Individual and contextual factors influencing patient attrition from antiretroviral therapy care in an urban community of Lusaka, Zambia

Abstract

IntroductionDespite the relatively effective roll-out of free life-prolonging antiretroviral therapy (ART) in public sector clinics in Zambia since 2005, and the proven efficacy of ART, some people living with HIV (PLHIV) are abandoning the treatment. Drawing on a wider ethnographic study in a predominantly low-income, high-density residential area of Lusaka, this paper reports the reasons why PLHIV opted to discontinue their HIV treatment.MethodsOpened-ended, in-depth interviews were held with PLHIV who had stopped ART (n = 25), ART clinic staff (n = 5), religious leaders (n = 5), herbal medicine providers (n = 5) and lay home-based caregivers (n = 5). In addition, participant observations were conducted in the study setting for 18 months. Interview data were analysed using open coding first, and then interpreted using latent content analysis. The presentation of the results is guided by a social-ecological framework.FindingsPatient attrition from ART care is influenced by an interplay of personal, social, health system and structural-level factors. While improved corporeal health, side effects and need for normalcy diminished motivation to continue with treatment, individuals also weighed the social and economic costs of continued uptake of treatment. Long waiting times for medical care and placing “defaulters” on intensive adherence counselling in the context of insecure labour conditions and livelihood constraints not only imposed opportunity costs which patients were not willing to forego, but also forced individuals to balance physical health with social integrity, which sometimes forced them to opt for faith healing and traditional medicine.ConclusionsComplex and dynamic interplay of personal, social, health system and structural-level factors coalesces to influence patient attrition from ART care. Consequently, while patient-centred interventions are required, efforts should be made to improve ART care by extending and establishing flexible ART clinic hours, improving patient-provider dialogue about treatment experiences and being mindful of the way intensive adherence counselling is being enforced. In the context of insecure labour conditions and fragile livelihoods, this would enable individuals to more easily balance time for treatment and their livelihoods. As a corollary, the perceived efficacy of alternative treatment and faith healing needs to be challenged through sensitizations targeting patients, religious leaders/faith healers and herbal medicine providers.

Identifying Perceived Barriers along the HIV Care Continuum

“…In conclusion, our study echoes previous findings concerning the barriers patients face along the HIV care continuum 4–7,10–13,32–34 and expands on those findings by highlighting the complex and often interrelated barriers to linkage in care, retention, and timely ART initiation from the perspective of providers and peer educators. Providers and peer educators recognized the value of counseling for helping patients traverse the HIV care continuum but suggested that both at posttest and after enrollment in care it was often insufficient.…”

Spiritual care may impact mental health and medication adherence in HIV+ populations

“…Patients may not be well informed about the consequences of non-adherence, the efficacy of therapy, and the potential for side effects 42. They tend to rely heavily on complementary alternative therapies in the form of herbs, holy water, and guidance from spiritual leaders 37,38,42,46,48…”

The Role of ARV Associated Adverse Drug Reactions in Influencing Adherence Among HIV-Infected Individuals: A Systematic Review and Qualitative Meta-Synthesis

“…Thirty-three out of 39 studies reported that perceived adverse ARV reactions decreased adherence [12, 15–46], whilst six studies [47–52] described no apparent relationship. Nineteen studies [12, 15–27, 29, 32, 36, 44, 47] were conducted in high-income countries, eight [30, 31, 33, 34, 41, 42, 46, 49] in middle-income countries, and twelve [28, 35, 37–40, 43, 45, 48, 50–52] in low-income countries. (Countries—see Tables 1, 2).…”

“…Psychological suffering associated with adverse drug reactions (e.g., being reminded of being sick, delusional, a feeling of being killed by taking the drugs, and getting mad) were occasionally considered to be severe enough to contribute to poor adherence [17, 19, 20, 37, 40, 47, 49]. This finding has a CERQual high level of confidence.…”