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Abstract

Background:

Antiretroviral Therapy (ART) has transformed life threatening HIV/AIDS scenario into chronic manageable disease.

Methodology:

In this cross-sectional, 409 People Living with Human Immunodeficiency Virus (PLHIV) aged ≥ 18 years, who were on ART, were assessed regarding the adherence to ART and factors affecting adherence using semi-structured questionnaire. The association between factors affecting adherence and the level of adherence were analyzed using multiple logistic regression model and odds ratio (OR) with 95% confidence intervals (CI) were reported.

Results:

Among 409 PLHIV, 70.4% showed adherence to ART (≥95%). Univariate analysis yielded many factor associated with adherence (P < 0.05). However, on multivariate analysis, PLHIV who do not forget to take ART and not consuming alcohol were the factors consistent with adherence to ART (P < 0.05).

Conclusion:

Regular patient education and counseling regarding the usage of memory aids and abstinence from alcohol could be useful for adherence and long term success of ART among PLHIV.

Keywords

HIV/AIDS adherence ART South India

Introduction

Antiretroviral therapy (ART) among people living with HIV (PLHIV) has become crucial in the absence of cure for HIV and nonavailability of vaccination for its prevention. Introduction of ART has greatly reduced the mortality and morbidity related to HIV in developed as well as in developing countries.^1,2

Antiretroviral therapy has shown to inhibit viral replication, thereby decreasing viral load to an extent where viral particles in the blood of PLHIV remain undetected.^3,4 With the easy availability of efficient antiretroviral drugs, the perception of HIV/AIDS has been transformed from that of a fatal illness to chronic but manageable illness. However, the therapeutic effect of ART requires PLHIV to strictly adhere to the prescribed treatment regimen.⁵

World Health Organization defines adherence as “the extent to which a person’s behavior in taking medication, following a diet, and/or executing lifestyle changes corresponds with agreed recommendations from a health-care provider.”⁶

Suboptimal adherence to ART regimens leads to inadequate inhibition of viral replication, immunological failure, emergence of drug-resistant strains, and transmission of resistant strains, which ultimately lead to primary regimen failure.^7,8 From the available evidence, an average rate of 24.8% of nonadherence to medication has been reported in most of the patients having chronic diseases⁹; however, the level of ART adherence among PLHIV is higher compared to most of the other chronic diseases.¹⁰

Previously published studies reported multiple barriers for optimal adherence to ART in both developed and developing countries,^11

–14 which could be categorized into patient-related, medication-related, and health system–related factors.¹⁵ As these barriers vary across settings, identification of the factors responsible for nonadherence to ART and contextualization of these factors will be helpful in designing and developing intervention strategies to improve adherence to ART. The present study was conducted to assess the level of adherence to ART and factors influencing adherence to ART among PLHIV in coastal South India.

Methodology

This facility-based cross-sectional study was conducted among PLHIV attending Infectious Disease Department of the tertiary care hospitals, at Mangalore, Karnataka. People living with HIV were interviewed and their ART adherence level was assessed during the period from April 2014 to April 2015.

The study protocol was approved by the institutional ethics committee (IEC) at Kasturba Medical College (Manipal University), Mangalore, prior to the commencement of the study. The sample size was calculated considering the proportion of adherence to ART among PLHIV as 63.7%.⁵ Taking absolute precision of 5%, confidence interval of 95%, and nonresponders as 10%, the sample size was calculated to be 409.

A total of 409 PLHIV aged 18 years and above receiving ART were included in the study. Study participants were clearly explained about the study objectives in language they can understand. A written informed consent was obtained from those PLHIV who were willing to participate in the study. People living with HIV were interviewed in a separate consultation room. The information was collected in a pretested semistructured questionnaire regarding patient-related, medication-related, and health system–related factors affecting adherence to ART. Socioeconomic status was assessed using modified Kuppuswamy scale,¹⁶ which includes education, occupation, and income of the participants. The average duration of the interview was about 30 minutes.

Participant’s level of adherence to ART was assessed based on patients recall and their self-reported intake of antiretroviral drugs for the past 30 days.

Adherence to ART was calculated using the formula:

Adherence rate = \frac{Total number of drugs taken}{Total number of drugs prescribed} \times 100 .

People living with HIV reporting ≥95% of adherence were considered as having high level of adherence, and those with <95% of adherence were considered as having low level of adherence to ART per the national ART guidelines.¹⁷

The collected data were analyzed using Statistical Package for Social Sciences (SPSS) version 16.0 (SPSS, Inc), and the results were expressed as proportions. The association between the independent variables such as patient-related, medication-related, and health system–related factors with dependent variable (adherence rate) was studied using unadjusted odds ratio. Multivariate stepwise logistic regression was then done to evaluate the simultaneous effects of various exposure variables, with adjustment for the potential confounding effects of other factors. P < .05 was considered to be statistically significant. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) are also reported.

A total of 409 PLHIV were interviewed to assess their ART adherence level, among which 256 were males (62.6%). A higher proportion of the participants (42.1%; n = 172) were in the age-group between 41 and 50 years and belong to middle socioeconomic status (49.6%; n = 203). Majority of the PLHIV were staying with companion (96.1%; n = 393).

Patient-Related Factors Influencing Adherence to ART

As shown in Table 1, adherence to ART was higher among PLHIV aged above 40 years (71.8%), compared to those below or equal to 40 years of age (68.3%; OR = 0.8, CI = 0.5-1.3), but this association was not found to be statistically significant (P > .05). Among other patient-related factors, females (79.7%; OR = 0.5, CI = 0.3-0.8), participants who do not forget to take ART (85.6%; OR = 9.0, CI = 5.1-15.0), participants who do not consume alcohol (76.4%; OR = 3.7, CI = 2.1-6.0), and those with good family care (74.0%; OR = 3.0, CI = 1.2-5.2) were found to be adherent to ART (P < .05).

Table 1.

Patient-Related Factors Determining Adherence to ART.^a

Variables	Total (N)	Adherent, N = 288 (70.4), (%)	Unadjusted OR, (95% CI)	P Value
Age-group, years
≤40	164	112 (68.3)	1.00
>40	245	176 (71.8)	0.8 (0.5-1.3)	.4
Gender
Male	256	166 (64.8)	1.00
Female	153	122 (79.7)	0.5 (0.3-0.8)	.002
Cohabitation status
Alone	016	009 (56.2)	1.1 (0.7-5.2)	.3
Companion	393	279 (71.0)	1.00
Socioeconomic status
Upper	042	029 (69.0)	1.00
Middle	203	146 (71.9)	0.9 (0.4-1.8)	.7
Lower	164	113 (68.9)	1.0 (0.5-2.0)	1.0
Motivation to take ART
Self-motivated	316	226 (71.5)	1.00
Compulsion	093	062 (66.7)	1.2 (0.8-2.0)	.4
Forgetfulness
Yes	132	051 (38.6)	1.00
No	277	237 (85.6)	0.1 (0.1-0.2)	<.001
Family care
Present	350	259 (74.0)	0.3 (0.2-0.6)
Absent	059	029 (49.2)	1.00	<.001
Alcohol consumption
Yes	083	039 (47.0)	1.00
No	326	249 (76.4)	0.3 (0.7-0.5)	.001

Abbreviations: ART, antiretroviral therapy; CI, confidence intervals; OR, odds ratio.

^aN = 409.

Medication-Related Factors Influencing Adherence to ART

As shown in Table 2, the absence of opportunistic infection (71.9%; OR = 2.6, CI = 1.2-5.6) and the sense of feeling better after taking ART (74.8%; OR = 0.6, CI = 0.4-0.1) were the factors associated with adherence to ART, and this association was statistically significant (P < .05).

Table 2.

Medication-Related Factors Determining Adherence to ART.^a

Variables	Total, (N)	Adherent, N = 288 (70.4), (%)	Unadjusted OR (95% CI)	P Value
Duration of ART, months
<12	092	067 (72.8)	1.00
>13-36	317	221 (69.7)	1.2 (0.7 -1.9)	.6
Opportunistic infection
Present	028	014 (50.0)	1.00
Absent	381	274 (71.9)	0.4 (0.2-0.8)	.02
Felt better after taking ART
Yes	222	166 (74.8)	0.6 (0.4-0.1)	.03
No	187	122 (65.2)	1.00
CD4 count, cells/mm³
<200	028	020 (71.4)	1.0 (0.4-2.6)	.9
201-500	244	169 (69.3)	1.2 (0.7-1.8)	.5
>501	137	099 (72.3)	1.00
Pill burden
Yes	027	018 (66.7)	1.2 (0.5-2.8)	.7
No	382	270 (70.7)	1.00

Abbreviations: ART, antiretroviral therapy; CI, confidence intervals; OR, odds ratio.

^aN = 409.

Health System–Related Factors Influencing Adherence to ART

As shown in Table 3, PLHIV who travelled >25 km to get ART had shown better adherence rate (74.1%; OR = 0.4, CI = 0.3-0.7) compared to those who traveled ≤25 km, and this association was found to be statistically significant (P < .05).

Table 3.

Health System-Related Factors Determining Adherence to ART.^a

Variables	Total (N)	Adherent N = 288 (70.4), (%)	Unadjusted OR (95% CI)	P Value
Distance from hospital, km
≤25	077	042 (54.5)	0.4 (0.3-0.7)	.001
>25	332	246 (74.1)	1.00
Hospital not accessible
Yes	064	043 (67.2)	1.2 (0.7-2.1)	.5
No	345	245 (71.0)	1.00
Unable to understand instructions given
Yes	012	008 (66.7)	1.2 (0.4-4.0)	.8
No	397	280 (70.5)	1.00

Abbreviations: ART, antiretroviral therapy; CI, confidence intervals; OR, odds ratio.

^aN = 409.

In univariate analysis, among patients, medication-related and health system–related factors, such as, females, PLHIV who did not forget to take ART, those who felt better after taking ART, participants with good family care, participants who do not consume alcohol, the absence of opportunistic infection, and those who traveled more than 25 km to get ART, improved the ART adherence level (P < .05).

However, in multivariate analysis, the factors that remained significantly associated with adherence included not forgetting to take ART (OR = 0.1, CI = 0.1-0.2) and not consuming alcohol (OR = 0.3, CI = 0.2-0.6; Table 4).

Table 4.

Multivariate Logistic Regression.^a

Variables	Unadjusted OR (95% CI)	P Value	Adjusted OR (95% CI)	P Value
Gender	0.5 (0.3-0.8)	.001	0.9 (0.5-1.7)	.7
Forgetfulness to take ART	0.6 (0.4-0.1)	<.001	0.1 (0.1-0.2)	<.001
Family care	0.3 (0.2-0.6)	.001	0.9 (0.5-1.9)	.8
Alcohol consumption	0.3 (0.7-0.5)	.001	0.3 (0.2-0.6)	.001
Opportunistic infection	0.4 (0.2-0.8)	.02	0.6 (0.2-1.5)	.2
Felt better after taking ART	0.6 (0.4-0.1)	.03	0.9 (0.5-1.5)	.7
Distance from hospital, km	0.4 (0.3-0.7)	.001	0.6 (0.3-1.1)	.1

Abbreviations: ART, antiretroviral therapy; CI, confidence intervals; OR, odds ratio.

^aN = 409.

Discussion

Present study examined the factors associated with self-reported measure of adherence to ART among PLHIV in tertiary care hospitals at Mangalore, South India. The study results indicated that out of 409 PLHIV interviewed, 288 (70.4%) PLHIV had shown good adherence (≥95% CI) to ART.

The adherence rate was better in our settings compared to some studies^18
–20; however, other studies conducted elsewhere have shown higher adherence to ART compared to our study findings.^{10,12,21

–27} Better adherence in our settings could be due to the fact that all PLHIV receive free ART, regular adherence monitoring, and better literacy rate and awareness about HIV disease in coastal South India. Our facility is one of the earliest center in coastal south India, taking care of health care needs of PLHIV. When PLHIV visit our center, they are regularly asked for any missing pills and counseled by the trained counselor at the center regarding the importance of adherence and the risks of occurrence of ART resistance and ill effects on their health due to nonadherence to ART. Additionally, PLHIV were contacted personally through phone calls if they missed their appointment for collecting the drugs at the center. All these support systems might have helped them to stay motivated and adhere to the treatment.

In the present study, among the patient-related factors affecting adherence to ART, it has been observed that females were more adherent to ART than were males. Similar results were found in other studies,^{10,12,18,23,24,28} and this association between gender and adherence to ART has found to be statistically significant (P < .05). This could be due to the fact that many of the female participants were widows, and they were living with their parents and/or other family members who might remind them to take their medication regularly without fail. Widows who got HIV infection through their husband, after witnessing the physical and emotional distress, with the deteriorating health conditions of their partner due to HIV infection, and the psychological effect on their family members and children might have lead them to be adherent to the treatment. Females in our study setting were independent, that is, who didn’t have to be dependent on others for procuring ART, and also had high literacy rate and better awareness toward HIV/AIDS. The concern about their health could be also due to their responsibility to take care of their children and/or other family members. However, in contrast to our findings, other studies have shown males were more adherent compared to females.^{5,21,25,26,27,29}

People living with HIV aged more than 40 years were more adherent compared to those who aged ≤40 years. This could be explained by considering the fact that PLHIV were aware of their HIV status in the later stage of their life because of opportunistic infections and compromised immunity caused by HIV infection. This could be the reason for the concern about their health and better adherence. These findings were similar to other studies.^{10,18,21,25,26,27} In contrasts, the participant’s age and adherence to ART have not shown any statistically significant association in our study (P < .05).

In cohabitation status, PLHIV who are residing with their companion are better adherent to ART compared to those who are living alone. Similar findings were observed in other studies,^22,29 but some study results also showed that PLHIV residing alone are more adherent to ART.^10,23,24 People living with HIV belonging to middle socioeconomic status and who were self-motivated to take ART was better adherent to ART. However, neither the socioeconomic status nor the cohabitation status of PLHIV had shown statistically significant association with ART adherence (P > .05).

Forgetfulness is one of the major factors for missing pills, affecting adherence to ART.^5,10,20,29 In our study, PLHIV who have not forgotten to take ART had shown better level of ART adherence. This association was found to be statistically significance (P < .05). This could be due to the fact that the majority of the participants in our study were residing with a companion (71.0%), PLHIV might get remainder from the partner or companion in case they forget to take ART, enabling them to be adherent to ART, without fail.

In our study, PLHIV who receives good care from their family had shown better adherence to ART compared to those who do not get care from their family members and relatives (P < .05). Similarly, alcoholism is one of the main reasons for nonadherence to ART.³⁰ Our study participants those who don’t consume alcohol had shown good adherence to ART compared to those who consume alcohol, and this association between adherence to ART and not consuming alcohol had showed significant association (P < .05). This could be due to the proper counseling given prior to the start of ART at our study setting, regarding the possible consequences of alcohol consumption and their effects on ART regimen.

Among medication-related factors affecting ART, our study participants who are on ART for less than 1 year had shown better adherence than those PLHIV who are receiving ART for more than 1 year. People living with HIV who have initiated the ART have shown optimal adherence to ART, and as they get better and their health status improved, they tend to neglect their ART regimen over a period of time.

In our study, participants with absence of opportunistic infection had shown good adherence to ART, similar findings were observed in other studies,^12,18,27 and PLHIV who had felt better after taking ART had also shown better adherence to ART. Both the factors, absence of opportunistic infection and feeling better after taking ART, have shown significant association with ART adherence (P < .05). Our study results also show that PLHIV with CD4 count (cells/mm³) more than 500 had shown better adherence to ART.

Among the health system–related factors affecting ART, participants who had traveled more distance (>25 km) to receive ART had shown better adherence to ART compared to those who had traveled lesser distance (<25 km). This finding shows the motivation and dedication among PLHIV for procuring ART and to stay adherent to their treatment. Good reputation of our center regarding the quality of health-care service, treating doctors, and counseling providers also influenced PLHIV from many other neighboring cities to receive treatment. Additionally, PLHIV who traveled more distance (>25 km) to procure ART could be due to their worry of unintentional disclosure of their HIV status to friends, relatives, or family members.

However, our study had some limitations. We followed self-reported measure of adherence to ART, which might overestimate the level of adherence, and other ART measurement methods were not used. Our study participants predominantly belong to urban setting, so our findings may not reflect the other settings. Also, adherence to ART being dynamic in nature and our cross-sectional study design measured adherence and factors affecting adherence to ART at certain point of time.

Conclusion

The study concludes that nonforgetfulness to take ART and not consuming alcohol were the main factors responsible for good adherence behavior. Rigorous counseling were provided for PLHIV regarding the usage of memory aids like alarms, looking at the clock and calendars, and so on. Remainder through phone calls, text messages, and remainder from the family member, companion, or someone you can trust could be useful among those who forget to take ART. Study also recommends that, educating patients regarding the importance of abstaining from consuming alcohol through the usage of flip charts, audiovisual aids, and counseling on the importance of ART adherence is essential for the long-term success of ART.

Footnotes

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.

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Factors Influencing Adherence to Antiretroviral Therapy among People Living with HIV in Coastal South India

Abstract

Background:

Methodology:

Results:

Conclusion:

Keywords

Introduction

Methodology

Patient-Related Factors Influencing Adherence to ART

Medication-Related Factors Influencing Adherence to ART

Health System–Related Factors Influencing Adherence to ART

Discussion

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References