ADHERENCE WITH ANTIRETROVIRAL

THERAPY AND ASSOCIATED FACTORS

AMONG ADULT HIV PATIENTS IN ARBA
MINCH HOSPITAL, SOUTHERN ETHIOPIA
By:
Hayat

ADVISOR:
Mr. Nuredin Nassir (Ass. Prof.)
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 OUTLINE OF THE PRESENTATION

Background
Significance of the Study
Conceptual Framework
Objectives
Methods
Ethical Considerations
Expected Outcomes and Beneficiaries
Work Plan and Cost of The Project

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 INTRODUCTION
Background
 Acquired Immune-Deficiency Syndrome (AIDS) is unique in human
history in its rapid spread, extent and the depth of impact.

 The world has struggled to come to controls with its extraordinary

dimension since the diagnosis of first AIDS case in 1981. (UNAIDS,
2014)

 According to WHO estimation, globally in 2013;

 More than 35 million people living with HIV; among this, 3.2
million are under the age of 15

 In sub-Saharan countries more than two-thirds of (24.7 million)

PLWHA
(WHO, 2014) 3
 Cont…
 In 2013, the national adult HIV prevalence of Ethiopia was 1.3%
 Higher prevalence was reported among women [1.8%] than men
[0.9%]
 There were 34,365 HIV related mortalities occurred in the adult
population (WHO, 2014)

 To prevent HIV/AIDS, there are various interventions: condom

distribution, behavioural change programs, and blood supply safety;
correspondingly, to reduce deaths related with HIV, we use ART

 ART was first introduced in 1996; with the goals of achieving

maximal and durable reduction in plasma viral load and restoration of
immunological function (Palella J, 1998)

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 Statement of the Problem
 In Ethiopia, the National Antiretroviral Drugs Policy was developed
in 2002, and ART was first offered in 2003 (MOH, 2007)

 In 2014, over 350,000 PLWHA who are accessing ART program

(MOH, 2014)

 The provision of ART has transformed HIV infection into a chronic

manageable disease (Seema S et al., 2011)

 To manage chronic disease features like human power and economic

perspective, provision of health services and medication adherence
are the most important issues (Sharada PW et al., 2012)

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 Cont…
 As a result, adherence medication to be a major problem in chronic
medical condition. (Adegoke O et al., 2013)
 The challenge now is to encourage and empower patients to take the
medications correctly.
 Therefore, PLWHA requires long term treatment with adherence to
medication for the success of the therapy.
 Recently, significant proportions of HIV infected patients do not reach
high level of adherence (95%); so this can leads to devastating public
health problems in resource limited countries. (Ayalu AR et al., 2012)
 Patients admitted at Arba Minch Hospital (AMH) that are on ART
ward have history of sub-optimal adherence to treatment based on
monthly follow up reports.
 As such this has to be looked into to find out what are factors
associated with sub-optimal adherence.
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 Significance of the Study
 In order to achieve the success of therapy and realize the benefits of
ART, adherence is very critical for patients to strictly adhere to
treatment instructions.

 Patients admitted at AMH who are on ART ward have history of sub-
optimal adherence to treatment based on monthly follow up reports.

 The assessment of patients’ adherence to treatment with its associated

factors will be enable
 To identify major factors related with adherence
 For policy makers in southern part of the country
 To prevent treatment failure
 Supportive for program managers and decision makers working on
HIV/ADIS area for proper design and planning
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 Scope of the Study
 The proposed study will specifically focused on determining factors
of Adherence to ART at Arba Minch General Hospital, so the study
will be conducted in this hospital among adult ART drug users.

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 OBJECTIVES OF THE STUDY
General Objective

 To assess adherence with Antiretroviral Therapy and associated

factors among adult HIV/AIDS patients in Arba Minch Hospital,
Southern Ethiopia, 2015

Specific Objectives

1. To determine adherence to ART among adult HIV/AIDS patients.

2. To identify factors associated with adherence to ART among adult
HIV/AIDS patients.

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 METHODOLOGY
Study Area and Period
 Arba Minch Hospital, which is found in Arba Minch town, Gamo
Gofa Zone
 The town, 505 kms South of Addis Ababa, 275 kms SW of Hawassa.
 Total population projected on the year 2014 (103,355 )

 The hospital has been provides general health care service and higher
levels of clinical care for the catchment area
 Also, it has been providing ART for thousands of HIV patients since
1996

 In the Hospital, 1511 adult patients started ART treatment and on

follow up in 2014
 The study will conducted from March 5 to May 5, 2015
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 Cont…

Study Design A Hospital based cross sectional study

Source Population All adult HIV/AIDS patients who started

HAART and have follow up in the Hospital
All HIV/ADIS adult outpatients
Study Population systematically selected who receiving
HAART and on follow up at the study
setting.
All individual whose age ≥ 18 years and
Inclusion Criteria who have been on treatment for more than 3
month period
All HIV/AIDS patients who were pregnant,
Exclusion Criteria mental ill and missing clinical record.
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 Sample Size Determination
 To determine the sample size, it is calculated by using the 74%
proportion of adherence from recent study conducted in Wolaita
Soddo Hospital (Amsalu A et al., 2013).
 A precision of 5% and with 95% confidence level
 To obtain the largest possible sample size, by using the Single
Population Formula.
n = Z (α/2)2 P(1-P), n = 296
D2
 Where:
– n = sample size
– Z (α/2) = 1.96, which is the upper percentile of the standard normal distribution,
– P= ART adherence rate, which is assume to be 74% and
– D= difference from the actual figures of source population, which is take 5%.
 To compute for non-response rate, 10% of the total sample size [n =
296] and then the total sample size is to be 326. 12
 Sampling Procedures
 Systematic random sampling method will used to selected the
participant

 The individuals will be selected by using the interval: J, J+k, J+2K,

J+3K……J+ (n-1)K; Where:
 N (total number of study population) = 1511
 n (total number of sample size) = 326
 K (interval size) = N/n ≈5
 J (the first participant or starting point)

 The first participant will be selected by using lottery method and

every 5th patients were taken among daily appointees

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 Variables of the Study
 Response variable:
Patients related factors
Adherence to HAART
 Social support
 Adherence (Yes=1)
 Depression
 Non-adherence (No=0)
 Substance use
 Disclosed HIV status
 Explanatory variables:
 Using reminder aids
Socio-demographic
factors:
 ART benefit and adherence knowledge
 Sex
 Age Treatment and clinical factors:
 Residence  Duration of treatment
 Religion  Perceived medication side effect
 Educational level  CD4 count (initial and resent)
 Employment status  Other medications in addition to ARV
 Monthly income  ART schedule fitness to daily routines
 Marital status  Feeling comfort on taking ART drug in front
 Ethnic group of others
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 Data Collection Method and Procedure
 Data will be collected through using interviewer administered
questionnaire technique and patient clinical records

 Three data collectors who health professionals and one supervisor

will used

 Every three interval patients who came for ART service will be
interviewed; and at the same time their clinical records are reviewe.

 Patient clinical records will involve that: CD4 count, duration of

treatment, other medications in addition to ARV, and monthly
dispense schedule were reviewed and recorded.

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 Quality Control
 The investigator is offered one day training for all data collectors and
a supervisor

 The training is includes explanation of the study objectives,

techniques for interviewing, how to approach potential respondents
and how to keep confidentiality later

 Pre-testing will be imlement (5% of the sample size)

 The supervisor and principal investigator performed immediate

supervision on a daily basis

 Each and every completed questionnaire will checked for

completeness.

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 Data Processing and Analysis
 Epi-Info version 3.3.2 (entered and coded)

 Exported to SPSS version 20 (analysis)

 Descriptive statistics (frequencies, percentages), mean, and standard

deviations (for continuous variables)

 Bivariate analysis using logistic regression will used

 Variables at p-value <=0.25 are selected as candidates for

multivariable analysis.

 Multicollinearity between independent variables will checked.

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 Cont…

 Then multivariable analysis is done to determine presence of

independent statistically significant association between explanatory
variables and the outcome variable

 Backward stepwise selection method will used to identify the

significant predictors

 Model fitness is assessed using Hosmer-Lemeshow tests of Goodness-

of-fit test (P-value=0.78)

 P-value < 0.05 and OR with 95% CI will used to measure the degree
of association between independent variables and the outcome
variable.
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 Operational Definitions

 Adherence: is the extent to which patients’ behaviour coincides with

the prescribed regimen as agreed up on through a shared decision
making process between the patient and the health care providers.
When patients took greater than or equal to 95% of their prescribed
medication, we call it adherent; unless non-adherent. (Solomon HE et
al, 2014)

 Adherence percentage: Number of dose taken (number of doses

prescribed minus number of dose missed) divided by number of doses
prescribed and multiplied by 100. (Solomon HE et al, 2014)

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 ETHICAL CONSIDERATION

 The ethical approval and clearance was obtained from AMU College
of medicine and health science, ethical review committee

 All the participants were given an explanation about the objective of

the study and verbal informed consent was secured

 In addition they were told that they had the right to refuse to
participate in the study

 The information obtained from respondents were kept confidential by

using codes instead of any personal identifiers

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 RESULTS AND DISCUSSION
Socio-demographic characteristics of the respondents
 A total of 428(100%) adult HIV patients participated in the study,
among this female constitutes 221(51.6%)

 One hundred sixty six (38.8%) of the respondents were in the age
group of 31-39 years, with a mean (SD) age of 36.98(8.32) years.

 Among the study participants 341(79.7%) were urban and the rest
were living in rural area

 Regarding their ethnicity, 246(57.6%) respondent was Gamo

 Out of the total respondents 251(58.6%) were Orthodox and

170(39.7%) were Protestant. Table 2.pptx
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 RESULTS AND DISCUSSION cont…
Patient related variables
 Four hundred sixteen (97.2%) had disclosed their HIV status to their
family members, friends or work mate

 The majority of the participants 344(80.4%) were getting social

support

 Out of this participants were helped by their family members, friends

or work mate in remembering to take their medications 276(64.49%),
material and financial support 186(43.46%) and advising 71(16.58%)

 Three hundred thirty four (78%) of subjects were free of any

substance abuse, however 57(13.32%) drink alcohol, 23(5.37%) use
kcat, 2(0.47%) smoking cigarette and 12(2.84%) use the above
substances in some combination. Table 3.pptx
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 RESULTS AND DISCUSSION cont…
Patients’ adherence support strategies
 Almost the entire participants 421(98.4%) were used at least one
strategy to remind them to take their medication on time.
Table 4.pptx

Treatment and clinical related characteristics

 As to the treatment durations, 243(56.8%) of the participants were
more than 5years on ART, with a mean (SD) of 5.6(2.5) years (range
of 4 month to 12 years)
 About forty four (10.3%) patients responded that they have side
effects of ARV drugs
 The commonest reported side effects were nausea and vomiting
19(30.65%), pain and numbness 13(20.96%), skin rash 12(19.35%),
headache 9(14.52%), and fever or chills 6(9.68%). Table 5.pptx
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 RESULTS AND DISCUSSION cont…
ART adherence: Table 6.pptx
 Patients’ dose adherence (77.1%), which is almost consistent with the
study done in Nekemte Hospital (77.9%) (Solomon HE et al., 2014)
 However, which is lower than that reported in Dessie (90%)
 This may suggest that patients having low socioeconomic status were
able to achieve optimal adherence with ART. (Birhanu D et al, 2014)

Reasons for missing doses

 The principal reasons reported for skipping doses were change in their
daily routine work 47(25.54%), busy with doing other things
34(18.48%), being away from home 32(17.39%) and forgetting
28(15.23%). Figure 2.pptx
 The finding was similar with other studies in Hiwot Fana and Jugal
hospitals, and Debre Markos referral hospital (Habtamu M et al.,
2013), (Mulugeta A et al., 2014) 24
 RESULTS AND DISCUSSION cont…
Factors associated with adherence to ART
 On bivariate analysis, the following variables were selected (at p-
value <=0.25) as candidates for multivariate analysis

 Age
 Sex
 Active substance use
 Depression
 Drug side effect
 Resent CD4 count
 ART schedule fitness to daily routines and
 Feeling comfort on taking ART drug in front of others
 Residence
 Social Support
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 RESULTS AND DISCUSSION cont…
Multivariable logistic regression

 Multivariable analysis showed that:

 Sex
 Active substance use
 Side effect
 ART schedule fitness to daily routines and
 Feeling comfort on taking ART drug in front of others

 Were all significantly associated with adherence. Table 7.pptx

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 RESULTS AND DISCUSSION cont…
 Sex: Table 7.pptx

 The cause might be female participants were busy to work with

burden of routine daily household activities which might have
contributed to missing of daily dose.

 For instance, many females have to obtain permission from a male

spouse or a relative to seek HIV care, which is difficult when take
time away from household tasks.

 The findings is contradicts from the study conducted in Zambia

(Yuri S et al., 2012).

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 RESULTS AND DISCUSSION cont…

 Active substance use: Table 7.pptx

 These finding is supported by study done in Southern Ethiopia. (Belay

DB et al., 2014)

 Active substance users would change their life style, and also sleeping
pattern; therefore it can result in to forgetfulness of the dosing timing

 Also, alcohol consumption was exacerbates ARV side effects.

(Boniphace I et al., 2012)

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 RESULTS AND DISCUSSION cont…
 Side effect of drugs: Table 7.pptx

 This finding also agree with the study conducted in Nepal and Nigeria
(Shigdel R et al., 2014), (Bello SI, 2011)
 Patients having drug side effects were usually leads to stop taking
their drugs correctly because they are depressed by side effects.
(Seema S et al., 2011)

 ART schedule fitness to daily routines:

 This is consistent with the findings of study conducted in Desee,

Northern Ethiopia. (Birhanu D et al, 2014)
 Study showed that unstable employment was associated with
suboptimal adherence. (Bach X et al., 2013)
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 RESULTS AND DISCUSSION cont…

 Feeling comfort on taking ART drug in front of others:

Table 7.pptx

 Which was agrees with the finding from the study done in Debre
Markos (Mulugeta A et al., 2014)

 Patients have disclosures may enhance felling comfort, and

psychologically free from the facts that they gave no place from
stigma and discrimination associated influences by masking the effect
of stress and anxiety (Ayalu AR et al., 2012)

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 LIMITATIONS OF THE STUDY

 The cross-sectional nature of study couldn’t be able to address the

temporal and cause-effect relationships

 Self-report measurements of adherence might be recall bias and social

desirability bias

 The study was conducted at a single site

 The excluding of in-patients from the study

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 CONCLUSIONS

 Patients self report of ART adherence in this study was relatively low
compared with WHO standard and other study in Ethiopia.

 The major contributing factors for ART adherence were sex,

substance use, drug side effect, ART schedule fitness to daily routines,
and feeling comfort on taking the ART drugs in front of others.

 The main reasons for missing dose(s) in order were change in their
daily routine work, being busy, being away from home and forgetting.

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 RECOMMENDATIONS
 For Health Professional:

 To increase about ART adherence of the client, health care

provider should give education about adherence especially female
patients; and on patients’ behavioral change about active substance
uses

 Health professional and adherence supporters should give advice

at the commencement of ART service to increase patients’
awareness of the side effects of ARV and manage them

 To fit the daily treatment schedule with the daily routine work,
health care providers should work with the patients to draw up the
plan that considers the everyday activities
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 RECOMMENDATIONS cont…

 Adherence counseling and health information dissemination need

to decrease missing doses include strategies to minimize missing
dose by using multiple memory aids

 For Researchers:

 Further study on adherence and its associated factors with multiple

adherence measurements to resolve the barriers to adherence and it
should be carried out in longitudinal base by integrating with
qualitative study design to identify behavioral related factors.

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REFERENCES

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THANK YOU!!!

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