A quantitative analysis of food insecurity and other barriers associated with ART nonadherence among women in rural communities of Eswatini

Abstract

Background Eswatini has the highest global prevalence of HIV despite decades of universal access to free antiretroviral therapy (ART). We conducted a mixed methods study to investigate barriers to ART adherence among women living with HIV (WLHIV) in rural communities of Eswatini. Qualitative findings were reported in our previous publication. This subsequent paper expands on our qualitative analysis to examine the magnitude to which identified barriers impacted ART adherence among WLHIV in the same communities. Methods We used an exploratory sequential design to collect data from WLHIV (n = 166) in rural Eswatini. Quantitative data were collected using interviewer-administered survey questionnaires between October and November 2017. ART adherence was measured using the CASE Adherence Index, with scores less than 10 indicating nonadherence. Log-binomial regression models were used to examine the extent to which critical barriers affected ART adherence among study participants. Results A majority of the women in our study (56%) were nonadherent to ART. Of the barriers identified in our prior qualitative analysis, only eight were found to be significantly associated with ART nonadherence in our quantitative analysis. These include, with adjusted risk ratios (ARR) and 95% confidence intervals (95% CI): household food insecurity (ARR: 3.16, 95% CI: 1.33–7.52), maltreatment by clinic staff (ARR: 2.67, 95% CI: 1.94–3.66), forgetfulness (ARR: 1.80, 95% CI: 1.41–2.31), stress (ARR: 1.47, 95% CI: 1.14–1.88), gossip (ARR: 1.57, 95% CI: 1.21–2.04), mode of transport (ARR: 0.59, 95% CI: 0.44–0.79), age (ARR: 0.98, 95% CI: 0.97–0.99), and lack of community support (ARR: 0.55, 95% CI: 0.35–0.85). Conclusions Among numerous barriers identified in our study, food insecurity was found to be a significant contributor toward ART nonadherence among women living with HIV in rural Eswatini. Future strategies aimed at improving ART adherence in Eswatini should include programs which provide food and nutrition support for people living with HIV, particularly rural women living in poverty.

Exploring the barriers to the antiretroviral therapy adherence among people living with HIV in Bangladesh: A qualitative approach

“…There was significant evidence that the discriminatory act eventually led to fear of disclosure due to harassment and rejection [36][37][38][39][40][41][42]; we also observed the same among our study respondents, which seriously affected their treatment adherence. Similar to other study findings [32,43,44], our study respondents showed their concerns about the new PLHIV, as they may be afraid of visiting ART centre to avoid social discrimination related to social isolation and harassment.…”

Food insecurity and the risk of HIV acquisition: findings from population-based surveys in six sub-Saharan African countries (2016–2017)

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“…20 Food insecurity has also been associated with lower efficacy of antiretroviral treatment (ART) due to drug malabsorption or decreased adherence, with virological failure. [21][22][23] As countries pursue the new UNAIDS 95-95-95 goals, weather extremes disrupting food production and supplies could jeopardise epidemic control, both in terms of increased risk behaviours, as well as disruption of treatment due to displacement or poverty, impacting access to testing and ART services. 24 This results in increasing community-level infectiousness, driving the synergistic relationship between land degradation, vulnerability to drought, food insecurity and HIV transmission.…”

“…The impact has been assumed to be gendered in that women are particularly vulnerable to income shocks and to disruption to access to health resources 20. Food insecurity has also been associated with lower efficacy of antiretroviral treatment (ART) due to drug malabsorption or decreased adherence, with virological failure 21–23. As countries pursue the new UNAIDS 95-95-95 goals, weather extremes disrupting food production and supplies could jeopardise epidemic control, both in terms of increased risk behaviours, as well as disruption of treatment due to displacement or poverty, impacting access to testing and ART services 24.…”