Voices on adherence to ART in Ethiopia and Uganda: a matter of choice or simply not an option?

Abstract

This paper explores HIV patients’ adherence to antiretroviral treatment (ART) in resource-limited contexts in Uganda and Ethiopia, where ART is provided free of charge. Qualitative semi-structured interviews were conducted with 79 patients, 17 peer counselors, and 22 providers in ART facilities in urban and rural areas of Ethiopia and Uganda. Interviewees voiced their experiences of, and views on ART adherence both from an individual and a system level perspective. Two main themes emerged from the content analysis: “Patients’ competing costs and systems’ resource constraints” and “Patients’ trust in ART and quality of the patient–provider encounters.” The first theme refers to how patients’ adherence was challenged by difficulties in supporting themselves and their families, paying for transportation, for drug refill and follow-up as well as paying for registration fees, opportunistic infection treatment, and expensive referrals to other hospitals. The second theme describes factors that influenced patients’ capacity to adhere: personal responsibility in treatment, trust in the effects of antiretroviral drugs, and trust in the quality of counseling. To grant patients a fair choice to successfully adhere to ART, transport costs to ART facilities need to be reduced. This implies providing patients with drugs for longer periods of time and arranging for better laboratory services, thus not necessitating frequent revisits. Services ought to be brought closer to patients and peripheral, community-based healthworkers used for drug distribution. There is a need for training providers and peer counselors, in communication skills and adherence counseling.

Keywords:

• adherence
• antiretroviral therapy
• East Africa
• HIV/AIDS
• qualitative research

Acknowledgements

JC, CO, TA, RW, GT, SP designed, planned and implemented the study. AME and AT designed and planned the study. TA and CO selected facilities for the study in their respective countries, helped train data collectors, carried out the study and assisted in the analysis of the data from their respective countries. AKG, RW, and GF performed the major part of analysis and the main writing of the article. All authors have commented on article drafts and read and approved the final text as submitted to AIDS Care.

The authors would like to acknowledge the following members of the INRUD-IAA:

Ethiopia: Abraham Gebre Giorgis, Ethiopian Drug Administration and Control Authority; Gabriel Daniel, Negussu Mekonnen and Hailu Tadeg, Management Sciences for Health; Assegid Tassew, Wubegzier Mekonnen, Ezra Mulunch, Wolde-Kidan Kifle, Tigist Mekonnen, Ethiopian Research Teams.

Uganda: Paul Waako, Makerere University Medical School; Sarah Namusoko, George Okello Ekwaro, Ugandan Research Team.

USA: Keith Johnson, Lloyd Matowe, Jude Nwokike, Management Sciences for Health; Anita Wagner, Dennis Ross-Degnan, Catherine Vialle-Valentin, Harvard Medical School Drug and Harvard Pilgrim health Care.

Switzerland: Richard Laing, World Health Organization Department of Medicine Policy and Standards.

We wish to express our gratitude to all patients and healthcare personnel in Ethiopia and Uganda who contributed to this study by sharing their experiences, ideas, and thoughts with us. We also thank the Ministries of Health in both countries, the National AIDS Control Program in Uganda and DACA in Ethiopia for supporting and facilitating our work. This study was made possible through support provided by the Swedish International Development Cooperation Agency, under the terms of contribution 72300310, the World Health Organization under an Agreement for Performance of Work OD-AP-07-00516 and by the Rational Pharmaceutical Management Plus Program, which is funded by the US Agency for International Development, under the terms of Cooperative Agreement number HRN-A-00-00-00016-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the Swedish International Development Cooperation Agency, the World Health Organization or the US Agency for International Development.