to remote areas can provide essential maternal health services to women who have limited access to healthcare facilities.

2. Telemedicine: Utilizing telemedicine technology can enable pregnant women to receive prenatal care and consultations remotely, reducing the need for them to travel long distances to healthcare facilities.

3. Community health workers: Training and deploying community health workers can help bridge the gap between healthcare facilities and communities, providing education, prenatal care, and referrals for pregnant women.

4. Transportation support: Providing transportation support, such as vouchers or subsidies, can help pregnant women overcome transportation barriers and ensure they can access healthcare facilities when needed.

5. Maternal waiting homes: Establishing maternal waiting homes near healthcare facilities can accommodate pregnant women who live far away, allowing them to stay closer to the facility as they approach their due dates.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population that will benefit from the recommendations, such as pregnant women in rural areas.

2. Collect baseline data: Gather information on the current access to maternal health services, including the number of women receiving care, distance to healthcare facilities, and any existing barriers.

3. Develop a simulation model: Create a model that incorporates the recommendations and their potential impact on improving access. This could include factors such as the number of mobile clinics, the coverage area of telemedicine services, the number of community health workers, and the availability of transportation support.

4. Input data and parameters: Input the collected baseline data into the simulation model, along with parameters related to the recommendations, such as the number of mobile clinics or the coverage area of telemedicine services.

5. Run simulations: Run multiple simulations using different scenarios and assumptions to assess the potential impact of the recommendations on improving access to maternal health. This could include varying the number of mobile clinics, the coverage area of telemedicine services, or the level of transportation support.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This could include assessing changes in the number of women receiving care, reductions in travel distances, or improvements in overall access.

7. Refine and validate the model: Continuously refine and validate the simulation model based on real-world data and feedback from stakeholders to ensure its accuracy and reliability.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different recommendations on improving access to maternal health and make informed decisions on which interventions to prioritize and implement.

Author

Dima Health

Identifiers:

DOI: 10.11604/pamj.2022.43.187.37172

Research Areas:

Community Interventions, Disability, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Substance Abuse

Study Countries:

Cameroon, Multi-Countries, Nigeria

Study Design:

Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female