The Effect of Antiretroviral Stock-Outs on Medication Adherence Among Patients Living With HIV in Ghana: A Qualitative Study

Moriarty, Kathleen; Genberg, Becky L.; Norman, Betty; Reece, Rebecca

doi:10.1016/j.jana.2017.09.014

Cited by 20 publications

(14 citation statements)

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“…Our review search was conducted on 9 December 2016 and it is possible that some of the landscape regarding stigma and access to care may have changed in the ‘test and treat’ and differentiated service delivery era. However, after conducting an updated search and rapidly appraising recently published studies (up till 1 August 2018), we identified several studies which supported our findings, specifically regarding quality of health services [130–133], disrespectful health workers and the role of power in health service delivery [132, 134], lack of access to health services [130, 131], competing priorities and unpredictable life circumstances [135–138], the role of the social world [131, 132, 139], influence of gender roles [140], medical pluralism [132, 141], the motivating influence of having dependents [142, 143], the challenges of same day ART initiation[144], the barriers to care caused by stigma [130, 131, 138, 143, 145, 146], challenges to accessing care for PWD [147], the benefits of support [131, 132, 148, 149], and fluctuations in engagement over time [131]. We therefore feel that the findings of this review remain relevant to current HIV populations.…”

Section: Discussionsupporting

confidence: 65%

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

et al. 2019

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BackgroundAdherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies.MethodsWe used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains.ResultsWe included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism—these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a “tipping point”, a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time.ConclusionThis analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead ‘normal’ lives.

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Section: Discussionsupporting

confidence: 65%

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

et al. 2019

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“…The patient may weigh the value (i.e., attending the club and continuing to receive the benefit and convenience of club-based care) with the cost (i.e., loss of a day’s worth of wages), and decide that, although more time-consuming, receiving clinic-based standard care is ultimately more flexible, given the unpredictability of work opportunities. Typically, within the routine clinic-based standard of care, there is little downside to skipping a clinic appointment (if such appointment systems even exist), and many experienced ART patients may maintain a stockpile of medication to bridge short-term gaps [13]. Other models of differentiated care such as ART delivered in vending machines or at fast-track pharmacy queues may offer less stringent rules and thus more flexibility for some patients.…”

Section: Discussionmentioning

confidence: 99%

The impact of community- versus clinic-based adherence clubs on loss from care and viral suppression for antiretroviral therapy patients: Findings from a pragmatic randomized controlled trial in South Africa

Hanrahan

Schwartz

Mudavanhu³

et al. 2019

PLoS Med

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Background Adherence clubs, where groups of 25–30 patients who are virally suppressed on antiretroviral therapy (ART) meet for counseling and medication pickup, represent an innovative model to retain patients in care and facilitate task-shifting. This intervention replaces traditional clinical care encounters with a 1-hour group session every 2–3 months, and can be organized at a clinic or a community venue. We performed a pragmatic randomized controlled trial to compare loss from club-based care between community- and clinic-based adherence clubs. Methods and findings Patients on ART with undetectable viral load at Witkoppen Health and Welfare Centre in Johannesburg, South Africa, were randomized 1:1 to a clinic- or community-based adherence club. Clubs were held every other month. All participants received annual viral load monitoring and medical exam at the clinic. Participants were referred back to clinic-based standard care if they missed a club visit and did not pick up ART medications within 5 days, had 2 consecutive late ART medication pickups, developed a disqualifying (excluding) comorbidity, or had viral rebound. From February 12, 2014, to May 31, 2015, we randomized 775 eligible adults into 12 pairs of clubs—376 (49%) into clinic-based clubs and 399 (51%) into community-based clubs. Characteristics were similar by arm: 65% female, median age 38 years, and median CD4 count 506 cells/mm 3 . Overall, 47% (95% CI 44%–51%) experienced the primary outcome of loss from club-based care. Among community-based club participants, the cumulative proportion lost from club-based care was 52% (95% CI 47%–57%), compared to 43% (95% CI 38%–48%, p = 0.002) among clinic-based club participants. The risk of loss to club-based care was higher among participants assigned to community-based clubs than among those assigned to clinic-based clubs (adjusted hazard ratio 1.38, 95% CI 1.02–1.87, p = 0.032), after accounting for sex, age, nationality, time on ART, baseline CD4 count, and employment status. Among those who were lost from club-based care ( n = 367), the most common reason was missing a club visit and the associated ART medication pickup entirely (54%, 95% CI 49%–59%), and was similar by arm ( p = 0.086). Development of an excluding comorbidity occurred in 3% overall of those lost from club-based care, and was not different by arm ( p = 0.816); no deaths occurred in either arm during club-based care. Viral rebound occurred in 13% of those lost from community club-based care and 21% of those lost from clinic-based care ( p = 0.051). In post hoc secondary analysis, among those referred to standard care, 72% (95% CI 68%–77%) reengaged in clinic-based care within 90 days of their club-based care discontinuation date. The main limitations of the trial are the lack of a comparison group r...

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“…Where drought and co-morbidities interact with economic stress, social vulnerabilities, medication stock-out, pills burden or side-effects from ART regimens, this can be detrimental for adherence. 28–38,116,125…”

Section: Results: a Systems Understanding Of The Sensitivity Of Art Amentioning

confidence: 99%

Exploring linkages between drought and HIV treatment adherence in Africa: A Systematic Review

Orievulu

Ayeb‐Karlsson

Ngema

et al. 2020

Preprint

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Climate change is directly and indirectly linked to human health, including through access to treatment and care. Our systematic review presents a systems understanding of the nexus between drought and antiretroviral treatment (ART) adherence in HIV-positive individuals in the African setting. Narrative synthesis of 111 studies retrieved from Web of Science, PubMed/Medline, and PsycINFO suggests that economic and livelihoods conditions, comorbidities and ART regimens, human mobility, and psycho-behavioural dispositions and support systems interact in complex ways in the drought-ART adherence nexus in Africa. Economic and livelihood-related challenges appear to impose the strongest impact on human interactions, actions and systems that culminate in non-adherence. Indeed, the complex pathways identified by our systems approach emphasise the need for more integrated research approaches to understanding this phenomenon and develop interventions.

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The Effect of Antiretroviral Stock-Outs on Medication Adherence Among Patients Living With HIV in Ghana: A Qualitative Study

Cited by 20 publications

References 1 publication

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

The impact of community- versus clinic-based adherence clubs on loss from care and viral suppression for antiretroviral therapy patients: Findings from a pragmatic randomized controlled trial in South Africa

Exploring linkages between drought and HIV treatment adherence in Africa: A Systematic Review

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