The factors influencing non-adherence to HAART among HIV patients receiving antiretroviral therapy in the CMA MUEA

CHAPTER ONE

1.1 INTRODUCTION

 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 millions were living with HIV (UNAIDS, 2006). The number of people living with HIV world wide continued to grow reaching 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 that lowered from 3.4 million in 2001 to 2.3 million in 2012 ; similarly, the number of deaths by AIDS declining from 2.3 million in 2005 to 1.6 million in 2012. From the geographical point of view, the HIV/AIDS pandemic in the various continents and countries as well, appear 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 sero-prevalence 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 occured 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 tranfusion from imported products as the main source of known tranmissions, which was principally recognized in middle East and Asia (Von reyn and Mann, 1987).

1.2 BACKGROUND OF THE STUDY

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). Sub-Saharan Africa 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 « 3 by 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 has 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 African, where almost two-thirds (64percent) of the estimated HIV/AIDS population lives.The HIV prevalence varies considerably across the region, with driving forces of the epidemic being varied and diverse. The heterogeneity in the 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 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 treatement (MOHSS, 2007). Although HAART cannot cure the disease, it has dramatically reduced mortality, prolong lives and improve the quality of life of many living with HIV/AIDS. HIV has transformed from a rapidly progressive and universal fatal disease 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 treatment access and initiation to a broader set of long term challenges in sustaining a vast and complicated public health endeavor. One of these concerns 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 al, 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 developement 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 developement of resitance. Antiretroviral treatment success depends on sustainable high rates of adherence to 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). Most non-adherence is intentional with patients making a rational decision not to take their medicine based on their knowledge, experience and beliefs ( WHO, 2012). Patients maybe frightened of potential side effects as they might have witnessed side effects experienced by a friend or family member. Patients also fail to adhere to HAART as a result because they do not understand the need for it, mistrust for HAART and lack of symptoms.(WHO,2012). Most HIV patients are often faced with depression and worry and this may lead to non-adherence( Fid et al, 2004). Taking HIV medicines everyday prevents HIV from multiplying, which reduces the risk that HIV will mutate and produce drug resistant HIV (WHO, 2012). Skipping HIV medicines allows HIV to multiply, which increases the risk of drug resistance and HIV treatment failure. Poor adherence to an HIV treatment regimen allows HIV to destroy the immune system. A damaged immune system makes it hard for the body to fight off infections and certain cancers.

1.2 PROBLEM STATEMENT

Highly active antiretroviral therapy (HAART) has significantly improve the lives of many HIV patients world wide. (WHO, 2004). 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.(Paterson et al, 2000). 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 the Buea Regional Hospital 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 as per statistics from the Buea Regional hospital treatment center 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 CMA Muea. 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

MAIN OBJECTIVE

To assess factors influencing non-adherence to HAART among HIV patients receiving antiretroviral  therapy in the CMA MUEA

SPECIFIC OBJECTIVES

1. To assess patient perceptions towards adherence to ART among HIV patients.

2. To assess the socio-cutural factors which affect adherence to ART in the. CMA MUEA

3. To assess how accessiblity to ARV influence adherence to ART among HIV patients receiving ART in the CMA MUEA

1.4.2 MAIN RESEARCH QUESTION

What are the factors influencing non-adherence to ART among patients receiving antiretroviral therapy in the CMA MUEA

1.4.3 SPECIFIC RESEARCH QUESTIONS

• Does patients perception towards HAART hinders adherence to the ART regimen among HIV /AIDS patients.
• What are the socio-cutural factors that influence non-adherence to ART among HIV/AIDS patients ?
• How does accessibility to ARV influence non-adherence to ART regimen among HIV/AIDS patients ?

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