TABLE OF CONTENT
ABSTRACT…………………………………………………………………………………………………………………. i
CERTIFICATION………………………………………………………………………………………………………. iii
ACKNOWLEDGEMENT……………………………………………………………………………………………. iv
DEDICATION…………………………………………………………………………………………………………… vi
LIST OF TABLES……………………………………………………………………………………………………….. x
ABBREVIATIONS…………………………………………………………………………………………………….. xi
CHAPTER ONE
INTRODUCTION……………………………………………………………………………………………………….. 1
- Background……………………………………………………………………………………………………………. 1
CHAPTER TWO
LITERATURE REVIEW……………………………………………………………………………………………… 6
CHAPTER THREE
METHODOLOGY…………………………………………………………………………………………………….. 19
- Study Area……………………………………………………………………………………………………………. 19
CHAPTER FOUR……………………………………………………………………………………………………… 27
RESULTS…………………………………………………………………………………………………………………. 27
- Demographic characteristics of Respondents…………………………………………………………….. 27
A) STRATIFIED ANALYSIS…………………………………………………………………………………….. 44
- : Stratification by Social Class…………………………………………………………………….. 44
DISCUSSION, CONCLUSION AND RECOMMENDATION……………………………………… 56
REFERENCES………………………………………………………………………………………………………….. 69
APPENDIX I: Evaluation of Self Reported Adherence………………………………………………….. 83
APPENDIX II: Medical Outcomes Study: Social Support Survey Instrument…………………… 84
APPENDIX III: Factors Influencing Adherence……………………………………………………………. 86
APPENDIX IV: Ethical Clearance Certificate……………………………………………………………….. 93
LIST OF TABLES
Table Title Page
Table 1: Demographic characteristics of Respondents in UPTH, 2016………………………………….. 28
Table 2: Socio-economic characteristics of respondents in UPTH, 2016……………………………….. 30
Table 3: Rate of Adherence to ART medication among HIV patients in UPTH, 2016……………. 32
Table 4: Differences in CD4 cell count among HIV patients in UPTH, 2016………………………… 34
Table 5: Reasons given by respondents for missing ART medication……………………………………. 36
Table 6: Disclosure of HIV Status and Membership of Support Groups among HIV patients in UPTH, Port Harcourt, 2016…………………………………………………………………………………………….. 38
Table 7: Mean scores of dimensions of MOSSS Social support scale among HIV Patients in
UPTH, 2016………………………………………………………………………………………………………………….. 40
Table 8: Relationship between social support and adherence to ART……………………………………. 42
Table 9: Relationship between dimensions of social support and adherence to ART………………. 43
Table 10: Adherence and Social support among HIV Patients in UPTH, 2016; stratified by Social class……………………………………………………………………………………………………………………………..
45
Table 11: Knowledge of HIV and ART among HIV Patients in UPTH, 2016………………………. 47
Table 12: Relationship between Adherence and Disclosure of HIV status, and satisfaction with support received by respondents in UPTH, 2016……………………………………………………………….. 49
Table 13: Use of Alcohol and Substance among study respondents……………………………………… 51
Table 14: Satisfaction of HIV patients with health care providers and services at the treatment centre in UPTH, 2016 …………………………………………………………………………………………………….
53
Table 15: Unconditional Stepwise Forward Logistic Regression for factors associated with non- adherence to ART………………………………………………………………………………………………………….. 55
ABBREVIATIONS
| AIDS | – | Acquired Immune Deficiency Syndrome |
| ART | – | Anti Retroviral Therapy |
| ARV | – | Anti Retroviral |
| APHA | – | American Public Health Association |
| GFATM | – | Global Fund to fight AIDS, TB and Malaria |
| HAART | – | Highly Active Anti-Retroviral Therapy |
| HIV | – | Human Immunodeficiency Virus |
| MEMS | – | Medication Event Monitoring System |
| NACA | – | National Agency for the Control of AIDS |
| NARHS | – | National AIDS and Reproductive Health Survey |
| PEPFAR | – | US President‟s Emergency Fund for AIDS Relief |
| PLWHA | – | People Living with HIV/AIDS |
| PMTCT | – | Prevention of Mother to Child Transmission |
| SACA | – | State Agency for the Control of AIDS |
| SASCP | – | State AIDS and STI Control Program |
| SES | – | Socio-Economic Status |
| UNAIDS | – | Joint United Nations Programme on HIV/AIDS |
| WHO | – | World Health Organisation |
CHAPTER ONE INTRODUCTION
Background
HIV/AIDS is a chronic and debilitating disease of global public health concern.(UNAIDS, 2013) The disease has been declared a global public health emergency by the World Health Organization. Thirty-four years after its first appearance, HIV still remains one of the most challenging pandemic and the greatest health crisis currently facing the world. The pandemic has caused millions of deaths worldwide and has crippled the lives of many more. Since the start of the epidemic, about 75 million people have become infected with the virus.(UNAIDS, 2012) In 2012 alone, there were 35.3 million people living with HIV and 1.7 million died from AIDS related causes worldwide.(UNAIDS, 2013)
Sub-Saharan Africa remains the worst affected region of the world, accounting for two-thirds of the global burden of disease. Current statistics put the numbers of people infected by the virus in Sub-Saharan Africa at 25 million adults and children, accounting for nearly 70% of the global total. There are an estimated 1.6 million new HIV infections and 1.2 million AIDS-related deaths in the region (Averting HIV and AIDS (AVERT), 2012). Nigeria bears the brunt of this epidemic with an estimated 3.2 million people living with HIV (NACA, 2011). The country ranks as one of the countries with the highest burden of HIV in the world, next only to South Africa. According to the National Agency for the Control of AIDS (NACA), the number of persons requiring Anti-Retroviral Therapy (ART) stands at 1,476,741 in 2013, and only 43% (639,397) are currently receiving treatment. (NACA, 2014) Statistically, the south-south zone currently has the highest rate of HIV infection at 5.5%. Rivers state with a sero prevalence of 15.2% has the highest prevalence in the country.(Federal Ministry of Health, 2014)
The world has not been resting on its oars however, as intense efforts are being made globally to control the spread of this infection. These efforts have recorded giant strides in the industrialized nations of the world, drastically reducing HIV disease burden and longer life spans for those infected with the disease. This has been largely possible through the introduction of the Highly Active Anti-Retroviral Therapy (HAART) which has turned what was once a death sentence to nothing more than a chronic illness.(American Public Health Association (APHA), 2004)
Remarkable progress has also been made in reversing the trend of HIV/AIDS epidemic in Nigeria, in the last decade. The National AIDS and Reproductive Health Survey (NARHS) conducted in 2013 showed a national HIV prevalence of 3.4% down from a peak of 5.8% in 2001(Federal Ministry of Health, 2012). This achievement has been largely attributed to the Behaviour Change Programs, HIV care and support programs, Prevention of Mother to Child Transmission (PMTCT) and the use of Highly Active Anti-Retroviral Therapy (HAART), (NACA, 2011). The main aim of treatment with HAART is to achieve a reduction in viral load to undetectable levels. This allows immune reconstitution and leads to marked clinical improvement. Treatment with HAART has also been proven to prevent episodes of opportunistic infections.(United States Department of Health and Human Services, 2002) Adherence to HAART is crucial to achieving treatment goals of undetectable viral load, increasing CD4 cell counts and improvement in the clinical condition of people living with HIV-AIDS. However, drugs do not work in non-compliant patients and in the management of HIV/AIDS, optimum adherence to HAART is critical to the successful outcome of treatment (Shah, 2007)(Giri et al., 2013). The reported adherence rates to ART medication among people living with HIV (PLHIV) in Nigeria vary from 44% (Afolabi et al., 2009) to 98% (Onyeonoro et al., 2013). Factors shown to be associated with good adherence include text message as reminders (Maduka and Tobin- West, 2013), patient selected treatment partners, (Taiwo et al., 2010) use of pill box, (Ukwe et al., 2010) age and gender (Olisah et al., 2010). On the other hand, psychiatric morbidity negatively had adverse impacts on adherence (Salami et al., 2010).
Social support is a significant resource for individuals and family members encountering stress and is seen as one of the keys to well-being of individuals, especially for those experiencing major life transitions and crises (Caplan, 1974). Assessment of social support among PLWHA, should include (a) the kinds of support available, such as emotional support, information, financial aid; and (b) the sources of support, such as family, friends and peers. There is paucity of literature in our environment on the influence of social support on ART adherence. A literature search done on the subject using e-databases such as Medline, Pubmed, HINARI and AJOL as well as a search of local libraries yielded only five published studies done in Sub Saharan Africa that addressed the importance of social support to improve adherence, and none of these studies examined social support using these dimensions. In view of the foregoing, this
study intends to investigate the relationship between social support and ART Adherence among PLWHIV using the two key dimensions of social support.
Problem Statement
Where there is access to HAART, the problem becomes that of adherence to the treatment regimen. Indeed adherence is one of the key factors that determines the success or failure of HAART. However studies done in Nigeria have shown that about 21.7% (Igwegbe and Ugboaja, 2010) to 37.1% (Olowookere et al., 2008) of Nigerian patients on HAART are not adherent to their medication. If adherence of 95% and above is not achieved, treatment failure is most likely to occur. Thus, non-adherence to HAART is a major cause of HIV drug resistance and subsequent immunological and clinical failure (Machtinger, 2005). Globally, the world is witnessing a gradual increase in drug resistance to the anti-retroviral drugs. In North America, the overall prevalence of high-level resistance to 1 or more drugs increased from 3.4% to 12.4% within a 5 year period (Grant, 2002) with significant increases seen within each class of antiretroviral medication. The prevalence of resistance to drugs from 2 or more classes also increased from the earlier period to the later period, from 1.1% to 6.2%. Evidence is accumulating of a rising prevalence of transmitted HIV drug resistance (TDR), predominantly associated with non-nucleoside reverse transcriptase inhibitors (NNRTIs), in east and southern Africa (Hamers et al., 2013). A cross-sectional study of HIV drug resistance in adults with HIV-
1 in Kenya, Nigeria, South Africa, Uganda, Zambia, and Zimbabwe revealed a drug-resistance prevalence of 5.6%, ranging from 1.1% South Africa, to 12.3% in Uganda (Hamers et al., 2011).
HIV/AIDS patients had repeatedly shared that they did not want to take their tablets in front of anyone including family members because of fear of stigmatization. This indicates that socio- cultural barriers may affect ART adherence (Afolabi et al., 2013). Much research has been done in the area of adherence to antiretroviral treatment and on interventions to improve adherence, however these have mostly been in the developed world, and had mainly focused on behavioural and cognitive interventions such as adherence counseling and different forms of reminders. There is not enough evidence for the wide spread implementation of interventions focused on improving patients‟ social support, largely due to insufficient knowledge of the impact of social support on adherence. Determination of the relationship between social support and adherence to
HAART is therefore of paramount importance if the gains of HAART are to be experienced and sustained both at an individual and national level.
Justification
Of all the factors thought to influence treatment failure, patient adherence to medication is the most important and most modifiable.(American Public Health Association (APHA), 2004) With the appreciable rise in drug resistance due to non-adherence, it is important to improve and maintain adherence to HAART among people living with HIV and AIDS. It is therefore necessary to reduce the rate of non-adherence among HIV patients. It is known that several sociological and psychological factors influence adherence of patients to treatment. Again, it is common knowledge that multi-faceted interventions, including social support are needed for good chronic disease care outcomes, however, research on ART adherence has tended to focus on micro factors limited to experimental control such as educational strategies, scheduling accommodations to the regimen, and various forms of reminders, which achieve only modest results. Adequate attention has not been paid to research required to understand how social factors influence adherence. Although multiple studies have confirmed the positive association between social support and adherence to medication regimens across different chronic illnesses (Becker and Maiman, 1980; Caplan et al., 1980), and on adherence to ART (Remien et al., 2003), these have been limited to the developed world and there‟s paucity of literature in our environment on studies assessing the effect of social support and adherence to ART.
Again, to successfully address the problem of adherence, it is crucial to measure it, and identify its determinants and influencing factors. Identifying factors that determine adherence will help to tailor interventions to address it. This underscores the need to conduct a thorough assessment of the patient specific factors, medication specific and health facility specific factors that influence adherence, develop and maintain a therapeutic alliance between the patient and his/her health care providers, and implement multiple interventions to address barriers to adherence.(APHA, 2004) This is of paramount importance if the gains of HAART are to be experienced and sustained both at an individual and a national level. The findings of this study could also prove useful to policy makers, program planners and antiretroviral service providers in the state and country for implementing large scale adherence interventions.
Research Questions
- What is the rate of adherence among HIV patients on ART in Rivers State
- What is the level of social support provided to patients on ART medication in Rivers State
- Is there any association between patients‟ social support and non-adherence to ART
- What factors determine non-adherence to ART among HIV patients on ART in Rivers State.
Aim and Objectives
General Objective
To determine association between social support and non-adherence to Anti-Retroviral Therapy among HIV patients in Rivers state
Specific Objectives
- To determine the rate of adherence to anti-retroviral therapy among HIV patients on ART in Rivers State.
- To measure the level of social support received by patients on ART in Rivers State
- To determine the association between social support and non-adherence to ART among HIV patients in Rivers State.
- To identify patient specific, medication specific and health facility specific factors associated with non-adherence to ART among HIV patients in Rivers State
Hypothesis
Ho: There is no significant association between social support and non-adherence to ART among HIV patients on ART in Rivers State
H1: There is a significant association between social support and non-adherence to ART among HIV patients on ART in Rivers State
