Background
Methods
Study setting
Sample size
Sampling
Data collection
Data analysis
Results
Demographic characteristics of health care workers
Demographic characteristics of study participants
Variable | Defaulter (n) | non_defaulter (n) |
---|---|---|
gender | ||
Male | 6 | 6 |
Female | 6 | 6 |
participant age | ||
20–30 | 2 | 2 |
31–50 | 10 | 9 |
> 50 | 0 | 1 |
Education Level | ||
Secondary | 2 | 8 |
University | 10 | 4 |
Employment Status | ||
Unemployed | 0 | 1 |
self employed | 3 | 2 |
employed by government | 2 | 5 |
employed in private | 7 | 4 |
residence | ||
Rural | 0 | 0 |
Urban | 12 | 12 |
treatment | ||
first line | 9 | 11 |
second line | 3 | 1 |
Disclosure | ||
Yes | 4 | 12 |
No | 8 | 0 |
marital status | ||
Single | 3 | 2 |
Married | 9 | 10 |
Divorced | 0 | 0 |
Widow | 0 | 0 |
Duration on ART | ||
less than 2 yrs | 0 | 1 |
2–4 yrs | 9 | 9 |
> 4 yrs | 3 | 2 |
Factors that influence adherence to Antiretrovirals
Patient level factors
Participants further reported that in instances when clients run out of their ARVs and have no one to remind them about refilling their drugs, some opted to default especially if they had missed taking treatment for a long period of time.“My wife knows my status but does not support me because she is HIV-negative herself. Sometimes she tells me that she is tired of looking after me because I am HIV-positive. In such cases, sometimes I don’t even take the drugs.” (Male participant, non-adherent)
Health workers noted that an individual’s behavior significantly contributes to rates of defaulting among adults who are on ART. A health care worker stated:“After drinking alcohol, I could not remember to take the drugs since I will go home very late and no one would remind me to take the ARVs.” (Male participant, non-adherent)
“Those clients who are addicted to smoking and alcohol, tend to forget to take the ARVs.” (Health Provider, Clinician)
Health care workers also collaborated that a better perception of health affects adherence to ARVs. One health care worker explained as follows:“Before I started (on ARVs), I was often sick but when I started ARVs, I immediately got well and was fit just like those who are not on ARVs and I thought I was cured so I did not see any reason to continue taking ARVs.” ( Female participant, non-adherent)
“I don’t understand some of these clients, because when we are initiating on treatment we normally give them information so that they should understand why they are taking ARVs every day, but once they get well, most of them they default from treatment thinking that they are cured especially after you tell them that their viral load is undetectable.” (Health Provider, ART Clerk)
“Honestly I did not accept and I still ask my God, why me? As of now I cannot do anything because I know I will die just now, so the best option I should do is that I should be drinking alcohol and smoking.” (Male participant, non-adherent)
Health workers also collaborated that denial of one’s HIV-infected status explains some clients’ behavior on defaulting from ARVs:“I never expected this in my life, I never had girlfriends apart from my wife, so I wonder where this disease you call HIV is coming from.” (Male participant, non-adherent)
“What I have observed in these clients is that they do not want to accept their status after testing positive. So if they have not accepted their status, it is difficult to take the ARVs hence any day one may decide to default from treatment.” (Health Provider, Nurse)
“I did not want to tell anyone about my HIV status. I did not want to be a laughing stock that am HIV-positive’. (Male participant, non-adherent)
A health care worker collaborated on the same and reported as follows:“Ah why should I tell people? … Eh I cannot do that I don’t want to be exposed.” (Male participant, non-adherent)
“Some people really default from treatment just because they don’t want to tell their relatives, even a partner just because they are afraid that they will be laughed at if their loved ones come to realize that they are HIV-positive.” (KII 002)
Another participant explained:“I don’t know what happens to other people when they start ART, they become sicker than before so they would rather stop and get better than continuing with ART.” (Female participant adherent)
“I was indeed sick but when I started ARVs my condition got worse. I was vomiting every day and also experienced dizziness plus headache. So when I went back to the clinic, I was told that I would get better and yet my condition got worse so I decided to stop so that at least I should be relieved as I was before.” (Female participant, non-adherent)
“Honestly I was tired of taking drugs every day. It was just too much, I wanted to rest a bit.” (Female participant, non-adherent)
“Many clients are defaulting from treatment because they are tired of taking ARVs daily and also with the fact that they will take the ARVs for the rest of their life.” (Health Provider, Clinician)
“Ah I don’t see any reason for taking ARVs, the drugs are made from herbs so it is good for me to take herbs for example “Terasi” (a herbal mixture believed to boost one’s immunity) any time I feel like rather than these ARVs… taking these drugs daily give me a tough time”. (Female participant, non-adherent)
Health system level factors
Human resources factors
“Sometimes some health workers do not interact well with clients, they shout…so based on how they were raised up and the respect they receive in society, some clients decide to stop rather than go to the hospital for a refill and get embarrassed at the facility.” (Male participant, adherent)
“Health workers too are contributing to default from treatment, sometimes due to staff shortage. With many clients waiting to be initiated on ART, we sometimes involve untrained nurses to assist in counseling so that we clear the queue. It’s obvious the untrained staff may not provide adequate information thereby clients can easily default from treatment.” (Health Provider, Clinician)
Financial and geographical accessibility of ARVs
Participants also highlighted that long distances contribute to defaulting from ARVs.“Money is a problem, even businesses are not going on well, so for someone who is not working but doing business only cannot manage every month to come for refill. Where is he/she going to find money for transport? Later they will start missing the appointments and then in the end will completely stop.” (Male participant, adherent)
“Some clients stay far away from the facility and cannot manage to come monthly for a refill because it is not always the case that they have money every day. For those who stay a bit close to the hospital, they can walk to the clinic for a refill when they don’t have transport money.” (Female participant, adherent)
Facilitators to ART adherence
Individual level factors
“It is not easy to be told that you are HIV-positive and you accept immediately. It is a shock so these people normally go through denial process before they accept, so when they get support from the family, health workers, even community, they get encouraged. As a result, they have less chances of defaulting from ART.” (Health Provider, Nurse)
Health systems factors
Follow up visits after missed visits
Health workers argued that:“When health workers observe that they are some clients missing appointments for two months, they have to go in to their houses since when starting treatment we are asked our physical addresses. So if they visit them at their homes they need to find out why they are not coming for refill, and should help them. This can help to reduce many clients to default from treatment.” (Male participant, adherent)
“The main problem is with us the ART providers, we see that clients are not coming for refill for two consecutive months and we just observe instead of taking action and following it up and in order to find out the problem and address it.” (Health Provider, ART Clerk)
Positive relationship with health workers
“When we were told that we are HIV-positive honestly, we felt like we will die tomorrow, so when we go for refill of drugs we are already stressed up….if they can welcome and interact well with us, we can open up and get assisted well… do you think one can then decide to default from treatment?” (Male participant, adherent)
Adequate information, education and counseling
Participants also mentioned the importance of sensitizing clients about possible side effects upon commencement of treatment as a retainer in ART care.“To say the truth, some ART providers are not well trained as a result may not give adequate information to clients leading to clients not understanding…why they are taking ARVs including the benefits…or even for how long will they take ARVs for. So once the client is blank and does not know all these, they can easily decide to stop treatment anytime.” (Health Provider, ART Clerk)
“When clients are initiated on ART, they sometimes develop side effects and yet they were not told during counseling process. When they go back to the clinic for assistance, health workers may not attend to them properly and at times they are only told to go back and they will be fine and yet that client is very sick. When they go back home, they may decide to default since they were not assisted well.” (Female participant, adherent)