All about antiretroviral treatment (ART)

Once patients begin antiretrovirals (ARVs), non-adherence to treatment regimens can have important implications for the community. Non-adherence
is a powerful predictor of virus replication, disease progression, emergence of drug resistance and death for people with HIV. Indeed, concerns about poor ART adherence and development of widespread drug resistant strains of HIV have been a major consideration in the effort to expand ART access in Africa.

Fortunately, several studies have shown that high adherence rates are possible in Africa. Factors reported to reduce ART adherence in Africa include the following: cost; not disclosing HIV status to a loved one; fear of being stigmatized; alcohol abuse; and lack of transport to attend clinics to get medicines. The main barriers are discussed in greater detail below.

Barrier one – revealing HIV status
Good support (both practical and emotional) has been shown to be an important factor in maintaining ART adherence. However, in order to receive direct social support, people must disclose their HIV-positive status to others. Greater disclosure predicts higher social support. As a result, patients who report greater openness about their HIV status are likely to have higher rates of adherence.

A qualitative study in South Africa found that ensuring ART adherence depends on patients revealing their HIV status. Doing so means they will not hide their tablets from their loved ones. While HIV status disclosure is an important step towards getting social support and improving adherence, it can also lead to stigma and discrimination. In the latter study, some female patients were afraid that family members would spread information about their status when drunk. Some had expected that family members would support them, but in fact they were rejected. The social status of women has an impact on their access to medication and their ability to adhere. More importantly, there is a need to provide patients with skills to maintain adherence in situations where disclosing their status is not safe. Patients may also need help to make informed choices about selective disclosure.

Barrier two – HIV stigma and fear of stigma
Although studies from Soweto and KwaZulu-Natal province suggested that people should admit their HIV status, those who had done so often reported fear, as well as the likelihood of missing ART doses or being isolated from their communities. This revealed the importance of stigma and the fear of stigma in getting and adhering to ART. In the latter study, men were more likely to say that their isolation was imposed by others. Women were more likely to say that their isolation was self-inflicted. Participants said that issues linked to stigma included ignorance of the disease, denial, fear of infection, and the use of frightening language and negative comparisons to describe HIV infection.

Barrier three – alcohol and substance abuse
Few studies in Africa have examined the effect of alcohol abuse in HIV-positive people. No studies to date have examined the effect of substance abuse on ART adherence. Many reports in both developed and developing countries have found that both alcohol and other forms of substance abuse are probably important barriers to ART adherence. For example, in the townships of South Africa, 78% of men and 30% of women being treated for sexually transmitted infections report current alcohol use. A history of alcohol abuse was linked to increased odds of poor adherence (less than 95%).

Barrier four – lack of money for food and transport to the clinic or hospital
Unemployment and a lack of food affect ART adherence in Africa. A study conducted in South Africa examining the role of treatment supporters found that patients interviewed mentioned lack of food, transport and money as barriers to medication adherence. These patients often relied on financial
support from family members as well as government grant money. In Uganda, Tanzania, and Botswana, patients reported transport costs, user fees, and lost wages from clinic appointments as barriers to adherence. They also reported increased hunger during their initial treatment phase. Lack of money for transport can cause treatment interruptions that contribute to the development of drug resistance.

Conclusion
While adherence to ART in Africa may not be as poor as predicted earlier, there are emerging structural and social barriers. Alcohol abuse, HIV status non-disclosure and stigma, as well as treatment interruptions due to transport costs and drug stock shortages are being identified as important challenges to ART adherence and to efforts to reduce the burden of HIV in sub-Saharan Africa. There is a need to do both qualitative and quantitative research on these issues so that culturally appropriate targeted interventions can be implemented to overcome these barriers.

 

This material on adherence barriers has been adapted from an article in the Treatment Action Campaign’s Equal Treatment Issue number 28 entitled 'Side effects and adherence'. This issue is available online or can be requested in hard copy in several different languages.

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