Factors influencing adherence to antiretroviral therapy in rural Zimbabwe: implications for health policy and practice

© 2010 Dr. Rosemary Mhlanga-GundaBackground: The extraordinarily high thresholds of adherence (≥95% of doses taken) currently deemed essential for good control of HIV has proved daunting for patients and challenging to clinicians in antiretroviral therapy (ART) programmes. Typical average adherence in other chronic diseases is between 50%-70%. Non-adherence to ART leads to the possibility of increased viral load, threatening the survival of individual patients and potentially raising the incidence of HIV in the general population. Adherence to ART is further complicated by lack of a gold standard tool to measure it. This study was conducted in Zimbabwe, one of the eight Southern African countries with generalised HIV epidemics (estimated prevalence of 15.3% in 2007). ART roll out began in 2004 as part of responses to address the epidemic. The ART programme is being implemented within an unprecedented humanitarian crisis. Aim: The study aimed to contribute to public health policy and program development by documenting adherence levels and assessing patient, community and health delivery factors influencing adherence to anti-retroviral therapy among patients in rural Zimbabwe. Method: The study design was mixed methods in two phases. The qualitative phase comprised six focus group discussions (FGDs) with 48 participants and 39 semi-structured interviews with the community and patients on ART, and one FGD with health staff; this phase was conducted to gain insight into influences on adherence in a specific context. The quantitative phase was a cross sectional survey with 180 patients on first line ART using an interviewer administered questionnaire that included three measures to estimate levels of adherence (visual analogue scale [VAS], seven day recall and unannounced pill counts [UPC] and questions exploring influences on adherence. Qualitative data were thematically analysed. Quantitative data were analysed using descriptive statistics, Chi-square and T tests to ascertain associations between variables Predictors of adherence were identified through binary logistic modelling. Results: Enablers of adherence identified qualitatively were: availability and accessibility of food; improved quality of life; hope of living longer; psychosocial support; and reliable drug supplies. Obstacles to adherence were: poverty, food unavailability and inaccessibility, alcohol use, denial and non-disclosure of HIV diagnosis, stigma and discrimination, lack of psychosocial support, cultural beliefs and practices, and lifelong duration of ART. Quantitative results showed levels of ≥95% adherence varied by method of measurement: 80.7%, 64.5% and 44.4% by VAS, seven day recall and UPC, respectively. Predictors of suboptimal adherence were: reported feelings of depression [OR 4.3, 95% CI 1.85-9.75]; need for a break from taking ARVs [OR 3.9, 95% CI 1.22- 12.15]; being female [OR 2.6, 95% CI 1.08-6.11]; feeling of not being listened to by health workers [OR 3.2, 95% CI 1.20-8.34]; having completed at least secondary education [OR 5.0, 95% CI 2.22-11.13]; perceived experience of stigma and discrimination as a disadvantage of disclosure [OR 2.5, 95% CI 1.15-5.20]; and difficulties travelling to the health centre for collection of ARVs and clinical review [OR 2.4, 95% CI 1.14-5.10]. Conclusions: Variations in adherence by measure indicate a need for further development of feasible tools. Patients alone do not hold the key to adherence. The complex problem of non-adherence should be urgently addressed from a multilayered, collaborative and complementary perspective that considers implications of the current humanitarian crisis. A range of context appropriate recommendations for patients, community and health provider levels are identified