Exploring how the management of household incomes impact on antiretroviral therapy adherence behaviour of people living with HIV in the Western Cape, South Africa

Thesis (MPhil)--Stellenbosch University, 2021.ENGLISH ABSTRACT: The Human Immunodeficiency Virus (HIV) epidemic presents a global health crisis, with approximately 38 million people worldwide living with HIV (PLHIV) in 2019. Amongst them, an estimated 7.8 million PLHIV live in South Africa. In 2016, the South African government increased access to HIV testing and treatment following the proposed ‘universal test and treat’ strategy advocated by the World Health Organisation (WHO). However, there remains a significant treatment gap as only 4.8 million PLHIV are estimated to be receiving antiretroviral therapy (ART) in the country, and many of those on ART are experiencing challenges in adhering to treatment. Several studies have found that factors surrounding household income are contributing to these challenges. In this study, I explored how the management of household incomes impact the ART adherence behaviour of PLHIV from 13 families affected by HIV in the Western Cape of South Africa. I have drawn findings from the data collected as part of the HPTN 071 (PopART) trial, where in intervention communities, HIV care was delivered at a household level and HIV treatment was made available to all PLHIV prior to changes in the national HIV guidelines. I used Bronfenbrenner’s ecological framework, which entails characterising social life in five levels including the microsystem, mesosystem, exosystem, macrosystem, and chronosystem to interpret the results. Using a thematic approach to organise and analyse data, I first described how families ‘got by’ including social grants and social support; informal borrowing and loans; employment; and independent survival strategies. I found that families managed their procured incomes differently depending on varying household priorities. I found that there is fluidity on the ART adherence behaviours of PLHIV. People could iteratively move from being reluctant, to being adherent and interrupt treatment due to life changes. In the study, I found that factors in the immediate environment (micro-level), including competing household priorities, lack of resources, and recreational activities, have the strongest influence on ART adherence behaviours of PLHIV. I found that households have the potential to create a positive health-enabling environment for PLHIV through adjusting their expenditure patterns in a manner that facilitates optimal adherence to care. However, there were various determinants surrounding ART adherence that operated beyond the influences located at the household level. I propose that future health interventions should be increasingly tailored for household-specific needs, but should also be wary of neglecting factors associated with ART adherence existing beyond the household level.AFRIKAANSE OPSOMMING: Die Menslike Immuniteitsgebreksvirus (MIV)-epidemie skep 'n wêreldwye gesondheidskrisis, met ongeveer 38 miljoen mense wereldwyd wat met MIV leef (PLHIV) in 2019. Na beraming woon 7,8 miljoen mense wat met MIV leef in Suid-Afrika. In 2016 het die Suid-Afrikaanse regering toegang tot MIV-toetsing en behandeling verbreed na aanleiding van die voorgestelde strategie vir 'universele toets en behandeling' wat deur die Wereldgesondheidsorganisasie (WGO) voorgestaan word. Daar is egter 'n beduidende behandelingsgaping, aangesien slegs 4,8 miljoen PLHIV na verwagting antiretrovirale terapie (ART) in die land ontvang, en baie van diegene op ART ervaar uitdagings om behandelings riglyne na te kom. Verskeie studies het bevind dat faktore rondom huishoudelike inkomste tot hierdie uitdagings bydra. In hierdie studie ondersoek ek hoe die bestuur van huishoudelike inkomste die ART-nakomingsgedrag beïnvloed van PLHIV uit 13 gesinne wat deur MIV in die Wes-Kaap van Suid-Afrika geraak word. My bevindinge is gebaseer op data wat versamel is as deel van die HPTN 071 (PopART) -proef, waar MIV-sorg op huishoudelike vlak gelewer is in intervensiegemeenskappe en MIV-behandeling aan alle PLHIV beskikbaar gestel is voordat die nasionale MIV-riglyne verander is. Ek het die ekologiese raamwerk van Bronfenbrenner gebruik om my resultate te interpreteer. Volgens hierdie raamwerk word sosiale lewe op vyf vlakke beskryf insluitend die mikrosisteem, mesosisteem, eksosisteem, makrostelsel en chronestelsel. Met behulp van 'n tematiese benadering om data te organiseer en te ontleed, het ek eerstens beskryf hoe gesinne 'klaar kom', wat insluit maatskaplike toelaes en maatskaplike ondersteuning, informele lenings, indiensneming, en onafhanklike oorlewingstrategieë. Ek het bevind dat gesinne hul verkrygde inkomste anders bestuur, afhangende van die verskillende huishoudelike prioriteite. Ek het bevind dat daar n ‘vloeibaarheid’ in die ART nakoming is deur PLHIV. Mense beweeg tussen huiwering oor behandeling, tot getrou aan behandeling, tot onderbreekte behandeling, afhangend van lewensveranderinge. In die studie het ek gevind dat faktore in die onmiddellike omgewing (mikrovlak), waaronder kompeterende huishoudelike prioriteite, gebrek aan hulpbronne, en ontspanningsaktiwiteite, die grootste invloed het op PLHIV se nakomingsgedrag aan ART. Ek het bevind dat huishoudings die potensiaal het om 'n gesondheids-omgewing vir PLHIV te skep deur hul uitgawepatrone aan te pas op 'n manier wat optimale nakoming van sorg kan fasiliteer. Daar was egter verskillende faktore rondom ART-nakoming wat buite die invloed van huishoudelike vlak bedryf word. Ek stel voor dat toekomstige gesondheidsintervensies toenemend aangepas moet word vir huishoudingspesifieke behoeftes, maar ook moet waak teen die verwaarlosing van faktore wat verband hou met ART-nakoming wat buite die huishoudelike vlak bestaan.Master