FACTORS INFLUENCING NON-ADHERENCE TO HAART AMONG HIV PATIENTS RECEIVING ANTIRETROVIRAL THERAPY IN THE CENTRAL HOSPITAL YAOUNDE

Abstract

Antiretroviral therapy (ART) adherence of at least 95% has been proven necessary in order for treatment to be effective. Failure to meet this level results in poor immunological and virological outcomes.

The general objective of the study was to assess factors influencing non-adherence to HAART among HIV patients receiving ART in central Hospital Yaounde. The specific objectives were; To assess patient perceptions towards adherence to HAART among HIV patients,to assess the socio-cultural factors which affect adherence to HAART in the central hospital Yaounde and to assess how accessibility to ARV influence adherence to HAART among HIV patients receiving HAART in the central hospital Yaounde.

A cross-sectional study was carried out at the Central Hospital Yaounde from March to July2021.  Patients receiving ART and meeting the inclusion criteria were selected using a convenient sampling technique. Data was  collected with the use of structured questionnaire with opened and closed ended questions where an approximate of 385 participants were selected using the Cochran’s formula.

Data was analyzed using Microsoft 2013. Data was presented using charts and frequency tables. Level of adherence was sub-optimal (less than 95%). Stigma, negative perception, lack of family and community support are some obstacles to ART adherence. Long travel and distance to hospital for ART and poor weather are barriers to accessibility of ART during such rainy seasons hence a major hindrance to optimal adherence.

This study is set to be useful to other scholars doing studies in this area and for planning interventions and effective strategies for maximizing long-term adherence to ART for successful treatment of HIV patients. It will also let the investigator to uncover barriers, identify strategies and set behavioral goals to improve adherence to HAART among HIV/AIDS patients in Central hospital Yaounde.

CHAPTER ONE

INTRODUCTION

1.1 Background Of The Study

The world at large is facing an unrivalled public health crisis as HIV/AIDS are reported to have reached every corner of the globe and continues to spread disproportionately fast in marginalized population in most countries (WHO, UNAIDS, & UNCEF 2009).

Since 1981 when the first cases of AIDS were reported, infection with HIV has grown to pandemic proportions, resulting in an estimated 65 million infections and over 25 million deaths globally.  In 2006 alone, an estimated 2.9 million persons died from AIDS, 4.3 million where newly infected with HIV and 39.5 million were living with HIV (UNAIDS, 2006).

The number of people living with HIV worldwide continued to grow to reach an estimated 35.3 million in 2012, which was more than 20% higher than the number in 2000. Despite the prevalence, however, there was a decrease of 33% in the incidence lowered from 3.4 million in 2001 to 2.3 million in 2012; similarly, the number of deaths by AIDS declined from 2.3 million in 2005 to 1.6 million in 2012. From a geographical point of view, the HIV/AIDS pandemic in the various continents and countries as well appears to have developed in different ways (Arbona and Loytonen 1997; loytonen 2003, wood 1988).

During the first decade of the pandemic,it was common to characterize the HIV/AIDS pandemic in terms of the geographical patterns of HIV transmission : pattern I, where AIDS had been recognized since late 1970s,with low seroprevalence in general population and homosexual and bisexual intercourse the predominant forms of transmission,was recognized principally in industrialized nations, including the united states and western Europe; Pattern II, where HIV was present since mid-1970s, and transmission occurred among large risk groups, with prevalence in general population over 1% and heterosexual transmission as the major mode of transmission, which was recognized mainly in Sub-saharan Africa and Haiti ; and pattern III, were HIV infection was introduced in early 1980s, with prevalence levels insignificant and homosexual and heterosexual transmissions just being documented and blood transfusion from imported products as the main source of known transmissions, which was principally recognized in middle East and Asia (Von reyn and Mann, 1987).

The HIV pandemic is one of the most serious health crisis the world faces today. Globally there was an estimated 33 million people living with HIV by the end of 2007 and more than 25 million people since 1901 have died from AIDS. In 2007, there were 2.7 million new infections and 2 million HIV-related deaths (WHO, 2013). The Sub-Saharan African region is by far the most affected in the world by the epidemic. The region has just over 10%  of the world’s population but it is home to 67% of all people living with HIV and 75% of AIDS deaths in 2012.

Through combined efforts of affected countries and international partners, there is substantial ongoing progress towards providing HIV interventions in low and middle countries (WHO, 2010). In 2012, due to concerns of limited access to ART, the WHO « 3by 5 » initiative was launched as a strategy for answering that 3 million people living with HIV/AIDS in low and middle income countries have access to the treatment by the end of 2015 which meant meeting 50% of the estimated need. Although the WHO target of providing access to ART for 3 million people by 2015 was not achieved by the end of June 2015, an estimated 1 million people in low and middle-income countries had access to ART (WHO, 2015).

The geographical patterns and spatial diffusion characteristics of the HIV/AIDS pandemics have been of interest in the investigation of the factors influencing the heterogeneity of the pandemic. Different perspective levels have suggested variation in the factors influencing the patterns, right from the global to the local areas.

The great disparity between the industrialized and developing regions suggested the role of existing differences in medical care, where lack of early diagnoses in sexually transmitted infections (STIs) in the developing countries may have caused the high rise in number of reported AIDS cases (USAID, 2007). Of great importance is the state of the pandemic in Sub-Saharan Africa, where almost two-thirds (64percent) of the estimated HIV/AIDS population lives.

The HIV prevalence varies considerably across the region, with the driving forces of the epidemic being varied and diverse. The heterogeneity in HIV patterns has been thought to be a product of local social and economic determinants. Among the factors are human migration patterns, relative gender distribution in the communities, culture, poverty, war and religion. Other factors are biological and sexual behaviour that directly affect the risk of infection, and include various sub-types of the virus, stage of infection and presence of STIs. (USAID, 2007). Three major issues dominate: different strains of HIV, the biological disposition of men and women and sexually transmitted infections. Different sub-types of the virus have significant implications for the transmission of HIV and progression to AIDS.

The dominance of HIV-1 type of virus in East and South Africa compared to HIV-2 commonly found in West Africa, explains why there is a major difference in the epidemic patterns between the two regions. West African countries have always had a lower number of HIV/AIDS cases compared to East and Southern Africa (UNAIDS, 2004). The introduction of highly active antiretroviral therapy (HAART) in 1996 was a turning point for hundreds of thousands of people who had access to the treatment (MOHSS, 2007). Although HAART cannot cure the disease, it has dramatically reduced mortality, and prolonged lives and improved the quality of life of many living with HIV/AIDS. HIV has transformed from a rapidly progressive and universal fatal desease to a chronic and often stable condition (Arnsten et al. 2007 ; Mills et al. 2006).

As large scale programmes to provide antiretroviral treatment (ART) for HIV/AIDS have expanded and matured in Sub-saharan Africa, attention has shifted from a single minded focus on treatement access and initiation to a broader set of long-term challenges in sustaining a vast and complicated public health endeavour. One of these concerns is the retention of patients in care.

ART is a life-long commitment that requires patients to adhere diligently to daily medication dosing schedules and more frequent clinic visits for care. Consistent with experiences in treating chronic diseases globally, a systematic review of patients who initiated ART across Sub-saharan Africa found that approximately 25% were no longer in care one year after initiation, a figure rising to 40% after 2 years.

Among the group of patients, a minority died, while the majority was classified as « lost to follow up » (ROSA et al. 2007). Patients who discontinue treatment are at high risk of illness and death because of AIDS related conditions such as tuberculosis. Defaulting diminishes the immunological benefit of ART and increases AIDS-related morbidity, mortality and hospitalisations (Hogg et al. 2015).

Consequently, many studies have attempted to quantify and ascertain the status of patients reported as lost to follow-up (Macpheson et al. 2009, Dahab et al. 2017, Maskew et al. 2015). In resource-constrained settings where the health care services are not well develped, poor adherence to treatment and defaulting from treament are the two major challenges that ART programs face (Hogg et. 2015).

Cameroon has an estimated 504,472 people living with HIV (Spectrum, 2019). Prevalence among women is nearly twice that of men with the prevalence highest among women between 35-39years of age (6.5%) and 40-44years of age (6.4) and close to 5% among women aged 45-49 and 50-64years.For men, HIV prevalence is highest in the age group 40-44. Adolescent girls and young women are equally affected compared to their male counterparts in the 15-19 age group. HIV prevalence remains high among key populations (KP) at 24.3% for female sex workers and 20.7% for men who have sex with men (IBBS, 2016). From DHS 2018, HIV prevalence is higher in urban areas compared to rural areas.

As of December 2019, 312.214 people living with HIV (PLHIV) were on treatment representing 62% coverage nationally. The development and widespread use of antiretroviral therapy (ART) as the treatment of choice in HIV has improved significantly the conditions of HIV positive individuals who could have untimely death.The ART however, has transformed the perception of HIV/AIDS from a fatal incurable disease to a manageable chronic illness (Deeks et al. 2013). The treatment causes improvement in immunologic status and reduction in the viral load (Erb et al. 2000) which consequently reduces the incidence of hospitalisation and mortality (Pater et al. 2000).

However incomplete medication adherence is the most important factor in treatment failure and the development of resistance. Antiretroviral treatment success depends on sustainable high rates of adherence to the medication regimen of ART (Mills et al.2015).On the other hand, ART regimens are habitually complicated with variable dosage schedules, dietary requirements and adverse effects (Ferguson et al. 2017).

1.2 Problem Statement

Highly active antiretroviral therapy (HAART) has significantly improve the lives of many HIV patients world wide. To archieve effective treatment and realize the benefits of treatment, strict adherence to treatment instructions are very critical due to the fact that the human immuno-deficiency virus poses a unique challenge due to its rapid replication and mutations rates hence very high levels of adherence are required to achieve long term suppression of viral load.

The failure to adhere to HAART often leads to treatment failure and to the likelihood of accelerating the emergence of drug-resistant strains of HIV. Despite health education provided to patients on the consequences of non-adherence to medication such as; inadequate suppression of viral load replication, continued distruction of CD4 cells, progressive decline in immune function and disease progression. It has been noted that many patients receiving ARV in central hospital Yaounde still miss their appointments, some have become lost to follow-up,others are taking ARV but the viral load remain high as 2million copies/ml and these patients are traced to be defaulters.

A significant proportion of all hospital admissions and mortality are due to drug non-adherence and there has been a number of patients with HIV related complications admitted at the central hospital Yaounde.Therefore this study aimed at determining all the possible factors that influence non-adherence to HAART among people living with HIV/AIDS despite health and Psychosocial Counselling Provided.

1.3 Research Objective

1.3.1 Main Objective

To assess factors influencing non-adherence to HAART among HIV patients receiving antiretroviral therapy in the central hospital Yaounde.

1.3.2 Specific Objectives

1. To assess patient perceptions towards adherence to HAART among HIV patients.
2. To assess the socio-cultural factors which affect adherence to HAART in the central hospital Yaounde.
3. To assess how accessibility to ARV influences adherence to HAART among HIV patients receiving HAART in the central hospital Yaounde.