(Non)Adherence in Doctor/Patient Interactions in Nigerian HIV Clinics

In the context of chronic-routine doctor/patient consultations, interactions are focused on care and support for the patients, which is achieved when patients periodically attend the routine consultations and adhere to medical recommendations. This study examines the consultations between female HIV-positive patients and doctors/counsellors in outpatient clinics covering Nigeria’s south-western geo-political zone. It specifically discusses the interactional activities prevalent in the consultations, and participants’ (doctors, counsellors and patients) views on patients’ adherence behaviours, as recovered from interview data. Using insights from conversation analysis (CA) and socio-cognitive theory (SCT) as methodological and theoretical backgrounds respectively, this study qualitatively analyzes transcribed data derived from seventy audio recordings of doctors’ conversations with female HIV-positive patients. Supplementary data include seventeen semi-structured interviews with the research participants, which were subjected to inductive thematic analysis. This study also considers data from patients’ case notes, current reports on HIV/AIDS in Nigeria from international organizations, and participant observations. Findings from this study reveal that the notion of adherence is a multi-dimensional concept that entails both adherence to medications and compliance with other medical recommendations (including regular clinic visits and CD4 count cell tests). Taken together, these expectations are used as indicators of patients’ willingness to take an active role in adhering to treatment regimens. While doctors make provision for solicitation of patients’ medical concerns among others pertinent concerns in the consultations, the opening phases, history-taking phases and treatment discussion phases are majorly contextualized by one central objective: doctors’ expectations of patients’ nonadherence to medical recommendations. Participants orient to this expectation as they negotiate interactional trajectories that seek to address patients’ nonadherence through practices of accusations, and explicit and implicit references to adherence during medical history-taking. When patients are accused of nonadherence, they often respond by justifying their behaviours with accounts. However, responses are more cooperative when accusations are absent. During treatment discussions, adherence is ensured through instructions on drug use, explanations about the importance of regularly conducting CD4 count cell tests and planning next appointments to the clinics. These findings are further supported by results from the analysis of interview data which show that doctors and counsellors constantly work with the beliefs that patients’ nonadherent behaviours do exist, and can be attributed to their social situations, including subjective beliefs about illness. Another significant finding is that patients who indulge in alternative therapeutic options do so in pursuit of optimizing positive treatment outcomes. Hence, they treat these alternative options as facilitator and motivators for optimizing the outcome of treatment regimens. However, doctors and counsellors view these options as barriers to adherence. It is suggested that doctors and counsellors view patients’ adherence behaviours by subscribing to their subjective beliefs. This study contributes to the discourse on doctor/patient consultations in Nigeria by discussing how these adherence-related interactional dynamics are negotiated between doctors, patients and counsellors in the routine medical context of HIV consultations in south-western Nigeria