Challenges in PMTCT antiretroviral adherence in northern KwaZulu-Natal, South Africa

Abstract

Background. Women living with HIV in sub-Saharan Africa face significant challenges in accessing HIV care and adhering to antiretroviral therapy. Most reports have focused on issues relating to long-term adherence such as those surrounding stigma and disclosure, hunger, cultural factors, lack of accurate health information, lack of social support, medication side effects and overcrowded health systems. Information related to the challenges facing pregnant women when taking antiretrovirals for prophylactic purposes is limited.

The “Kesho Bora Study” is a multicentre prevention of mother-to-child transmission (PMTCT) trial in sub-Saharan Africa evaluating the PMTCT efficacy of triple therapy until cessation of breast feeding compared to short course zidovudine monotherapy in a predominantly breast feeding population. Following unexplained discrepancies during objective adherence assessments, a sub-study was conducted at one site to examine the underlying adherence issues.

Methods. The counselling and clinical notes of all 100 enrolled Zulu women were examined. Extracted information was supplemented by unstructured, free-ranging interviews conducted by trained adherence counsellors on 43 consecutive women attending the trial clinic over a two-week period. Adherence was defined as good (>95% adherence), or poor (<95% adherence).

Results. Reasons provided for sub-optimal adherence included therapy misconceptions/misunderstandings, antiretroviral use by relatives, domestic violence, poverty and issues relating to disclosure and stigma. About 61% (57/94) of antenatal women had good adherence with their PMTCT prophylaxis, with no significant difference shown between those taking the long and short course.

Conclusion. Antenatal women in northern rural KwaZulu-Natal face significant challenges in taking antiretroviral PMTCT prophylaxis.

Keywords:

• antiretroviral adherence
• antenatal
• pregnancy
• developing country

Acknowledgements

We acknowledge other members of the Kesho Bora Study Group. These include the WHO Coordination Team, Geneva, Switzerland (Isabelle de Vincenzi, Tim Farley, Philippe Gaillard, Ndema Habib and Sihem Landoulsi); the sponsoring institutions of National Institute of Child Health and Human Development, National Institutes of Health, USA (Jennifer Read), Agence Nationale de Recherche sur le SIDA, France (Brigitte Bazin, Claire Rekacewicz), the Centers for Disease Control and Prevention, USA (Mary Glenn Fowler, Denise Jamieson, Allan Taylor and Michael Thigpen), and the European Developing Countries Trials Partnership. We would also like to acknowledge those in the other four sites that make up Kesho Bora, namely those in the Centre Muraz, Bobo Dioulasso, Burkina-Faso (Nicolas Meda, Paulin Fao, Clarisse Gouem, Paulin Somda, Hervé Hien, Elysée Ouedraogo, Diane Valea and Roselyne Some); those at the University of KwaZulu-Natal, Durban, South Africa (Nigel Rollins, Kevi Naidu, Lynne McFetridge and Johannes Viljoen); those at the International Centre for Reproductive Health, Mombasa, Kenya (Stanley Luchters, Marcel Reyners, Eunice Irungu, Christine Katingima, Mary Mwaura, Gina Ouattara, Kishor Mandaliya and Mary Thiongo); and those at the University of Nairobi, Nairobi, Kenya (Ruth Nduati, Judy Kose, Ephantus Njagi and Peter Mwaura). In addition, we would like to acknowledge the invaluable input from a number of supporting institutions including Université Montpellier, Laboratoire de Bactériologie-Virologie, Montpellier, France (Philippe Van de Perre); Coopération française (Francois Rouet); Institut de Recherche pour le Développement, France (Cecile Cames, Amandine Cournil, Kirsten Simondon); International Centre for Reproductive Health, Belgium (Patricia Claeys). Finally, we would like to thank the clinic staff of the Kesho Bora Study, KwaMsane, KwaZulu-Natal, namely Thembi Blose, Makhosi Ndlovu, Jabu Ndlovu, Petros Khambule, Phumzile Vilakazi and Londi Mthetwa. James Ndirangu provided advice on the statistical analysis.