From Access to Adherence: The Challenges of Antiretroviral Treatment - Studies from Botswana, Tanzania and Uganda, 2006: Factors that facilitate or constrain adherence to antiretroviral therapy among adults in Uganda: a pre-intervention study: Chapter 3: Literature review: 3.3 Factors affecting adherence to ART

From Access to Adherence: The Challenges of Antiretroviral Treatment - Studies from Botswana, Tanzania and Uganda, 2006
(2006; 320 pages)

Table of Contents

Acknowledgments
Acronyms and abbreviations
Foreword
1. On hunger, transport costs and waiting time: a synthesis of challenges to ARV adherence in three African countries
	Introduction
	Methods
	Discussion
	Conclusion
	References
2. Overview of antiretroviral therapy, adherence and drug-resistance
	Background
	References
3. From training to action: the process of engaging health professionals in operational research on adherence to antiretroviral therapy
	Introduction
	Promoting the rational use of drugs
	Promoting Rational Drug Use in the Community course
	Three ARV adherence studies: the process
	How the process was funded
	Discussion and conclusion
	References
	Annex 1: PRDUC course participants by region, type of institution, sex and source of funding
	Annex 2: URLs for country proposals
	Annex 3: Call for proposals
4. There's hope - early observations of ARV treatment roll-out in South Africa
Factors that facilitate or constrain adherence to antiretroviral therapy among adults at four public health facilities in Botswana: a pre-intervention study
	Acknowledgements
	Acronyms and abbreviations
	Executive summary
	Chapter 1: Introduction
		1.1 Research problem
		1.2 Research questions
		1.3 Study objectives
	Chapter 2: Background
		2.1 History of HIV and AIDS in Botswana
		2.2 Botswana's ART programme
		2.3 Literature review
		2.4 Definition of concepts
	Chapter 3: Methodology
		3.1 Introduction
		3.2 Study design
		3.3 Study population
		3.4 Description of study sites
		3.5 Inclusion and exclusion criteria
		3.6 Selection and training of data collectors
		3.7 Qualitative data collection
		3.8 Observations
		3.9 Semi-structured interviews
		3.10 Exit interviews
		3.11 Focus group discussions
		3.12 Quantitative data
		3.13 Data analysis
		3.14 Emic perspective
		3.15 Ethical considerations
		3.16 Feedback
	Chapter 4: Quantitative results
		4.1 Adherence measurement tool results
		4.2 Rates of adherence to ARVs
		4.3 Reasons for skipping medication
		4.4 Factors affecting adherence to ART
		4.5 Predictors of adherence to ART
		4.6 Quantitative results of exit interviews
	Chapter 5: Qualitative results
		5.1 Constraints to adherence to ART
		5.2 Facilitators of adherence to ART
		5.3 Observation of health facilities 5.3.1 Structural issues
		5.4 National level policy issues
	Chapter 6: Discussion, conclusion and recommendations
		6.1 Discussion
		6.2 Conclusions
		6.3 Recommendations
	References
	Annex 1: Mean of rates adherence
	Annex 2: Multivariate logistic regression analyses on the predictor variables
	Annex 3: Questionnaires
A study on antiretroviral adherence in Tanzania: a pre-intervention perspective, 2005
	Acknowledgements
	Acronyms and abbreviations
	Executive summary
	Chapter 1: Introduction
		1.1 Background
		1.2 Rationale
		1.3 Literature review
		1.4 Problem statement
		1.5 Objectives
		1.6 Output
	Chapter 2: Methodology
		2.1 Study design
		2.2 Study population
		2.3 Inclusion and exclusion criteria for interviewees
		2.4 Quantitative data
		2.5 Qualitative data
		2.6 Data collection tools
		2.7 Pilot study
		2.8 Sample size and sampling strategy
		2.9 Data collection
		2.10 Ethics
	Chapter 3: Study areas
		3.1 Health care facilities
	Chapter 4: Quantitative results
		4.1 Demographic characteristics of ARV users
		4.2 Adherence rates
	Chapter 5: Qualitative results
		5.1 Factors that influence adherence to ARVs from the users' perspective
		5.2 Quality of operating structures
		5.3 Opinions and suggestions given by respondents to improve provision of ARVs
	Chapter 6: Discussion, conclusion and recommendations
		6.1 Discussion
		6.2 Conclusion
		6.3 Recommendations
		6.4 Proposed interventions
	References
	Annex 1: Exit interview with ARV users
	Annex 2: Semi-structured interview with ARV users
	Annex 3: ARV users, FGDs
	Annex 4: Adherence measurement tools
	Annex 5: Key informant interview
	Annex 6: Semi-structured interviews (with staff)
	Annex 7: Observation (consultations)
	Annex 8: Observation of antiretroviral
Factors that facilitate or constrain adherence to antiretroviral therapy among adults in Uganda: a pre-intervention study
	Acknowledgements
	Glossary
	Executive summary
	Chapter 1: Introduction
		1.1 Background
		1.2 Research problem
		1.3 Research objective
	Chapter 2: Background to the study
		2.1 History of AIDS in Uganda
		2.2 History of ARVs in Uganda
	Chapter 3: Literature review
		3.1 Importance of adherence to ART
		3.2 Measurement of adherence
		3.3 Factors affecting adherence to ART
		3.4 Impact of the drug regimen on adherence
		3.5 Treatment characteristics affecting adherence 3.5.1 Physical state and disease stage
		3.6 The clinic setting and service provision
		3.7 Simplifying treatment regimes to improve adherence
		3.8 Conceptual framework
	Chapter 4: Methodology
		4.1 Study design
		4.2 Study population
		4.3 Inclusion and exclusion criteria
		4.4 Sample size and selection
		4.5 Data collector selection and training
		4.6 Pilot testing
		4.7 Data collection
		4.8 Data analysis
		4.9 Evaluation of methods
		4.10 Ethical considerations
	Chapter 5: Description of the study sites
		5.1 Jinja Regional Referral Hospital
		5.2 Nile Treatment Centre
		5.3 Study limitations
	Chapter 6: Results
		6.1 Demographic characteristics of ARV users
		6.2 Factors influencing adherence to ART
	Chapter 7: Discussion, conclusions and recommendations
		7.1 Discussion
		7.2 Conclusions
		7.3 Recommendations
	References
Back cover

3.3 Factors affecting adherence to ART

3.3.1 Demographic and socioeconomic factors

Although the literature consistently demonstrates that demographic characteristics are not strong predictors of adherence, some correlates of adherence are described below together with socioeconomic factors.

3.3.2 Age

Age may influence adherence. Studies have found that, with the exception of the most elderly, adherence increases with age. In two studies associated with ART adherence, sub-optimal adherence showed a positive correlation with being younger (Jones et al., 1999).

3.3.3 Level of education

A lower level of general education and poorer literacy may impact negatively on some patients' ability to adhere, while a higher level of education has a positive impact (Catz et al., 1999).

3.3.4 Financial constraints

Studies conducted in Africa reveal that the cost of medication is one of the most significant barriers to treatment adherence. In Botswana, Weiser et al. (2003) report adherence difficulties related to the financial demands of therapy and an inability to afford medicines for varying periods. They note that 70% of patients claimed that the cost of ARVs posed a problem for them, and 44% of patients believed that the cost impeded their ability to adhere to treatment. Similarly, over one-half of health care providers (56%) believed that financial problems often or always impeded adherence to ART. The extent to which financial difficulties played a key role in sub-optimal adherence is also reported in study findings in Uganda for patients receiving non-subsidized therapy (Byakika-Tusiime et al., 2003). Medications and clinic visits cost money and may stretch an already meagre budget. In resource-poor countries many people live below the poverty line and there is often no medical insurance or disability pension for people living with HIV (PLWHIV) (Katabira, 2002).

3.3.5 Social support

Living alone and a lack of support have been associated with an increase in sub-optimal adherence (Williams and Friedland, 1997), and social isolation is predictive of sub-optimal adherence. Not living alone, having a partner, social or family support, peer interaction, and better physical interactions and relationships are characteristics of patients who achieve optimal adherence (Motashari et al., 1998).