ABSTRACT
The surge in new cases of HIV infection has assumed significant global concern. The increase has resulted in high trends of patients on anti-retroviral treatment in hospitals, particularly in Sub-Sharan Africa including Ghana where more than 300,000 people are currently on ART. Even though targets, policies and efforts are being implemented to improve patients’ adherence and continuance stay in care, HIV incidence is increasing in Ghana, especially among youth.
This problem has been partly blamed on dearth of scholarly works on the issue, thus impeding effort towards the 90-90-90 targets. In order to contribute to policy and scholarly literature, this study explored facilitators and barriers to adherence and retention to ART among HIV patients at the Greater Accra Regional Hospital. This study was important because it provides adherence and retention policy recommendations to support Government and Internationals organisations such as UNAIDS. Anderson Model of Healthcare Utilisation was used to underpin the study.
Qualitative methods case study was employed.
The results show that, non-disclosure of status, socio-cultural relations, perceived improved medical condition, free medication, culture and religious orientation and support from health facility facilitate adherence to ART and retention in care. The study also found Model of Hopes play significant role as counselors, educators and hope models that visit patients at home, talk to them and encourage them to adhere. This has led to an improvement in adherence to ART among clients. The study also found that, older women who are not working adhere to treatment more than both working and non-working men. The study also noticed that, there is a gradual re- orientation where patients are not resorting to religious prayers, and spiritual assistance at the expense of ART. Financial, economic, stigma and religious related issues are barriers to adherence and retention among HIV patients.
CHAPTER ONE INTRODUCTION
- Background to the Study
In the last decades, scholars, policy makers and health practitioners have debated the causes, effects and solutions to the prevalence of Human Immune Virus (HIV) infection menace and its opportunistic deaths and ailment. Report from United Nations AIDS gap indicates that, over 35 million people around the world may be living with HIV/AIDS and out of this, about 19 million do not know if they have the disease (UNAIDS, 2014). The gap report further states that, just 10 nations in sub-Saharan African (SSA) contribute 56% of the total number of people with the virus. The Ghana AIDS Commission, (2013), report that, as at 2013, 260,000 Ghanaian were living with Human Immune Virus.
The surge in global HIV/AIDS statistics leaves many scholars and practitioners wondering how the spread can be controlled and contained at the patient level. Kranser et al. (2011) explain that, an improvement in HIV care management strategies is crucial to ensure patients retention and adherence to Antiretroviral Therapy for people living with the disease (Kranser, et al., 2011).
Antiretroviral Therapy reduces overall infection, incidence, and related deaths and improves quality of life patients living with the virus. For decades, issues of retention and adherence to ART, even though have barriers to full compliance, have featured significantly in HIV patient care management efficiency architecture and studies. Adherence and retention in HIV care is described as a continuous engagement with medical care at a healthcare facility after initial entry
into the system. It is the ability of the patient to fulfill at least two clinic visits during a calendar year spaced at least 2-6 months. (Bezabhe, Chalmers, Bereznicki…Kassie et al., 2014).
In Sub-Saharan Africa about 8 million HIV positive patients were on ART between 2004 and 2011 (Kranser et al., 2011). Jahn et al. (2008) noted that, access to ART has contributed to a reduction in HIV-associated morbidity and mortality in Sub-Saharan region. In Ghana also, some significant level of successes has been recorded with regards to ART coverage of 54% (Unit, 2001). In 2016, Ghana adopted the 2020 UNAIDS/WHO 90-90-90 target in a bid to end HIV epidemic by 2030. World Health Organisation (2017) explains that, Retention in HIV care and Adherence to ART, though are different, share similar barriers and facilitators (WHO, 2017).
Ghana Demographic and Health Service (GDHS 2014) reports that, “Ghana is classified as having a generalized HIV epidemic where HIV prevalence in the country has remained on average around 2% in adults 15-49 years”. With Antiretroviral therapy coverage for Ghana standing at 54% (Unit, 2001), the researcher believes that, the barriers and facilitators to Retention in HIV care and Adherence to ART must be identified in order to help scale up the number of HIV positive persons retained in care and adhere to antiretroviral therapy.
Emerging literature indicates that, negative stigma, depression, lack of awareness of importance of care, depression, location and poor access to transportation are likely to hinder the retention to HIV care and adherence to ART (Abdulai, 2016). On the other hand, issues such as friendly client-provider relationship and reminders of clinic days have also been identified as factors that facilitate retention in HIV care and adherence to ART. Other emerging studies have begun to analyse these barriers and facilitators from patients and environmental perspective, thus creating wider avenue for more investigation (Abuogi et al,2016)..
Adherence to a medication is a dynamic behaviour influenced by many factors. Studies in resource-limited settings show that “major facilitators of ART adherence encompass social support, positive treatment outcomes, and life-long projects. Factors such as access to health facilities, transport costs, and fear of stigma and discrimination are recognized barriers to adherence with ART” (Bezabhe. et al., 2014). This study seeks to explore from the perspective of HIV patients, the barriers to Retention in HIV care as well as Adherence to ART. The studies seeks to provide innovative HIV care management solutions to minimize the risk of opportunistic infection, reduces the risk of HIV transmission and reduce HIV-associated morbidity and mortality in Ghana.
Problem Statement
The World Health Organization has described HIV patient retention in care as an important indicator for efficiency of any HIV management program. Despite the effort of global health organisations to improve patient retention in care, the trend and statistics in Sub-Saharan Africa is falling. The Globally average retention rate at 12 months after initiation of ART is 81%. A meta-analysis showed that in Sub-Saharan Africa, the retention rate after 12 months of starting ART was 77% below the global threshold. A study done by Korle (2016) discovered that the retention rate in HIV care at the International health Care Centre in Accra, Ghana is 55% which is also below the global and African levels. It has been 2 years since Ghana adopted the 2020 UNADS/WHO 90-90-90 targets.
However, the country is performing at 57%, 39% and 64% with regards to the first, second and third 90 respectively compared to the worldwide performance of 75%, 79% and 81% respectively (UNAIDS,2017). Suboptimal adherence and retention in care can lead to viral
resistance to first line ART. This poses a risk in countries where there may be limited supply of second and third line antiretroviral drugs. This may result in poor viral suppression which increases the risk of HIV transmission, increases the risk of opportunistic infection and decreases the survival rate of persons living with HIV (WHO, 2017). This subsequently derails the national as well as global efforts at achieving the 909090 targets by 2020 (UNAIDS 2017).
Even though studies have examined the barriers to retention and adherence to HIV care ART (Bezabhe et al., 2014 ; Abuogi et al., 2016; Asmare et al., 2014), the researcher has identified very few studies in Ghana that has explored barriers and facilitators of adherence to ART and retention to HIV care. For instance, studies done in Europe, USA and other African countries such as Ethiopia reports various barriers such as Financial constraints, distance to ART clinics, patient load, patients’ beliefs, and alcohol and drug use as barriers to retention. However, there is dearth of studies on retention in HIV care and adherence to ART in Ghana. This study therefore aims to determine the barriers and facilitators of adherence and retention to ART.
“Previous studies mainly focused on exploring factors influencing patient retention at the healthcare level and were limited in their ability to identify barriers to, and facilitators of medication adherence at the individual patient level” (Bezabhe et al., 2014). This limited the understanding of the barriers and facilitators of adherence and retention to HIV care from the perspective of the patients. Therefore, this study focuses of HIV clients of the GARH who are accessing ART from the hospital.
