Adherence to ART

Adherence is defined as the "extent to which a client's behaviour coincides with the prescribed health care regimen as agreed through a shared decision-making process between the client and the health care provider" (KITSO Manual, 2004; Carter, 2004). For the purpose of this study, adherence has been defined as the use of ARVs at the right frequency of dosing. We also checked the number of pills (correct dose) and the time patients were taking them, using a 'sun and moon chart'. Ability to keep to this pattern of utilization is defined as 100% adherence, while adherence of >95% is accepted as optimal adherence. Levels of adherence below 95% are considered to be sub-optimal. A composite adherence measure was computed as the means of the optimal adherence rates of the three measures used.

Knowledge about HIV and ART

The Oxford Dictionary defines knowledge as the information, understanding and skills that is gained through education or experience. For the purpose of this study, knowledge shall be assessed in terms of: what HIV is and how it can be transmitted; how ARVs work and how they should be used; whether the ARV users know that ARVs are not a cure and that they have to be taken for life. The level of knowledge was graded on a scale of 0 - 8, with a score of 75% and above depicting good knowledge.

Side-effects

For the purposes of this study, medicine-related side-effects have been categorized according to patient/ARV user and biomedical perspectives. Where pills were missed because a patient assumed that they might be responsible for certain symptoms that are not measurable, this has been classified as a patient/ARV user perspective, while those instances where side-effects can be recorded and assessed in observable terms were regarded as a biomedical perspective.

Disclosure

For the purposes of this research, disclosure was deemed to have taken place if a patient on ART had shared his or her status and the fact of being on treatment with at least one friend and/or any other person (including family members) for the purpose of deriving support if needed.

Treatment costs

Botswana offers ARVs free of charge to any citizen who is eligible for treatment. Weiser et al. (2003) found the cost of ARVs to be a major predictor of low adherence in their cohort. However, since this study is conducted in the public health sector, where there is no longer a charge for ARVs, this study will focus on other treatment-related costs such as transport fares, foregone wages, expenditure on snacks and meals while waiting to be seen at the clinic, and increased spending on food as a result of being on ART.