AFFECTING ART ADHERENCE: the case of Tema General Hospital



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The Human Immune Deficiency Virus/ Acquired Immuno
Deficiency Virus (HIV/AIDS) epidemic has been a major pubic health challenge
globally in the past three decades. With the index case reported in the United
States of America in 1981 (UNAIDS 2003). The infection has spread swiftly and
affected all sections of the society, thus, women and men, poor and rich, old
and young (including babies) (FHAPCO 2012).

In 2012, an estimated 35.3 (32.2-38.8) million people
were living with HIV globally and new HIV infections summed up to 2.3 (1.9-2.7)
million people. AIDS-related death in 2012 averaged 1.6 million, almost half of
the 2.3 million deaths in 2005 (UNAIDS, 2013:4).

Sub-Saharan Africa

It has been two and a half decades since the emergence
of the HIV/AIDS epidemic in Sub Saharan Africa with detrimental health crisis
to people on the continent. The dominance of this epidemic among Sub-Saharan African
countries has ranged from 35% in Swaziland, to 25% in Botswana, Zimbabwe, and
South Africa. Central and West Africa has retained a 4% constant rate with
Senegal recording the lowest of 1%. Meanwhile, there was a progressive
reduction in the prevalence of HIV/AIDS in East African nations like Uganda and
Kenya (UNAIDS, 2006).

According to UNAIDS 2006 over 24.5 million Sub Saharan
Africans were estimated to be living with HIV/AIDS, which presented about 68%
of the global burden of HIV/AIDS. Out of the 68%, 59% were women (UNICEF; WHO; UNAIDS,
2011:24). HIV transmission is largely heterosexual although mother to child
transmission bears a substantial number. There is an estimated 2 million AIDS
orphans in Nigeria and ….. in Ghana. There is no available cure for HIV/AIDS,
hence ART offers the only viable remedy to reduce and manage the complications
of the infection. ART is a combination of antiretroviral medications, aimed to suppresses
the viral load to minimal levels, boost the patient’s immune system by
increasing CD4 cells and enhance quality of life of PLHIV (Lewis, Colbert, Erlen, & Meyers, 2006; Rao,
Kekwaletswe, Hosek, Martinez, & Rodriguez, 2007). However, the virus is not
eliminated from the body entirely, thus patients have to take the medications
for life.


Additionally, there was a 2.7 million new infections and
2.5 million AIDS related deaths in 2005 in Sub-Saharan African (UNAIDS, 2006). However,
the incidence of HIV/AIDS has been reported to decrease progressively compared
to earlier years, which saw 1.9 million new infections in 2010 compared to 2.2
million infections in 2001, and 2.7 million in 2005. This shows 16% fewer
infections from 2001 to 2010 and 27% fewer between1996 and 1998 when the
incidence was at its peak in sub-Saharan Africa.


The gradual reduction in AIDS related deaths has been attributed
to sustained availability of Highly Active Antiretroviral Therapy (HAART) (UNAIDS,
2010:19) as well as care and support achieved through drug adherence
counseling. Drug adherence therapy requires proper counseling to assist PLHIV
to understand their treatment course and how to live healthy as HIV patients. Adherence
to a treatment regime is defined as ”the act of
conforming to the recommendations made by the health care provider with respect
to timing, dosage, and frequency of medication taking”(2)

Adherence to ART yields positive HIV outcomes to
prevent further complications and to ensure better CD4 and ultimate viral
suppression (22). Antiretroviral therapy (ART) reduces and alters the
progression to AIDS and improves and prolongs the quality of life of HIV
infected individuals (Abera
et al., J Pharma Reports 2015, 1:1).

Nonetheless, ART
adherence usually poses a distinct challenge and requires commitment from both
the health care worker and patient (23). Owing to fast mutation and replication
of HIV, low adherence to ART results in the development of drug-resistant
strains of HIV.

To achieve ideal and
lasting viral load suppression and increased CD4 count, adherence to ART should
be at least 95.0%. ART adherence can be categorized as “good” when the patient
misses three or less doses, “fair” between three and eight doses, and “poor”
when they miss more than eight doses per month.


HIV In Ghana

Ghana, in the year 2011, there was an estimated number of 222,478 PLHIV (NACP,
2011). An estimated 599,007 PLHIV were receiving treatment at the end of 2012 (National
AIDS Commission, 2013). The incidence of HIV infections has been on a downward
trend, nonetheless, the trend seems irregular as the rates keep fluctuating
over a period. This saw new infections drop from 3.6% to 2.7% in 2005 and then
to 3.2% in 2006 and to 2.2% in 2008 (Yarney et al, 20). Also, the infection is
not evenly distributed across the nation. Most mining and border towns recorded
high prevalence, which can be attributed to commercial activities going on in
these towns (Ghana AIDS Commission, 2012). In 2017, Ghana recorded 80% increase
in HIV new infections as revealed by the Ghana AIDS Commission (GAC, 2018)




Global Fund has provided free antiretroviral treatment
for all persons living with HIV (PLHIV) in many health care facilities in Ghana
including Tema General Hospital since 2006 (). This led to an increase in the
number of PLHIV who receive ART services throughout Ghana. For a patient to
receive maximum benefits from ART services, he/she must be at least 95%
adherent to their medication and other components of the therapy. This implies
adherence is very important if we are to scale up the accomplishments of the
ART programme in resource limited settings: Ghana. In daily HIV care in the
Tema General Hospital, sustaining high-level adherence to ART is a challenge to
the ART programme as well as HIV care providers. According to a descriptive
cross-sectional study in the Upper West Region where 201 HIV 1 patients were
studied, an overall lifetime adherence rate was 62.2 % while medication in the
last 6 months, 3months 1 month and a week were 73.6%, 87.1%, 91% and 86%
respectively. The study found a positive correlation between adherence to ART
and immunologic success, with non-adherence increasing the risk (Obirikorang,
Selleh, Abledu & Fofie, 2013). Another cross-sectional study of 229 women
by Boateng, Kwapong -Baffour, 2013) concluded that 27% of PLHIV who
had good understanding and knowledge of ART defaulted treatment. This implies
that even knowledge about effects of non-adherence does not necessarily affect
defaulter rate. Similarly, a Nigerian study in Aminu Kano Teaching Hospital
reported 80% were adherent to ART (Mukhtar, Adeleke,Gwarzo & Ladan (2006).  Thus, these studies disclose that ART
non-adherence appears to be a huge challenge threatening the long-term scale up
and success of the ART programme in Sub-Saharan Africa.

The Tema General Hospital’s ART clinic report from 2016/2017
showed 2,535 PLHIVs were on ARVs. Eight Hundred and Sixty One (861) people,
making 33.9% were lost to follow up. This means that from the total population for
the year in review, more than a quarter was non-adherent to their drugs.

Moreover, patients had reported recurrent
opportunistic infections and 3% or 98 people are on second-line regimen at Tema
General Hospital due to non-adherence causing treatment failure and resistance
to the first line drugs. According various studies treatment failures, which
could result from non-adherence, can result in opportunistic infections and
death among PLHIV (Paterson et al. 2000; DeFino et
al. 2004; Sethi et al. 2003). In these studies, there is a significant
association of less than 95% adherence to treatment and virological failure.

According to an Indian study, experiencing
ART-related undesired effects was considerably associated with suboptimal
adherence. (Mehta et al, 2015). Kobin and Sethi, 2011 found that non-adherence could
lead to limited future treatment options, emergence of resistant strains,
higher treatment costs, treatment failure, and immune suppression.

Experience suggests
that PLHIV may be aware of the adverse effects of non-adherence through
counseling sessions, but still do not conform to the agreed commendations due
to diverse reasons. Some PLHIV do not keep to clinic appointments and give
varied reasons when they finally do attend. Apart from these challenges, there are
limited reports available on the factors affecting adherence in Ghana and in
Tema Metropolis. Therefore, in order to develop programs to support adherence,
it is important to understand the causes, hence the need to investigate into
the factors that affect adherence to ART.  

is for this reason the researcher want to investigate the factors contribution
to non-adherence in anti retroviral therapy among adults living with HIV/AIDS
in the Tema General Hospital.





To ensure a patient adheres to treatment regimen
they have undergo three intense counseling sessions before starting ARVs, with
the counselor being guided by a standard counseling form. This aims at
empowering the patient to understand the treatment they are to be initiated on
as this treatment is taken for the rest of their lives. Patient education is
provided to ensure long-term adherence to treatment, which is associated with
treatment success (NASCOP, 2005).

This study is to contribute to an understanding of the
factors affecting adherence to ART programme in the Ghanaian context. It will contribute
to the body of knowledge on the effects of non-adherence of ART and give
feedback to the ART programme at Tema General Hospital and Ghana in general on
effectiveness of interventions for patients receiving ART.




Investigations in both African and Ghanaian context
have indicated that there is a dearth in the level of ART adherence and several
factors have been cited to contribute to the gap. This investigation will
provide an understanding into the level of ART adherence and distinguish the
impediments to optimal ART adherence in the Ghana Context.

Again, it will provide requisite information to inform
policy and practice in scaling up ART programme, develop evidenced-based
interventions to increase adherence to ART. PLHIVs will benefit directly or
indirectly through the provision of relevant and appropriate services and the
health care provider will be well informed about the pervasiveness of non adherence and help to PLHIV
to understand the need of playing active roles in their care to achieve optimal
adherence with focus on improving ART adherence.



3.0 AIM

To investigate and define the factors affecting adherence
to ART among adult PLHIVs in Ghana, Tema General Hospital


investigate factors affecting adherence to ART

To determine the level of adherence of PLHIV to ART programme in TGH

establish the association between socio-cultural, socio-demographic,
socio-economic and other patient/client related factors affecting the ART

To determine patient’s lifestyle practices in relation to
treatment provided at the ART clinic. ?





4.1 Study Design

4.1.1 Cross-Sectional Design

The study design will be a cross-sectional survey,
which will employ quantitative research methods to answer the study objectives.
A cross-sectional study involves collecting data at one point in time. This
design is appropriate for defining the status of a phenomenon or relationship
among phenomena at a point in time, which is easy and less expensive to conduct
(Polit and Beck 2012:184; Joubert & Ehrlich 2007:87).


 4.2 Study

The study will be conducted in hospital(s) in Tema
Metropolitan Area, Greater Accra Region, Ghana. 
Ghana is a West African Country found along the coast of the Gulf of
Guinea and bounded to the south by the Atlantic Ocean, Cote d’Iviore to the
west, Togo to the east and Burkina Faso to the north. Ghana has several
hospitals, some directly under the Ministry of Health, Ghana Health Service,
Quasi Hospitals and Private owned hospitals. In addition, there are
non-governmental health agencies in Ghana helping bring good health to the
populace. Ghana is reported to be one of the fasted growing economies and a
multiethnic country with ten (10) administrative regions with various
socio-economic groups and an uneven distribution of wealth and health. Tema is
a city in Greater Accra Region.

Tema is a community located on the coast
of Atlantic Ocean 16 miles (25 km) east of Accra, the national capital of
Ghana. It has a population of approximately 402,637 people and the 11th most
populated settlement in Ghana as of 2010 (Ghana Statistical Service, 2010).
Tema has acquired the nicknames meridian city and harbour town because of the
passage of longitude 00 (the Greenwich Meridian) through the town and for its
prominence as the main seaport in Ghana (GhanaDistricts.com, 2013). The
community is built on a fishing settlement, which is now home to several
factories, and it is a major trading centre. Tema is a major commercial town
with numerous factories and an oil refinery. The town has one referral hospital, Tema General, and
a polyclinic with numerous private hospitals.


4.3 Study Population And Sample Selection

The eligible population will be adult PLHIVs on ART
that are registered and attending ART clinic at Tema General Hospital. Eligible
participants must be on ARVs for at least three months with the ability to give
consent, not take part in the pilot study, and be above 20 years of age.

4.3.1 Sampling

This study will employ systematic sampling technique,
which ensures some level of precision in estimating population parameters, thus
reducing sampling error (Burns and Grove 2005: 365). Study participants will be
selected using an ordered patient list based on their registered identification
numbers from the ART computer database.


Using a
precision of 5% and 95% confidence interval the sample size was determined by
the formula,

N= p
(1-p) z2 /
p = estimated proportion of patients adherent to ART,

z = the
cut off value of the Normal distribution and

d = the
precision required on either side of the proportion.

lost to follow up, transfer out, death and non-willingness, 10% of the sample
size was added to the total sample size. A pooled estimate of adherence to
antiretroviral therapy in Sub-Saharan Africa was found to be 77% (Mills et al
2006a:679). Therefore, the total sample size for this study was 300 using a
precision of 5% and 95% confidence interval.




4.3 Study

Quantitative Study

methods will be used to permit a range of statistical analysis of the numerical
data. This will actually help interpret and better understand the complex
reality of the situation and the implications of data collected.


4.3.1 Data Collection

The study
objectives determine the scope and nature of data to be collected. A structured
questionnaire will be used to interview participants. The questionnaire will be
piloted in a small group of PLHIVs on ARVs before data collection. Data
collectors will be trained and deployed to gather the necessary information by
interviewing participants using the structured questionnaires.

data collection will give an extent in terms of numbers of participants who
have problems adhering to ART services.


 4.3.2 Data Collection Tool

Structured questionnaires will be
used to collect data. The tool will be in four sections: section A soliciting
information on their demographic data, B, information to meet the objective of
factors affecting ART adherence, section C will determine the level of
adherence. Section D will solicit information to meet how
patients’ lifestyle affects their treatment .The questionnaire will
answer questions relating to demographics, adherence, socio-cultural,
psychosocial, socio-economics, health care provider attitude, health related
ART site and setting.

Data Analysis
Approach To Quantitative Analysis

analysis software SPSS will be used to analyse the data collected.

analysis will be used to analyse data and generate a summary of statistics of
cross-sectional data. Results will be presented in graphs, pie charts.






4.3.4 Inclusion Criteria

All adult PLHIV on ART attending clinic for the past 3
months who have agreed to participate, will be included in the study.

 4.3.5 Exclusion

PLHIV who are not interested in participating, those
below 20 years and those who do not attend Tema General Hospital ART clinic.

4.3.6 Withdrawal Criteria

Patients can
withdraw from the study at any point in time when they no longer feel comfortable
being part of the study.


Ethical Considerations

study protocol will be assessed and approved by the Research Ethics Committee
of the Ghana Health Service, before commencement of data abstraction. The study
will commit to respecting the standards of good scientific practice as well as
adhere to the requirements of the Helsinki Declaration.

 Participants would be informed before the study
to enable them makes a decision. The information given to participants will
include the purpose of the study, details of the investigator, and address
confidentiality and anonymity issues. Informed consent (verbal) will be sought
from PLHIV who have agreed to participate in the study. Moreover, their refusal
at any point will not have any effect on their care.


5.1 Quality Control

All data collected will be doubled
checked and cleaned before analysis is made.


5.2 Confidentiality
of data

This study will be
conducted in strict accordance with the standards for protection of privacy of
identifiable health information. Codes instead of names will be used in data
collection. It will ensure that all study records are managed in a secure and
confidential manner so as not to expose the identity of subjects.

Hard copies of data of
subjects will be secured and restricted to principal investigator and auditors
until data is entered into the software, after which the hardcopies will be
discarded safely and appropriately. All computers used in the collection and
saving of data will be password protected. Excel sheets for recording patients’
information will also be password protected.



The generalisabilty of
the study findings may be compromised because the study is single site health

Death, transfer out and
lost to follow up may affect findings.




UNAIDS (2010) Joint United Nations Programme on HIV/AIDS (UNAIDS)
Global report, UNAIDS report on the global AIDS epidemic. ?

Factors Influencing Adherence
to Antiretroviral Therapy among People

Living With HIV/AIDS at ART
Clinic in Jimma University Teaching

Hospital, Southwest Ethiopia

Abebe Abera*, Beletech
Fenti, Temamen Tesfaye and Fikadu Balcha Abera
et al., J Pharma Reports 2015, 1:1



Kobin AB, Sheth NU (2011) Levels of adherence required for
virologic suppression among newer antiretroviral medications. Ann Pharmacother
45: 372-379. ?

Paterson DL, Swindells S, Mohr J, Brester M, Vergis EN, et al.
(2000) Adherence to protease inhibitor therapy and outcomes in patients with
HIV infection. Ann Intern Med 133: 21-30. ?

. Mehta K, Ekstrand ML, Heylen E, Sanjeeva GN, Shet A (2015).
Adherence to Antiretroviral Therapy Among Children Living with HIV in South
India. AIDS Behav.


Lewis, M. P., Colbert, A., Erlen, J., & Meyers, M. (2006). A
qualitative study of persons who are 100% adherent to antiretroviral therapy. AIDS Care, 18(2), 140-148. doi:

Mukhtar-Yola, M., Adeleke, S., Gwarzo, D., & Ladan, Z. F.
(2006). Preliminary investigation of adherence to antiretroviral therapy among
children in Aminu Kano Teaching Hospital, Nigeria. African Journal of AIDS Research, 5(2), 141-144.

Smith, S. R., Rublein, J. C., Marcus, C., Brock, T. P., &
Chesney, M. A. (2003). A medication self-management program to improve
adherence to HIV therapy regimens. Patient
Education and Counseling, 50(2), 187-199. doi: 10.1016/s0738-








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