Voices on adherence to ART in Ethiopia and Uganda: a matter of choice or simply not an option?

Abstract

This paper explores HIV patients' adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Interviewees voiced their experiences of, and views on ART adherence both from an individual and a system level perspective. Two main themes emerged from the content analysis: "Patients' competing costs and systems' resource constraints" and "Patients' trust in ART and quality of the patient-provider encounters." The first theme refers to how patients' adherence was challenged by difficulties in supporting themselves and their families, paying for transportation, for drug refill and follow-up as well as paying for registration fees, opportunistic infection treatment, and expensive referrals to other hospitals. The second theme describes factors that influenced patients' capacity to adhere: personal responsibility in treatment, trust in the effects of antiretroviral drugs, and trust in the quality of counseling. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling.

Inadequate pre-antiretroviral care, stock-out of antiretroviral drugs and stigma: Policy challenges/bottlenecks to the new WHO recommendations for earlier initiation of antiretroviral therapy (CD<350 cells/μL) in eastern Uganda

“…Regular attendance to pre-ARV care enhances routine clinical assessment of a patient's eligibility for treatment and hence timely ART initiation. Non-adherence to pre-ARV care or loss to follow-up could be due to inadequate or poor quality post-test counseling, late disease presentation, long waiting times, lack of incentives to motivate the PLHIV to come for care in time or deterrent actions by other providers, such as traditional and spiritual healers [10,25,30,[34][35][36][37] Corresponds to L 18 by reviewer 2.…”

“…A recent qualitative study on adherence to ART in Uganda found that clients' competing costs and trust in ART, system resource constraints and the quality of counseling were vital factors influencing adherence [30]. We hypothesized that the reasons for late ART initiation differed from those influencing adherence to ART once already initiated on treatment and the policy implications/challenges would therefore also be different.…”

Improving ART adherence at reproductive and child health clinics integrating Option B+ in Tanzania

“…We showed that both individual-level and system-level barriers can affect appointment keeping and adherence to medications in East Africa, and this ultimately compromises optimal clinical outcomes (Gusdal et al 2009). For practical reasons, INRUD-IAA focused on developing affordable system-level interventions that target both systems-related and individual barriers to adherence (see Figure 1).…”

“…In our previous work in the International Network for the Rational Use of Drugs Initiative on Antiretroviral Adherence (INRUD-IAA), we used both quantitative and qualitative methods to explore the prevalence and determinants of adherence and appointment keeping in five East African countries (Gusdal et al 2009;Chalker et al 2010;Ross-Degnan et al 2010). We showed that both individual-level and system-level barriers can affect appointment keeping and adherence to medications in East Africa, and this ultimately compromises optimal clinical outcomes (Gusdal et al 2009).…”

“…These interventions build clinic staff commitment to focusing on attendance and encourage creative solutions to sustaining patients on therapy. The intervention was designed to increase: (1) patient engagement, by including patients in decision-making on their appointment schedule rather than demanding their presence on certain days (Gusdal et al 2009); (2) patient-staff communication because poor communication has been shown to discourage attendance (Gusdal et al 2009); (3) linkage to community support systems to encourage attendance and bring people back into care (Mwatawala et al 2012); and (4) a facility focus on improving quality of care (Nyamusore et al 2011;Mwatawala et al 2012;Boruett et al 2013). …”