Abstract
Introduction:
Stigmatization and discrimination impact negatively on interventions and act as barriers to all HIV/AIDS activities. This study assessed the relationship between stigmatization and discrimination and adherence to antiretroviral therapy (ART) among HIV-infected patients attending the Federal Medical Centre, Ido-Ekiti, Nigeria.
Methods:
A cross-sectional study was carried out among respondents selected by systematic random sampling. Structured, interviewer-administered questionnaires were used to collect data subsequently analyzed with SPSS 16.
Results:
A total of 100 respondents comprising 61 (61.0%) female participants were interviewed. A large proportion, 92.0%, had a low level of stigmatization. In all, 88 (88.0%) had a good level of antiretroviral adherence using a threshold of
Conclusion:
The PLWHAs with low levels of stigmatization and discrimination are more likely to adhere to ART than those with high levels. Counseling services and health education on adherence should be a strong component of all PLWHA care.
Introduction
Stigma remains the main reason why too many people are afraid to see a doctor to determine whether they are infected with the HIV virus or to seek treatment if so affected. 1 It helps make AIDS the “silent killer,” because people fear the social disgrace of speaking about it or taking easily available precautions. Stigma is a chief reason the AIDS epidemic continues to devastate societies around the world. 1 Stigma is often associated with discrimination and has been defined in various ways. Stigma has been defined as an undesirable or discrediting attribute that an individual possesses, thus reducing that individual’s status in the eyes of the society. 2 Stigmatization can lead to prejudicial thoughts, behavior, and actions on the parts of governments, communities, employers, health care providers, cowriters, friends, and families. 3
Discrimination is an aspect of stigma defined as a form of exclusion, restriction of expression, marginalization, or prevention from access to something or services. 4,5 Campbell et al described discrimination as negative behavior and described stigmatization as any negative thoughts, feelings, or actions toward people living with HIV/AIDS (PLWHA) irrespective of whether people are discriminated against because they know that they are devalued. 6 In other words, discrimination has to be acted out externally while stigmatization can be overt or constitutes libel, slander, or defamation of persons who are stigmatized. 7 Stigma and discrimination (S&D) are associated with many chronic health conditions, including leprosy, mental health, tuberculosis, and HIV/AIDS. The effects of stigma cause indescribable suffering to the stigmatized. 8 The S&D in the context of HIV/AIDS is unique when compared with other infectious and communicable diseases. It tends to create a “hidden epidemic” of the disease based on socially shared ignorance, fear, misinformation, and denial. 9 The S&D the PLWHA face can extend into the hospital setting, where it can lead to the denial of care, differential treatment, and disregard for the right to patient confidentiality and sometimes involves insensitivity to the concerns of PLWHA. 9
HIV/AIDS stigma and the resultant discrimination regularly impact on HIV interventions and may lead to delays in seeking care at heath facilities. The S&D also act as key barriers to all HIV/AIDS activities, from prevention to care and treatment. This study aims to explore the effects of stigmatization and discrimination on adherence to antiretroviral therapy (ART) among PLWHA attending Federal Medical Centre, Ido-Ekiti.
Methodology
This is a hospital-based, cross-sectional descriptive study of HIV-infected patients who are followed up at the medical outpatient and general outpatient department clinics of the Federal Medical Centre, Ido-Ekiti, a rurally located tertiary medical center. It was carried out between October and December 2011. Systematic random sampling technique was used to recruit 100 patients who had been on ART for a minimum of 3 months. Data were collected with a structured, pretested interviewer-administered questionnaire. The data were sorted out and coded serially. Data were entered into the computer for analysis using the Version 16 software packages of the Statistical Package for Social Sciences (SPSS). Informed written consent was obtained from each participant and ethical approval was obtained from the ethical review committee of the Federal Medical Centre, Ido-Ekiti.
Results
A total of 100 eligible PLWHAs who were receiving antiretroviral (ARV) drugs at the Federal Medical Centre, Ido-Ekiti were recruited for this study. Table 1 shows the respondents’ characteristics. Respondents’ ages ranged from 22 to 70 years with a mean age of 43 years (standard deviation, 12 years). The modal age group was 35 to 44 years, representing 31% of the study population. Sixty-one (61.0%) of them were women. Most respondents, 81 (81%), were married; 72 (72.0%) lived in a monogamous family setting, and the rest were from a polygamous family setup. Sixty-seven (67.0%) had a family size above 5. Respondents were mainly civil servants, comprising 33 (33.0%), and traders 35 (35.0%). The number of patients without formal education was 6 (6%) when compared with those who had secondary education, which constituted 29 (29.0%) of the population. Respondents have been on ARV drugs for a period ranging from 3 months to 6 years.
Characteristics of Respondents.
Abbreviations: ARV, antiretroviral; S&D, stigma and discrimination.
A larger proportion of the respondents, 88 (88.0%), had good adherence compared with 12 (12.0%) who reported poor adherence. In addition, 92 (92.0%) of the study participants had stigmatization and discrimination summated scores equal to or less than 7 representing a low level of stigmatization and discrimination, while only 8 (8.0%) had scores greater than or equal to 8, depicting a high level of stigmatization and discrimination.
A cross-tabulation of stigmatization and discrimination by adherence is shown in Table 2. Eighty-five (92.4%) respondents with a low level of stigmatization and discrimination self-reported good adherence to ARV medications compared with only 3 (37.5%) among those with high S&D level (χ2 = 21.00, degrees of freedom = 1, P = .001). Results of a multiple logistic regression of adherence on respondents’ characteristics are presented in Table 3. It shows that the only statistically significant predictor of self-reported adherence to ARV medications among respondents was stigmatization and discrimination.
Relationship between Respondents’ Adherence and Stigmatization and Discriminationa
Abbreviation: df, degrees of freedom; S&D, stigma and discrimination; χ2, chi-square.
aχ2 = 21.00, P = .001, df = 1.
Logistic Regression of Significant Correlates of Adherence to ARV.
Abbreviations: ARV, antiretoviral; B, beta coefficient; CI, confidence interval; OR, odds ratio; S&D, stigma and discrimination; SE, standard error.
Discussion
Respondents had a median duration of ARV usage of 15 months. This duration is important as it has been found that stigma attenuates over time, 10 and this is in agreement with findings from this study. A high level of adherence reported in this study could be due to the free access and ready availability of ARV drugs including drugs for opportunistic infections (OI) in the hospital. The OIs are supplied freely and bimonthly from the center through funding agencies. Also, adherence and psychosocial counseling and support services are offered to the PLWHAs on an on-going basis. Furthermore, adherence to drug regimen in Africa has become easier with the introduction of a generic 3-drug regimen that can be taken in as few as 2 pills a day. 11 Combined HIV drug formulations have led to a reduced pill burden and hence medication adherence. These combined HIV drug formulations are also available at the study center. On a general note, evidence is emerging that HIV-positive people in Africa follow their ARV drug regimen more closely. Studies in Botswana, Uganda, Senegal, and South Africa have shown that PLWHA take about 90% of the pills in their ARV drug regimens. 11 This is because financial barriers which have been the only consistent predictor of incomplete adherence in resource-limited settings to access to ART have been largely removed by the support from nongovernmental and international organizations. 12
Our findings also showed a strong association (P = .001) between the PLWHA’s adherence to medication and stigmatization and discrimination. Respondents’ with a low level of S&D were significantly more adherent than those with a high level of S&D. There is a paucity of relevant research on S&D related to the role of S&D in adherence to medication. The availability of ARV medications has transformed living with HIV infection into a manageable chronic illness, and high levels of adherence are necessary; however, stigma has been identified as one reason for suboptimal adherence. 13
The PLWHAs who experienced greater stigmatization might perceive more difficulty in accessing care because of fear of rejection and discrimination (consequences of stigma) which may lead them to perceive the health care setting as intolerant and inaccessible. 14,15 Therefore, PLWHA experiencing high levels of stigma are more likely to experience barriers to accessing and adhering to treatment. Other studies 15,16 have demonstrated that PLWHA who reported having missed doses also reported higher stigma. Edwards 17 and others supported this assertion, showing that HIV stigma is one factor that interferes with medication adherence. Similarly, Sellier and coworkers 18 found in their comparative study that the degree of adherence to ART among HIV-infected patients born in sub-Saharan African but living in France was clearly reduced during their visit to their country of origin. The reported reasons for nonadherence during their visit and specific to Africa include fear of social stigma and problems with confidential storage of drugs; in contrast, “being busy” was mentioned more as a reason for nonadherence when living in France. Several other workers in different regions of Nigeria, Ekong et al 19 in Lagos, Nwauche et al 20 in Port-Harcourt, and Mukhtar et al 21 in Kano have identified stigmatization as a major reason for nonadherence to ARV medication. Other authors have reported medication worries related to stigmatization as a fear of disclosing their HIV status thus making them miss their medications since they cannot take their drugs in front of relatives or friends without having to answer what the medications are being used for. 22
Conclusion
The PLWHAs attending Federal Medical Centre, Ido-Ekiti demonstrated a good level of adherence to their ARV medications as most respondents had adherence levels greater than or equal to 95%. A large proportion of them, 92.0%, had a low level of S&D. It was also found that those with low levels of stigmatization and discrimination were more likely to be adherent to ARV medications than those with high levels of stigmatization. Counseling services addressing stigmatization and discrimination and the potential impact on HIV treatment should be incorporated into programs targeting recently diagnosed PLWHAs, and health education on adherence should be a strong component of their care of all PLWHAs.
Footnotes
Authors’ Note
Ethical approval for this study was obtained from the ethical review committee of the Federal Medical Centre, Ido-Ekiti.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.