Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study

Abstract

BackgroundIndividuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.Methods and FindingsDeterminants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.ConclusionAdherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.

Disclosure, Knowledge of Partner Status, and Condom Use Among HIV-Positive Patients Attending Clinical Care in Tanzania, Kenya, and Namibia

“…Furthermore, disclosure often leads to support from partner(s) and family members, 8 which has been shown to improve the uptake of and adherence to HIV care and treatment programs. [9][10][11] Although studies indicate that the majority of PLHIV experience support and understanding from their partners following disclosure, [12][13][14] some PLHIV remain reluctant to disclose due to fear of their partner's reaction. 12 Substantial gender differences in the rates, barriers, and outcomes of disclosure have been found in a number of studies, with women particularly reluctant to disclose HIV-positive results for fear of losing economic support, being abandoned by their partners, and/or being subjected to physical and emotional abuse.…”

Knowledge and attitudes regarding HIV/AIDS and antiretroviral therapy among patients at a Nigerian treatment clinic

“…Substantial rates of decline in the number of opportunistic infections and in the prevalence of AIDS-related mortality have been observed [12,13]. A number of studies have reported reductions in the level of plasma HIV-1 RNA and increases in the number of the CD4 cell count, even among PLWHA with very low initial CD4 counts [14][15][16][17][18]. Antiretroviral drugs must be taken as a lifelong therapy and their success relies on continual adherence to the medication regimen.…”

The Importance of Social Ties in Sustaining Medication Adherence in Resource-Limited Settings

“…26 And, while barriers like inadequate knowledge, side effects, and regimen complexity adversely affect adherence in any setting, studies of HIV antiretroviral therapy adherence suggest that structural and economic barriers may be more relevant factors in resource-limited settings. [27][28][29] These puzzling discrepancies might be explained by the ways in which the social dynamics of treatment for these chronic illnesses differ in resource-limited settings. People living with HIV/AIDS in sub-Saharan Africa often initiate HIV antiretroviral therapy at advanced stages of illness characterized by severe debilitation.…”