Journal of Medicine and Medical Science Vol. 3(4) pp. 212-216, April 2012
Available online http://www.interesjournals.org/JMMS
Copyright © 2012 International Research Journals
Full Length Research Paper
Predictors of ART adherence among HIV infected
individuals in Dakar, Senegal
P.G. Sow¹,²*, K.Toure 3,4, M. Coume3,6, A.T. Dia2,5, I. Traore1
1
Social institute of Health and hygiene of Dakar
2
University of Bambey
3
Cheikh Anta Diop University of Dakar
4
Hospital Center of Fann
5
Health Institute and Development
6
Medicosocial and University Center of IPRES, Dakar-Senegal
Abstract
Treatment adherence is one of the challenges in the failure of HAART. According to studies, 10%
of patients are likely to experience virological failure even if they maintain 95% or more
adherences. Unfortunately, non-adherence to ART in adult population is varied from 33% to 88%.
Hence, in the present study, we report various predictors of ART adherence and suggest
appropriate intervention. We conducted a cross sectional study during the first quarter of year
2011 at the Institute of Health and Hygiene of Dakar. Based on certain inclusion criteria HIV
infected individuals included for the study after getting informed consent. Apart from sociodemographic details, Anthropometry and ART adherence were obtained directly from the
participants. CD4 count at “0” month and 6th month was obtained. Chi-square tests, “F” test and
“t” tests were performed to see the statistical significance. Of 60 participants interviewed 30 were
women. Median age of respondents was 35. Mean duration of illness was 34.05 months and
duration of ART was 17.67 months. Fifty five percent of respondent’s spouses were HIV positive.
Poor adherence was reported by 21%. Poor ART adherence has resulted in lower CD4 increase.
For example, persons reported good adherence had mean of 184.81 while participants reported
poor adherence had and increase of 78.12. No significant difference in BMI was observed. Pill
burden (p-value .000), Feeling better (p-vale .006) and adverse effects (p-value-.000) were directly
related to poor adherence. To lesser extend, experience of stigma (p-value-.053), and satisfaction
with quantum of drugs consumed (p-vale.015) have contributed to poor adherence. In conclusion
the results highlight the importance of addressing the issues of adverse effects and repeated
counselling session on sustained intake of drugs to improve ART adherence.
Keywords: Predictors, Anti-retroviral therapy, HIV, Senegal.
INTRODUCTION
According to estimates, by the end of 2010, adult HIV
prevalence in Senegal was approximately 2 percent,
Senegal has one of the Africa’s lowest HIV/AIDS
infection rates l but vulnerable groups such as sex
workers have higher HIV prevalence. Currently
(UNAIDS/WHO, 2010), HIV infection among legal sex
workers in Dakar has risen to 21%, compared to 1% 20
years ago. The rate is as high as 30% in the southern
city of Ziguinchor (Senegal, 2004). The HIV prevalence
*Corresponding Author E-mail: pgallo92000@yahoo.fr
for clandestine sex workers is not available; it thought to
be much higher than the rate for registered sex
workers. We estimate that more than 80% of Senegal
sex workers do not register. Although it is one of the
poorest countries in the world, with a per capita annual
income less than $600 in 2008, Senegal is considered
one of the world’s success stories in HIV prevention.
While other sub-Saharan African countries are
experiencing the worst epidemic in the world. with a
“concentrated” epidemic, the general population in
Senegal has remained relatively free of AIDS, through
vulnerable populations have significantly higher
prevalence among commercial sex workers. Senegal’
Sow et al. 213
success at maintaining low overall prevalence has been
attributed to the confluence of a number of factors,
including strong political leadership, early involvement
and leadership among religious leaders, conservative
cultural norms regarding sexual practices, and a
comprehensive strategic approach implemented early in
the epidemic. (UNAIDS/WHO, 2009).
The degree of government commitment in the fight
against AIDS is visible in its well developed public
sector ART program, the Initiative Senegalese Access
aux ARV (ISAARV) (UNAIDS/WHO, 2006). With the
advent of highly active antiretroviral therapy (HAART),
in 1998, more number of people are put on ART every
day in Senegal. Today, with the availability of ART
treatment, HIV-infected patients are living. In order to
obtain full benefit of ART, near Perfect and sustained
adherence to treatment is critical. Unfortunately, nonadherence is common among individuals treated with
HAART. Several studies have shown varying levels of
adherence. (Deeks et al., 1997; Safren et al., 2005)
.Reasons for adherence or poor adherence differ from
place to place and are multi- dimensional in nature.
From provider’s perspective lack of trust between
clinician and patient (Nischal et al., 2005), counseling
services provided (Sharma et al., 2007), waiting hours
all contribute to good or poor adherence. From the
receivers perspective, there can be several issues
starting from fear of disclosure, stigma, alcohol or
substance abuse, number of pills required, financial
burden (Sama et al., 2008) . Currently adherence
assessment is not done and rate is not available as a
result no preventive strategies are adopted to reduce
treatment non-adherence. Hence, this study was
planned to identify important barriers to treatment
adherence among HIV infected individuals in Senegal
and suggests ways and means to address the issue of
non-adherence.
METHODS
The anti-retroviral treatment (ART). Center located at
the Institute of Health and Hygiene Sociale in Dakar has
patients on ART which include male, women, Trans
gender and children. The HIV infected individuals who
were started on treatment six month prior to date of
interview and given consent were included for the
study. A structured interview schedule was used to
collect
information
on
the
socio-demographic
characteristics such as age, gender, education,
occupation, marital status, spouse HIV status and
income etc., Participants also completed a brief HIV
questionnaire related to self and that of family
members’ questionnaire. Information on shopping for
HIV was collected. Anthropometry was performed to
measure BMI. Interviews were conducted at the ART
center. Participants were informed of the study
objectives and procedures prior to data collection. Thus
obtained, data were entered in Excel spread sheet
followed by data cleaning and recoding. Further data
analysis was performed in SPSS version 11(SPSS inc.
Chicago, IL, USA). Univariate analysis was performed
to compare demographic and socio-economic
characteristics of patients using X2 test regression was
performed to assess the factors influencing ART
adherence of HIV infected Individuals.
RESULTS
Of 60 participants interviewed 30 were women. Median
age of respondents was 35 years. Fifty five percent of
respondent’s spouses were HIV positive. Respondents
mean age at marriage was 20 years and 21 years for
their spouses. Twenty two respondents were illiterate
and other details are presented in table 1.
Majority of the respondents sought treatment in a
public hospital. Thirty six percent of respondents sought
treatment at private hospitals before seeking treatment
in the public hospital. HIV test results were disclosed to
the respondents to 73.3% by the counsellors. Five
respondents did not disclose their HIV status to their
spouses. For 45% of the respondents, their spouse
either HIV negative or HIV status is not known. Mean
CD4 count at 0 months for respondents was 129.47 SD
(314.23) and at month was 314.23 SD(147.927).Mean
BMI score was just about 19.09 SD(2.93).
Mean duration of illness was 34.05 months and
duration of ART was 17.67 months (Table 2). Poor
adherence was reported by 21%. Poor ART adherence
has resulted in lower CD4 increase. For example,
persons reported good adherence had mean of 184.81
while participants reported poor adherence had and
increase of 78.12. No significant difference in BMI was
observed (Table 3).
Logistic regression analysis has shown that Pill
burden (p-value .000), Feeling better (p-value .006) and
adverse effects (p-value-.000) were directly related to
poor adherence. To lesser extend, experience of stigma
(p-value-.053), and satisfaction with quantum of drugs
consumed (p-vale.015) have contributed to poor
adherence (Table 4). Participants who were started on
treatment with low CD4 count were more likely to
maintain poor adherence and eventually end up with
lower CD4 count increase. Participants whose mean
CD4 count was relatively high at the time of initiation of
ART had higher mean CD4 count 6 months.
DISCUSSION
The study findings are in consistent with previous
findings that the rate of treatment adherence is
relatively poor (Sama et al., 2008).
Adverse effects of drug and pill burden appears to be
the primary factors that influence ART adherence.
Though addressing these two issues is a difficult task,
yet some efforts may be needed to reduce non-
214 J. Med. Med. Sci.
Table 1. Socio demographic characteristic of the participants
Factors
Male
Female
Sex
Age in years
Spouse Age
Marital Status
Married
Separated
Age at Marriage
Spouse age at Marriage
Mean Family Size(adult)
Mean Family Size(Children)
Illiterate
Literate
Illiterate
Literate
Daily wage
skilled
Unemployed/
Housewife
Daily wage
skilled
Unemployed/
Housewife
Literacy
S. Education
Occupation
Spouse
Occupation
Duration of illness(in Months)
Place of Treatment seeking
Place of screening
Result disclosure
Disclosure to spouse
Spouse HIV status
Frequency %
30
50
30
50
85
5
91.7
8.3
Mean 1.58
Mean 1.78
13
47
17
43
37
9
14
21.7
78.3
28.3
71.7
61.7
15
23.3
39
12
9
65
20
15
Mean 34.05
Private
22
Govt
57
Self
1
Traditional
2
healers
Private Hospital 18
VCTC/Govt
24
VCTC/NGO
2
Private lab
1
Counselor
44
Doctor
13
Technician
1
Not informed
2
No
5
Yes
55
Positive
33
Negative
16
Unknown
7
Median
35SD(7.139) .600
34(8.107)
.000
20.50SD(4.959)
21SD(4.640)
SD 1.046
SD .904
.000
.000
.000
.000
SD
36.7
95
2
3.3
23.596
73.3
21.7
3.3
1.7
73.3
21.7
1.7
3.3
8.3
91.7
55
26.7
18.3
3
Table 2. Bio Markers of HIV patients
Parameters
Duration of Illness
(in months)
Duration of ART
CD4(0 month)
CD4(6 Month)
BMI
2
X
1.00
Mean
34.05
Std. Deviation
23.596
17.67
129.47
314.23
19.098
9.24
314.23
147.927
2.9356
.000
.000
.000
.000
Sow et al. 215
Table 3. Adherence Vs biological parameters (BMI and CD4 count at 0
and 6 month)
Factors
Number
CD4 0 Months
CD4 6 months
BMI
Good Adherence
47
135.77
320.58
19.004
Poor Adherence
13
106.69
288.27
19.438
Table 4. Logistic regression values on predictors of ART adherence
Sl.no
1
2
3
4
5
6
Prdictors
Pill Burden
Stigma
Feel Better
Adverse Effect
Satisfied with Drug
Service availed at Public facility
adherence. Combined pill forms, half-longer life drugs
(e.g. single daily dose) or longer acting controlled
release forms may become important strategies in
improving compliance with anti-retro viral therapy
(Mehta et al., 1997). As documented by Mehta et al
some of or all of the commonest side effects like
leucopenia, anemia, transfusion and gastrointestinal
might have influenced decreased adherence among our
study participants too. In congruence with previous
studies Lower baseline CD4 count found to negatively
affecting ART (Sama et al., 2008). Currently in all
patients, regardless of their condition, only receive free
ARVs if their CD4 count is less than 200. Mean CD4
count at baseline of our study participants was 129.47.
Hence efforts can be made to enrol HIV patients to ART
programme with higher CD4 counts, if possible.
Stigma as reported by previous studies (Safren et al.,
2005), appear to its influence in treatment adherence.
Since the early days of the AIDS epidemic, stigma and
discrimination have been recognized as obstacles to
HIV prevention, treatment and support (UNAIDS 2010).
Particularly internalized stigma appeared to manifest in
feelings of shame, hopelessness and guilt, social
withdrawal and eventually lead to a tendency not to use
existing treatment or support services (Thomas et al.,
2005).
Therefore, pre-treatment interventions that aim to
reduce non-adherence should consider these predictors
and concentrate on the following the issues, in an
attempt to dispel the doubts the patients may have on
the following aspects.
Achieve good rapport and asses behavioural skills
such as goal setting, assertiveness and problem
solving.
Covey the common probable side effects of ART to
the patients. This awareness the patients confidence in
the physician and hence the adherence, Anticipate side
F-value
13.630
3.886
8.261
13.630
6.254
(t-test) 46.000
P-value
.000
.053
.006
.000
.015
.083
effects and treat them as soon as possible. This should
be followed by nutritional supplement as most of them
do not have enough means to meet their dietary
requirements.
Pill fatigue or treatment fatigue is quite common
among any person who requires long term treatment.
This is exactly true with HIV infected patients who
require consuming drugs for lifetime. Hence, intensive
and regular monitoring is the only solution. Further in
clinical practice, the most efficient method is to simply
ask the patient in supportive and non-judgemental
manner (Sakett, 1975)
CONCLUSION
Further, the information on adherence was obtained by
self reporting, hence, its authenticity is not clearly
known. Hence, findings from these analyses suggest, in
addition to planning for interventions mentioned above,
development of alternate assessment tools to measure
treatment adherence may be useful to obtain predictors
of ART adherence among HIV infected individuals.
REFERENCES
Deeks SG, Smith H, Holodiny M, Khan J (1997), HIV-1 Proteas
inhibitors.A review for clinicians, J. Ame. Med. Assoc. 277:145-153.
Mehta S, Moore RD, Graham NMH (1997). Potential factors effecting
adherence with HIV therapy; AIDS -Volume 11(14): 1665-1670
Nischal KC, Khopkar U, Saple DG (2005). Improving adherence to
antiretroviral therapy. Indian J. Dermatol. Venereol. Leprol. SepOct. 71(5):316-20.
Sackett DL, Haynes RB, Gibson ES, Hackett BC, Taylor DW, Roberts
RS, (1975). Randomized clinical trial of strategies for improving
medication compliance in primary hypertension. Lancet.1:1205-7
Safren SA, Kumarasamy N, James R, Raminani S, Solomon S, Mayer
KH (2005). Adherence, demographic variables and CD4 outcome
among HIV-positive patients on antiretroviral therapy in Chennai,
India.AIDS Care. Oct. 17(7):853-62.
216 J. Med. Med. Sci.
Sarna A, Pujari S, Sengar AK, Garg R, Gupta I, Dam J (2008).
Adherence to antiretroviral therapy and its determinants amongst
HIV patients in India. Indian J. Med. Res. 127(1):28-36.
Sharma M, Singh RR, Laishram P, Kumar B, Nanao H, Sharma C,
Ahmed T (2007). Access, adherence, quality and impact of ARV
provision to current and ex-injecting drug users in Manipur (India):
an initial assessment. Int. J. Drug Policy. 18(4):319-25.
Thomas BE, Rehman F, Suryanarayanan D (2005). How stigmatizing
is stigma in the life of people living with HIV: a study on HIV
positive individuals from Chennai, South India. AIDS Care
17(7):795-801).
UNAIDS/WHO (2009 February), “UNAIDS guidance note on HIV and
sex worker
UNAIDS/WHO Report on the global AIDS Epidemic, May 2010.
UNAIDS/WHO. Epidemiological fact sheets on HIV/AIDS and sexually
transmitted infections: update 2009.