Patient Retention and Adherence to Antiretrovirals in a Large Antiretroviral Therapy Program in Nigeria: A Longitudinal Analysis for Risk Factors

Abstract

BackgroundSubstantial resources and patient commitment are required to successfully scale-up antiretroviral therapy (ART) and provide appropriate HIV management in resource-limited settings. We used pharmacy refill records to evaluate risk factors for loss to follow-up (LTFU) and non-adherence to ART in a large treatment cohort in Nigeria.Methods and FindingsWe reviewed clinic records of adult patients initiating ART between March 2005 and July 2006 at five health facilities. Patients were classified as LTFU if they did not return >60 days from their expected visit. Pharmacy refill rates were calculated and used to assess non-adherence. We identified risk factors associated with LTFU and non-adherence using Cox and Generalized Estimating Equation (GEE) regressions, respectively. Of 5,760 patients initiating ART, 26% were LTFU. Female gender (p<0.001), post-secondary education (p = 0.03), and initiating treatment with zidovudine-containing (p = 0.004) or tenofovir-containing (p = 0.05) regimens were associated with decreased risk of LTFU, while patients with only primary education (p = 0.02) and those with baseline CD4 counts (cell/ml3) >350 and <100 were at a higher risk of LTFU compared to patients with baseline CD4 counts of 100–200. The adjusted GEE analysis showed that patients aged <35 years (p = 0.005), who traveled for >2 hours to the clinic (p = 0.03), had total ART duration of >6 months (p<0.001), and CD4 counts >200 at ART initiation were at a higher risk of non-adherence. Patients who disclosed their HIV status to spouse/family (p = 0.01) and were treated with tenofovir-containing regimens (p≤0.001) were more likely to be adherent.ConclusionsThese findings formed the basis for implementing multiple pre-treatment visit preparation that promote disclosure and active community outreaching to support retention and adherence. Expansion of treatment access points of care to communities to diminish travel time may have a positive impact on adherence.

Influence of Spirituality and Religion on Adherence to Highly Active Antiretroviral Therapy in Adult HIV/AIDS Patients in Calabar, Nigeria

“…A South African study reported similar finding [39]. In addition, similar finding was reported in a multicenter study across Nigeria where female gender was reported to have lesser risk to loss to follow-up [40]. In this study, the odds ratio indicated that female respondents were 1.6 times more likely to be adherent, compared with males when multiple logistic regression of adherence to HAART with relevant predictors was conducted.…”

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

“…In addition, 16% of the respondents believed that PLWHA had no hope. This belief could seriously hinder the ability of PLWHA to look into the future with a positive attitude and may affect their adherence to therapy, as positive Chi square test used attitude has been shown in several studies to contribute to good adherence to therapy [17,19].…”

“…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.…”

Universal test and treat and the HIV epidemic in rural South Africa: a phase 4, open-label, community cluster randomised trial

“…Findings from two of three studies in the African setting that compared adherence in individuals initiating ART at high CD4 count with those initiating at lower CD4 counts were contradictory [5,6]. Furthermore, these two studies evaluated adherence in patients who were on an ART regimen based mainly on a thymidine analogue backbone (zidovudine or stavudine), known to be less tolerable than tenofovir-based regimens [7].…”