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Abstract

Background: Adherence to antiretroviral therapy (ART) in children is influenced by multiple factors that can be linked to carer and children. The study aimed to assess the level of adherence to ART and its associated factors among children attending ART in East Wallaga zone public health institutions, Ethiopia. Methods: An institution-based cross-sectional study was conducted among ART attending children in East Wallaga public health facilities. Pretested and structured questionnaires were used to collect data. To determine the level of significance, bivariate and multiple logistic regressions and 95% confidence intervals were performed. Results: One hundred eighty-five (78.1%) of the 237 study participants’ caregiver stated that their children had adhered to ART in the month preceding the interview. The male children, children from urban, disclosure the human immunodeficiency virus status to the children, proximity to health facilities, good relationship of caregivers with healthcare providers, and children on first-line regimens were strongly linked with ART adherence. Conclusion: The adherence rate obtained in this study was less than 95%, which is an optimal level of adherence recommended by the World Health Organization. Therefore, much work has to be done to optimize adherence to ART.

Keywords

antiretroviral therapy antiviral HIV treatment Africa

Introduction

Human immunodeficiency virus (HIV) is the most common virus which challenges the population in this world. According to the Joint United Nations Program on HIV/AIDS (UNAIDS) report in 2020, 37.9 million people living with HIV in the world, among these 1.7 million were children under 15 years.¹ At the end of December 2020, 73% (27.4 million) people living with HIV in the world were accessing antiretroviral therapy (ART), of which 53% of them were children age 0 to 14 years.¹ It is estimated that 665,723 of Ethiopian population living with HIV, of which 54,651 were children under 15 years. In Ethiopia, 97.1% of adults aged 15 years and older living with HIV had access to highly active ART, but just 33% of children aged below 15 years had access.²

Adherence greater than 95% will ensure a good virological response and prevent the emergence of viral resistance, increase the success of the ART program, reduce HIV/AIDS-related disease, improves life expectancy and quality of life.^3,4 Therefore, efforts to improve adherence levels are likely to result in improved health outcomes. Adherence to the antiretroviral drug in children is problematic due to multiple factors which include high pill burden, child age, poor palatability, side effects, long-term toxicity, caregiver relationship with child, forgetfulness, and caregiver knowledge of their HIV status.⁵

The study conducted in the Africa region suggests that 47.5% in Ghana,⁶ 79.8% in South Sudan,⁴ 79% in Uganda,⁵ 89.1% in South Africa,⁷ and 91% in Nigeria⁸ of ART users achieve optimal adherence. Moreover, a previous study conducted in Ethiopia showed that 79.1% in 64.2% to 94% children were adherent to ART which was lower than adherent recommended by World Health Organization (WHO).^9-12

There is little information available about the adherence level of child HIV patients in the present study area. Hence, this study is aimed to assess the level of adherence and factors associated among children living with HIV in East Wallaga, Ethiopia.

Methods and Materials

Study Area, Period, and Design

A facility-based cross-sectional study was conducted from July to September 2018 at 7 selected public health facilities found in the East Wollega zone, Oromia Regional state, namely Nekemte specialized hospital, Gida Ayana district hospital, Jima Arjo, Gutin, Gudtu Arjo, Sire, and Nekemte health center. The East Wollega zone is one of the 17 administrative zones of Oromia national, regional, state and is located West of Addis Ababa.

Study Population

The study population consists of 215 primary caregivers of children taking antiretroviral medications and being monitored in the ART of chosen public health institutions during the study period.

Under 15 children living with HIV, children those follow up on ART for more than 6 months, and caregiver of children living with HIV those willing to provide consent was included in the study. However, a caregiver not with the child in the past 1 month, carers for children who have been diagnosed with terminal illness and have a major disability such as deafness were not included in the study. Children were selected by using a simple random sampling technique.

Data Collection Tools and Procedures

The questionnaire was adopted from the ART guideline, ART follow-up form and from different kind of literatures.^8-12 The questionnaire consists of sociodemographic characteristics, healthcare delivery system-related factors, therapy-related factors, and environmental factors. Data was obtained through face-to-face interviews with caregivers conducted by 8 trained nurses working in the health facility using a pretested and organized questionnaire. A questionnaire was prepared in English and then translated into Afaan Oromo (local language), and back-translated to ensure consistency. Adherence to the antiretroviral regimen was measured by using the caregiver's report. They were asked how many doses their children had missed in the previous 3, 7, and 30 days before the interview. To determine the adherence percentage, we divided the number of pills taken by the number of pills that were prescribed and then multiplied the result by 100.

Data Quality Assurance

Prior to data collection, 5% of the questions were pretested. For 2 days, data collectors and supervisors were taught in data collection methodologies and content.

Data Analysis

After data collection from the caregiver data was cleaned and entered into the Statistical Package for Social Sciences (SPSS) version 20 for analysis. Multivariable logistic regression analysis was used to identify significant independent predictors of ART adherence among children in East Wallaga health facilities. Bivariate logistic regression analysis was carried out and variables with p-values of ≤.2 were entered into the multivariable logistic regression for final analysis. Hosmer and Lemeshow fitness of Good test was computed. Statistical association with a p-value <.05 were reported as significant associations.

Operational Definitions

Adherence: If he/she missed no more than 1 dosage (> 95% of prescribed doses correctly) in the previous month or if he or she did not skip any doses (> 95% of prescribed dosages correctly) in the 3 and 7 days preceding the study.

Caregiver: Person who lives with the child, participates in the child's daily care, is responsible for providing the child medication, and transports the child to the clinic.

Ethics Approval and Informed Consent

Ethical clearance was obtained from Institutional review board of Wallaga University (approval number: DPH/114/12). A formal support letter was written to selected health facilities. All patients provided written informed consent prior to enrollment in the study and repeated verbal consent prior to interviews. The consent included the brief description of the study, use of the information to be collected, benefits and risks of participation, data confidentially and handling of the collected information. The consent form was written in clear and plain language to ensure participants’ understanding. Besides, participant's right was taken into consideration throughout the study process.

Result

Sociodemographic and Clinical Characteristics of Caregivers and Children

The analysis comprised 237 children and their caregiver among the 259 research participants, with a response rate of 92%. The study revealed that the median age of the children was 12 years. It was observed that a majority of 148 children (62.4%) were male, while the remaining 89 children (37.6%) were female. Of 237 caregivers, 215 (90.7%) were biological parents caregivers and 176 (74.3%) of them were females. More than half 167 (70.5%) of caregivers were living in urban. The majority of caregivers 195 (82.3%) are living with HIV. Besides, 146 (61.1%) of children were not informed about their HIV status by caregivers (Table 1).

Table 1.

Sociodemographic Characteristics of Care Givers and Children Living With HIV in East Wallaga, Ethiopia.

Variables		Frequency	Percentage
Sex of caregiver	Male	61	25.7
Sex of caregiver	Female	176	74.3
Age of caregiver	<20	6	2.5
	21-30	66	27.8
	31-40	111	46.8
	41-50	34	14.3
	51-60	16	6.8
	>60	4	1.7
Marital status of caregiver	Single	18	7.6
	Married	142	59.9
	Divorced	39	16.5
	Widowed	38	16.0
Educational status of care giver	No formal education	64	27.0
	Primary school	`93	39.2
	Secondary school	55	23.2
	College/university	25	10.5
Occupational status of care giver	Farmer	56	23.6
	Merchant	43	18.1
	Day laborer	69	29.1
	Government employee	33	13.1
	Unemployed	36	15.2
Income of care giver	<500	97	40.9
	501-1000	82	34.6
	1000-2000	34	14.3
	>2000	24	10.1
residence of care giver	Urban	167	70.5
residence of care giver	Rural	70	29.5
Proximity in km to ART health facility	<10	193	81.4
Proximity in km to ART health facility	>10	44	18.6
Sex of the child	Male	148	62.4
Sex of the child	Female	89	37.6
Age of the child in year	0-4	31	13.1
	5-9	68	28.7
	10-14	138	58.2
HIV status of caregiver	Positive	195	82.3
HIV status of caregiver	Negative	42	17.7
Caregiver on ART	Yes	195	82.3
Caregiver on ART	No	42	17.7
Disclosure of HIV status	Yes	91	38.4
Disclosure of HIV status	No	146	61.1
WHO stage at ART initiation	WHO stage 1	51	21.5
	WHO stage 2	86	36.3
	WHO stage 3	96	40.5
	WHO stage 4	4	1.7
Current treatment stage	T1	205	86.5
	T2	17	7.2
	T3	15	6.3
Baseline CD4 count	<500	119	50.2
Baseline CD4 count	>500	118	49.8
Current CD4 count	<500	62	26.2
Current CD4 count	>500	175	73.8
Current viral load	<1000	188	79.3
Current viral load	>1000	49	20.7
Duration on ART	<5years	77	32.5
Duration on ART	>5years	160	67.5

Abbreviations: ART, antiretroviral therapy; HIV, human immunodeficiency virus; WHO, World Health Organization.

Level of ART Adherence

According to the caregivers report 78.1%, 85%, and 91.6% of children were adhered to ART in the past 1 month, 7 days and 3 days from the date of data collection (Table 2).

Table 2.

Level of ART Adherence Among Children Attending an ART Clinic in East Wollega, Ethiopia.

Days	Level of ART adherence
Days	Adherent, N (%)	Nonadherent, N (%)
Past 3 days	217 (91.6)	20 (8.4)
Past 7 days	202 (85.2)	35 (14.8)
Past 30 days	185 (78.1)	52 (21.9)

Abbreviation: ART, antiretroviral therapy.

Factors Associated With Children Adherence to ART

In multivariable analysis, male children [adjusted odds ratio (AOR) = 3.08 (95% confidence interval (CI): 1.41, 6.70)], children from urban [AOR = 2.85 (95% CI: 1.27, 6.39)], disclosure the HIV status to the children [AOR = 5.50 (95% CI: 2.16, 14.04)], proximity to health facilities [AOR = 2.71(95% CI: 1.07, 6.84)], good relationship of caregivers with healthcare providers [AOR = 3.02 (95% CI: 1.34, 6.80)], and children on first-line regimens [AOR = 5.22(95% CI: 1.29, 21.03)] were associated with ART adherence (Table 3).

Table 3.

Factors Affecting Adherence to ART Among Children, East Wallaga, Ethiopia.

Variables	Adherence status		COR (CI)	p-value	AOR (CI)	p-value
Variables	Adherent	Nonadherent	COR (CI)	p-value	AOR (CI)	p-value
Place of residence
Urban	149	31	2.80 (1.45-5.44)	.00	2.85 (1.27-6.39) *	.011
Rural	36	21	1	.00		.011
Sex of the child
Male	124	24	2.37 (1.27-4.43)	.00	3.08 (1.41-6.70) *	.005
Female	61	28	1	.00		.005
Proximity of health facility (km)						.034
< 10	155	38	1.9 (0.92-3.9)	.083	2.71 (1.07-6.84)*	.034
>10	30	14	1
Relation of caregiver with parent
Biological parent	171	44	2.22 (0.88-5.63)	.09
Nonbiological parent	14	8	1	.09
Disclosure of HIV status
Yes	81	10	3.27 (1.55-6.91)	.00	5.50 (2.16-14.04) *	.000
No	104	42	1	.00		.000
WHO stage at ART initiation
WHO stage I	44	7	2.09 (0.19-23.09)	.06
WHO stage II	59	27	0.73 (0.07-7.33)
WHO sage III	79	17	1.55 (0.15-15.81)
WHO stage IV	3	1	1
Current treatment stage
1st line regimens	167	38	5.02 (1.72-14.69)	.00	5.22 (1.29-21.03) *	.020
2nd line regimens	11	6	2.09 (0.50-8.67)
3rd line regimens	7	8	1
Current CD4 count
<200	8	4	1	.01
200-499	32	18	0.89 (0.24-3.37)
>500	145	30	2.42 (0.68-8.55)
Current viral load
<1000	150	38	1.58 (0.77-3.23)	.21
≥1000	35	14	1	.21
Relation with healthcare provider
Good	145	29	2.88 (1.50-5.50)	.00	3.02 (1.34-6.80)*	.007
Poor	40	23	1	.00		.007
Got assistance information
Yes	179	48	2.49 (0.67-9.17)	.17
No	6	4	1	.17

*Significant at p-value <.05.

Abbreviations: 1, reference; AOR, adjusted odds ratio; ART, antiretroviral therapy; CI, confidence interval; COR, crude odds ratio; HIV, human immunodeficiency virus; WHO, World Health Organization.

Discussion

Adherence is a particular concern in children because many medications are not suitable for them. This study assessed the level of ART adherence and its associated factors among HIV-infected children in East Wollega public health facility. The study involving 237 children, several factors were investigated for their association with adherence to ART. The findings revealed that male children, those residing in urban areas, having knowledge of their HIV status, living closer to health facilities, maintaining a good relationship between caregivers and healthcare providers, and being on a treatment regimen were all significantly associated with higher levels of ART adherence. The reported adherence rates by caregivers were notably lower than 95%.

Accordingly, ART treatment adherence was observed to be 78.1% (95% CI: 72.2%, 83.1%) in the past 1 month, in which the carers’ reports were lower than the 95%, which is recommended by WHO. This report is consistent with other investigations in Tigray, Ethiopia which was 79.1%,¹⁰ 78.6% in Wollo, Northern Ethiopia,¹³ 79% in Uganda,⁵ and 90.9% in India.¹⁴ However, it was less than different researches done in Ethiopia which were 90% to 94%,^10-12 91% in Nigeria,⁸ and 89.1% in South Africa.⁷ However, the current study was higher than studies conducted in Fiche, Ethiopia which was 64.2%,⁹ 66.7% in Ambo (Ethiopia),¹⁵ 79.8% in South Sudan,⁴ 42.7% in Uganda,¹⁶ and 47.5% in Ghana.⁶ The discrepancies might be due to differences in the measurement of adherence assessment used and differences in clinical settings. Besides, the difference in duration prior to an interview may increase the probability of missing the drug.¹³

Studies showed that caregiver's disclosure to their child enables the child living with HIV to adhere to their treatment. Moreover, it allows children to comprehend HIV infection and to make meaning of disease-related events, as well as the significance of adherence.¹⁷ Similarly, the current study found that children who were informed about their HIV status by their caregivers had higher odds of adherence to ART compared to who were not informed. This highlights the importance of open communication and age-appropriate disclosure of HIV status to children, as it can positively impact their understanding of the disease and motivation to adhere to treatment. Our finding is supported by studies conducted in Ethiopia,^11,13 South Africa,^7,18 and Ghana.⁶ This is because children who are aware of their HIV-positive status are more worried about their health and may be aware that these treatments are beneficial. Another reason might be that nondisclosed children didn't comprehend the reasoning for taking medications and became resistant to taking them since they didn't understand why they took medicine despite appearing to be well.

Furthermore, this study found that children's adherence to ART is related to their closeness to healthcare services. HIV-positive children near health facilities more adhered to ART. This finding was in line with reports from similar studies done in Ethiopia,¹³ Uganda,⁵ and Nepal.¹⁹ This might arise if patients skip appointments due to transportation issues. Besides, lack of transportation, extensive travel distances, and geographical inaccessibility may all contribute to ART nonadherence.

In this study, the relationship between the healthcare professional and the patient was found to be a major predictor of adherence. Study participant those have a good relationship with their healthcare provider was adherent to ART drugs than their counterparts. Similarly, a research done in South West Ethiopia reported a link between the relationship between the healthcare professional and the patient and adherence.²⁰ Our finding underscores the significance of supportive and collaborative relationships between caregivers and healthcare providers in promoting adherence to ART in children living with HIV. This could be due to the relationship with healthcare providers promoting trust relationship, confidentiality and encourage open communication with the children and their caregivers.

Furthermore, the present study showed male children had 3 times odds of adherence to ART compared to female children. This is similar to the study conducted in Western Ethiopia,¹⁵ and India.²⁰ Female children are less likely than boys to adhere to ART owing to the effect of gender norms, are more likely to be preoccupied with household activities, and are more sensitive to family difficulties such as quarrels among their family members, and so experience developmental problems. Conversely, a study conducted in South Africa showed that female were more like adherent to the treatment compared to males.⁷

The current study also found a significant correlation between adherence and residence. Children who resident in urban had 2.8 times odds of adherence to ART than those whose children live in rural. A researches done in Kenya,²¹ and Zambia²² supports this finding. This is due to caregivers’ lives in urban have access to frequent information on HIV/AIDS treatment compared to rural caregivers. Besides, the urban child gets more access from nearby health facilities than a rural child. Furthermore, lack of transportation and long-distance might have a contribution to missing an appointment of ART. This finding emphasizes the importance of ensuring access to healthcare services for children living with HIV, particularly those in rural or remote areas.

Regarding treatment, children who were on current treatment WHO stage one had 5.2 times odds of adherence compared to children on WHO stage III. This finding is comparable to similar studies conducted by Biressaw.²² This may be due to the fact that children on their first treatment regimen are more likely to have recently initiated treatment and therefore may be more motivated to adhere. Besides, patients at this stage are less vulnerable to opportunistic infection.

In this study, however, level of ART adherent did not show any correlation with substance use of caregivers, the HIV status of caregivers, age of the child, duration of ART, WHO stage of ART initiation, and CD4 count. This finding is similar to previous studies done in Ambo, Ethiopia¹⁵ and Wollo, Ethiopia.²³

Conclusion

In this study, the level of adherence was lower than that suggested by WHO. However, it is important to note that these are self-reported measures and may not accurately reflect actual adherence levels. Future studies could consider using objective measures, such as pill counts or electronic monitoring devices, to assess adherence more accurately. The male children, urban children, disclose the HIV status of the children, proximity to health facilities, the good relationship of caregivers with healthcare providers and children on current treatment WHO stage I was associated with adherence to ART.

As a result, healthcare professionals must put in a lot of effort to attain the standard adherence level of higher than 95% in order to avoid nonadherence issues. Health facilities where the patients receive the ART should be facilitating near to the patients by the government through a healthcare provider. Healthcare providers should have a good relationship with caregivers of children to improve the adherence level to ART. Healthcare providers and counselor should also minimize forgetfulness by using memory aids such as pillboxes, phone, alarm for those have mobile and watch bell for those have no mobile phone. Besides, healthcare providers should educate the caregivers in order to give special attention to female patients to optimize adherence level among the pediatric population. Attempts must also be made to persuade caregivers and counselors to inform the children of their HIV status. Moreover, further study is recommended to detect significant associations by using different study designs in the study area.²³

Footnotes

Acknowledgments

We would like to thank Public health facilities found in East Wollega Zone administrative and staff members for their cooperation and provision of all the information they were asked. We also like to thank our study participant those were willing to give information.

Authors’ Contributions

BA conceived the study, designed data collection, conducted data analysis, and interpretation. BE and MA interpreted the results and reviewed the initial and final drafts of the manuscript. All authors read and approved the final manuscript.

Availability of Data and Materials

All data generated or analyzed during this study were included in this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Milkias Abebe

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