Measure of adherence to antiretroviral treatment amongst HIV positive patients attending antiretroviral clinics in selected rural, deep-rural and semi-urban areas of Ugu District in KwaZulu-Natal.
Mthethwa, Phumelele Perseverence.
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Background The roll-out of antiretroviral (ARV) treatment in public health facilities was initiated in 2004 in the KwaZulu-Natal province. The roll-out made ARV treatment available and accessible to the vast majority of the population which previously could not afford treatment due to their low socio-economic status. Adherence levels need to be monitored timeously in order to ensure that patients are adherent to their treatment. Treatment outcomes are affected by the level of adherence to treatment. Adherence to treatment is essential in providing a sustainable and effective antiretroviral rollout campaign. The ARV roll-out has been initiated in all areas of society in South Africa, and it is a known fact that there are certain factors that affect the level of adherence. It is therefore critical to measure the level of adherence to treatment by patients and to assess the factors that affect adherence. Few studies were done to determine whether geographical location of the patients and their clinics had an effect on adherence. This study was therefore undertaken with the following aims and objectives Aim and Objectives The specific objective of the study was to describe the demographics of the patients attending ART clinics in rural, deep rural and semi-urban areas of Ugu District in KwaZulu-Natal, to measure the level of adherence to ARV therapy, and to determine the factors that affect adherence to the therapy in these areas. Method A retrospective chart analysis of 1020 Human Immunodeficiency Virus (HIV) infected patients (18-60 years of age) who reside in Ugu District within the catchment population of the facility , registered on the ART programme in the facility and have been receiving ART from the facility for at least 2 years were selected to be in the study. The following research sites were chosen: 1 rural hospital, 1 deep-rural clinic and 1 semi-urban community health centre was chosen. Records of the patients from January 2011 to December 2014 were examined in order to select the patients. A closed-ended, coded questionnaire was administered to all patients in the study & was used to record the demographics, level of adherence and factors affecting adherence. After obtaining their consent the questionnaires were administered. The data was captured and analysed using SPSS version 23 software. Results Of the 1020 patients, there were 623 females (61%), with most patients between 18-35 years (56.9%). Almost 70% of the patients were African, with 57.5% single and 75.9% having less than 3 dependants. Forty nine percent of the patients had secondary level education, whilst 61.2% of them were unemployed. More than 62% of the patients use public transport to get to these facilities. Over two thirds of the patients (67%) were on the Fixed Dose Combination treatment, with 70% of the patients already on treatment for 2-4 years, and 30% on treatment for more than 4 years. More than half of the patients (51.7%) had missed between 2-4 appointments to collect their medication from health facilities in the previous 6 months. Although 80.9% of the respondents indicated that they understood the importance of adherence (p=0.008) an overall 58.5% were actually adherent to treatment, with the majority coming from the deep rural area (p=0.001). A number of factors affected the adherence to treatment for patients in the 3 areas, both positively and negatively, the first being their transport to the facility. A larger percentage of patients in the deep-rural (12.4%) area reported taking 2-3 hours (p=0.000) to arrive at these facilities due to transport problems. Over ten percent in the deep-rural area reported having travelled 15-20km (p=0.00).The second reason related to weather, where a much larger proportion of patients (73.8%) in the deep-rural area associated the weather with their ability to reach the health facilities to collect their medication. Other reasons included waiting time, where a great majority of patients from the semi-urban area (87.1%) reported to having waited longer than 2 hours to be attended to. With respect to stock outages 15.4% of patients in all 3 areas were affected by stock outages. Over 40% (42.8%) of the overall patients were affected by family deaths. They could not attend their clinics resulting from having to make arrangements for the burial of their loved ones. This significantly affected patients in the deep rural area (54.4%). Close to 25% of patients were the only caregivers at home, thereby sometimes being unable to collect their medication from the facilities due to having small dependants who cannot be left unattended at home. A greater majority (75.9%) of patients admitted to not collecting their medication from health facilities due to having sufficient treatment at home, with the smaller proportion (66.8%) being in the rural area (p=0.00).Forty two percent of patients related being depressed as one of the reasons for not taking their medication, with the larger proportion (49.4%) being in the semi-urban area (p=0.004). Over half of all patients (50.7%) used traditional medicines with the reported use of alcohol higher in the deep-rural area (93.5%) than in the other areas. Just over a quarter of the participants were involved in substance abuse. A larger proportion (62.4%) of patients who did not disclose their status were in the semi-urban area, compared to the other 2 areas (p=0.008), with 69.8% of patients indicating a fear of loss of social grant if adherent to treatment. This fear was much greater in the deep-rural area (88.5%) than in the other areas (p=0.000). A larger proportion of patients (30.9%) in the semi-urban area reported that they were not granted leave from work to collect their medication. Regimen changes affected adherence in 32% of patients while compliance to treatment for 67.9% of the patients was affected by side-effects. The association between mistrust of the new single tablet and adherence was statistically significant (p=0.023). A lower proportion of urban patients (35.6%) showed mistrust compared to the other areas, and 18.8% of patients taking single agents missed one of the two daily doses, with most (25.9%) of the patients who missed the dose being from the semi-urban area. Over 51% of patients did not see the need of taking their medication due to feeling better. This generally affected all 3 areas. Ninety two percent of patients in the deep-rural area indicated that they felt safe in the facility compared to the other areas. Just over half of the patients attending the semi-urban area clinic liked their facility, compared to 91.8% of the deep-rural area and 95.9% of the rural area patients. Staff attitude affected adherence, where71.2% in the deep-rural area felt that the staff attitude was good compared to the perception of patients in the other two areas (p=0.00). A larger proportion (87%) of the patients in the semi-urban area reported food frequently being available thus enabling them to take their medication, whilst 46.5% of these patients felt that reminder methods were not effective compared to 57.4% (rural) and 58.5% (deep-rural). Conclusion The adherence levels of patients in rural, deep-rural and semi-urban areas are affected by various factors. The area of residence had statistical significance in some of the factors that affected adherence, while some factors were cross-cutting across all the areas of residence.