Caregiver-reported adherence to antiretroviral therapy among HIV infected children in Mekelle, Ethiopia

An estimated 34 million people were living with HIV as of 2011 globally, including 3.3 million children of less than 15 years. More than 90% of these children live in sub-Saharan Africa. Approximately 2.5 million people, including 330,000 children, were newly infected with HIV. The estimated number of people dying from AIDS-related causes worldwide in 2011 was 1.7 million where 230,000 of them were children [1]. The study conducted among HIV-positive children from 2006–2011 at the Felege Hiwot Referral Hospital, Northwest Ethiopia shows that the mortality rate was 4/100 child years of follow up [2].

Thus, there is a critical need to provide antiretroviral therapy for children who become infected despite the efforts being made to prevent such infections. ART has substantially changed the face of HIV infection where it has been successfully introduced. HIV-infected children now survive to adolescence and adulthood [3]. However, non-adherence to ART may lead to suboptimal drug levels, which may result in therapeutic failure, deterioration of the immune system and/or emergence of drug-resistant HIV strains [4]. In addition to directly affecting personal well-being, poor adherence may compromise programmatic and economic efficiency. Many people receiving first-line regimens found that they fail to respond to treatment at an unnecessarily early stage and would therefore require to switch to more expensive, and often unavailable, second-line regimens [5].

Adherence is therefore a determinant of viral suppression and fundamental to successful ART treatment. There is a direct correlation between risk of virologic failure and proportion of missed doses of antiretroviral drugs [6]. Adherence is a complex health behavior which may be influenced by the dosage regimen prescribed, patient and family factors, and characteristics of health care providers [7]. Adherence behavior in children is found to be more complex in comparison to adults. Limited availability of palatable formulations for the young children is especially problematic, and food requirements for some antiretroviral agents make therapies difficult to administer to infants who require frequent formula feeding. Furthermore, children are dependent on adults for administration of medication; thus, assessment of the capacity for adherence to a complex multidrug regimen requires evaluation of the caregivers and their environments, as well as the ability and willingness of a child to take the drug. A child’s adherence to ART is strongly influenced by caregiver(s) and family function. The caregiver physically gives the medicine to children. Barriers faced by caregivers that can contribute to non-adherence in children include: forgetting doses, changes in routine, being too busy, and child refusal. Concerted effort in clinical care and research are urgently needed to support this vulnerable population [7‐9]. Therefore, this study aimed at measuring the prevalence and factors associated with adherence to ART among caregivers of HIV-infected children in Mekelle, Ethiopia.

Adherence to ART in pediatrics is critical in order to maximize the benefit of medication. Inadequate adherence is associated with immunological and virological failure; drug resistance, and treatment failure [15]. In this study, the prevalence of caregivers’ report of ART adherence among children was 89.1% in the past 3 days and 83.4% in the past seven days before the interview. The level of adherence was comparable with those reported in Addis Ababa, Ethiopia, where the prevalence of adherence to ART was 93% in three days and 86.9% in a seven day recall period [11]. Another study conducted at Tikur Anbessa Hospital, Addis Ababa among children on ART reported adherence rate of 93.3% based on caregivers’ report [16]. Similarly, high levels of adherence have been reported from other studies in Tanzania [15], Nigeria [17], Malawi [18], Jamaica [19] and Uganda [20]. A systematic review of pediatric ART adherence revealed that caregiver-reported adherence rates was ranged from 79.5% to 100% in low- and middle-income countries [21]. This suggests that these areas have similar setups in providing ART services to HIV-infected children.

There are different methods to measure pediatric ART adherence, including self- or caregiver-reports, pill counts, pharmacy records, clinic attendance, therapeutic drug monitoring, directly observed therapy, electronic drug monitoring and viral load monitoring. Of these methods, self- or caregiver-reports of adherence are the most frequently used to measure pediatric ART adherence in resource-limited settings. However, these methods overestimate adherence levels and caregiver-reported adherence is generally higher than self-report estimates. These could reflect biases from using a caregiver’s report, such as social desirability bias or recall bias. Both of these biases could result in falsely inflated adherence estimates [21].

The main problems cited by the caregivers which are responsible for a missed dose in this study were child being depressed, drug side effects, too many pills and difficulty in swallowing pills. However, other studies from resource-limited countries have reported that these factors were not the common barriers to medication adherence. The study conducted in Addis Ababa, Ethiopia shows that the most common reasons for missing dose were lack of medication, the child slept and forgetfulness to give the drugs [11] while the survey conducted in the Aminu Kano Teaching Hospital, Nigeria reported that running out of medication and the inability to purchase, travelling difficulty, forgetfulness, and children sleeping as adherence barriers [17]. Similarly, common reasons reported for missed doses in KwaZulu-Natal, South Africa were financial trouble that prevented caregivers from collecting medication on time, vomiting of medication without re-dosing, incorrect dosing by a caregiver, missed clinic appointments and pharmacy collections, confusion between multiple caregivers, and child refusal or self-discontinuation [22]. This may suggest that there is an expanded access to antiretroviral therapy for child patients receiving treatment in the present survey.

Multivariate logistic regression analysis indicated that marital status and ages of the caregivers were independent factors associated with adherence. However, marital status was not associated with adherence in another study [11]. The possible explanations for the greater adherence among children with unmarried and married caregivers in this study might be due to family support in providing care for their children. The religion of the caregivers was found to have an association with adherence in bivariate analyses, but in multivariate analysis it was found to be a confounder. This result was in agreement with another study, where there was no a significant association between religion of the caregivers and adherence [11]. A child’s adherence to ART is strongly influenced by the caregiver and the successful treatment of a child requires the commitment and involvement of a responsible caregiver [3, 8]. In this study, biologic caregivers were not associated with better adherence. Nevertheless, a biologic caregiver may experience a stronger emotional connection with the child and be more motivated to promote better adherence compared with a non-biologic caregiver [8].

The interaction between health care providers and the patients is crucial to treatment adherence. Healthcare provider-patient relationship was not a factor significantly associated with adherence in this study. However, the study conducted in South West Ethiopia has shown an association between healthcare provider-patient relationship and adherence [23]. Failure to find an association between healthcare provider-patient relationship and adherence in this survey could be due to the low sample size. Nevertheless, the result shows that there is a good environment for caregivers and/or child patients to tell what the children felt and about their medication course for health care providers in our setting. All study participants got adequate assistance/information from health care providers in this survey like other study [23]. Health care system barriers also affect adherence, especially a regular and timely supply of medication to patients. An unreliable supply of medications can severely reduce patient adherence rates [24]. However, access to reliable pharmacy, treatment changes/improvement and schedule appointment/confidentiality of treatment were found not to be associated with adherence in this study. Failure to find an association in this study may be due to small sample size and the cross-sectional study design used.

Nevertheless, this survey had some limitations. The main limitation was that the methods used for adherence measurement – caregiver reports, which tend to overestimate the prevalence of adherence. Caregivers might be prone to social desirability bias responding inappropriately to the data collectors. The cross-sectional nature may also hinder the ability to exactly identify the predictor of adherence, unlike a longitudinal design. The associations found cannot therefore be assumed to be causal. The sample size was small and may therefore not have been able to detect important associations. In addition, clinical parameters and in depth medication related factors were not explored.

The study reveals that the prevalence of caregivers’ report of ART adherence among children was found to be 89.1% in the past three days and 83.4% in the past seven days before the date of the interview and it is comparable to that of other similar setups. Marital status (unmarried and married) and age group (25–44) of caregivers of HIV-infected children were found to be significantly associated with adherence. Caregivers reported that child being depressed, drug side effects, too many pills and difficulty in swallowing pills were the main barriers to treatment. Encouraging the fundamental role of caregivers is so important to improve adherence in children with HIV. Further study is recommended to employ more rigorous study designs to detect significant associations.