FACTORSAFFECTING ART ADHERENCE: the case of Tema General Hospital 1.0  INTRODUCTIONGlobalThe Human Immune Deficiency Virus/ Acquired ImmunoDeficiency Virus (HIV/AIDS) epidemic has been a major pubic health challengeglobally in the past three decades. With the index case reported in the UnitedStates of America in 1981 (UNAIDS 2003). The infection has spread swiftly andaffected all sections of the society, thus, women and men, poor and rich, oldand young (including babies) (FHAPCO 2012).

In 2012, an estimated 35.3 (32.2-38.

8) million peoplewere 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 ofthe 2.

3 million deaths in 2005 (UNAIDS, 2013:4).Sub-Saharan AfricaIt has been two and a half decades since the emergenceof the HIV/AIDS epidemic in Sub Saharan Africa with detrimental health crisisto people on the continent. The dominance of this epidemic among Sub-Saharan Africancountries has ranged from 35% in Swaziland, to 25% in Botswana, Zimbabwe, andSouth Africa. Central and West Africa has retained a 4% constant rate withSenegal recording the lowest of 1%. Meanwhile, there was a progressivereduction in the prevalence of HIV/AIDS in East African nations like Uganda andKenya (UNAIDS, 2006).According to UNAIDS 2006 over 24.5 million Sub SaharanAfricans 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 childtransmission bears a substantial number. There is an estimated 2 million AIDSorphans 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 complicationsof the infection. ART is a combination of antiretroviral medications, aimed to suppressesthe viral load to minimal levels, boost the patient’s immune system byincreasing CD4 cells and enhance quality of life of PLHIV (Lewis, Colbert, Erlen, & Meyers, 2006; Rao,Kekwaletswe, Hosek, Martinez, & Rodriguez, 2007).

However, the virus is noteliminated from the body entirely, thus patients have to take the medicationsfor life. Additionally, there was a 2.7 million new infections and2.5 million AIDS related deaths in 2005 in Sub-Saharan African (UNAIDS, 2006).

However,the incidence of HIV/AIDS has been reported to decrease progressively comparedto earlier years, which saw 1.9 million new infections in 2010 compared to 2.2million infections in 2001, and 2.7 million in 2005. This shows 16% fewerinfections from 2001 to 2010 and 27% fewer between1996 and 1998 when theincidence was at its peak in sub-Saharan Africa. The gradual reduction in AIDS related deaths has been attributedto sustained availability of Highly Active Antiretroviral Therapy (HAART) (UNAIDS,2010:19) as well as care and support achieved through drug adherencecounseling. Drug adherence therapy requires proper counseling to assist PLHIVto understand their treatment course and how to live healthy as HIV patients.

Adherenceto a treatment regime is defined as ”the act ofconforming to the recommendations made by the health care provider with respectto timing, dosage, and frequency of medication taking”(2)Adherence to ART yields positive HIV outcomes toprevent further complications and to ensure better CD4 and ultimate viralsuppression (22). Antiretroviral therapy (ART) reduces and alters theprogression to AIDS and improves and prolongs the quality of life of HIVinfected individuals (Aberaet al., J Pharma Reports 2015, 1:1).Nonetheless, ARTadherence usually poses a distinct challenge and requires commitment from boththe health care worker and patient (23). Owing to fast mutation and replicationof HIV, low adherence to ART results in the development of drug-resistantstrains of HIV. To achieve ideal andlasting viral load suppression and increased CD4 count, adherence to ART shouldbe at least 95.

0%. ART adherence can be categorized as “good” when the patientmisses three or less doses, “fair” between three and eight doses, and “poor”when they miss more than eight doses per month.  HIV In GhanaInGhana, 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 (NationalAIDS Commission, 2013). The incidence of HIV infections has been on a downwardtrend, nonetheless, the trend seems irregular as the rates keep fluctuatingover a period. This saw new infections drop from 3.6% to 2.

7% in 2005 and thento 3.2% in 2006 and to 2.2% in 2008 (Yarney et al, 20). Also, the infection isnot evenly distributed across the nation.

Most mining and border towns recordedhigh prevalence, which can be attributed to commercial activities going on inthese towns (Ghana AIDS Commission, 2012). In 2017, Ghana recorded 80% increasein HIV new infections as revealed by the Ghana AIDS Commission (GAC, 2018)  2.0PROBLEM STATEMENTGlobal Fund has provided free antiretroviral treatmentfor all persons living with HIV (PLHIV) in many health care facilities in Ghanaincluding Tema General Hospital since 2006 (). This led to an increase in thenumber of PLHIV who receive ART services throughout Ghana. For a patient toreceive maximum benefits from ART services, he/she must be at least 95%adherent to their medication and other components of the therapy. This impliesadherence is very important if we are to scale up the accomplishments of theART programme in resource limited settings: Ghana. In daily HIV care in theTema General Hospital, sustaining high-level adherence to ART is a challenge tothe ART programme as well as HIV care providers.

According to a descriptivecross-sectional study in the Upper West Region where 201 HIV 1 patients werestudied, an overall lifetime adherence rate was 62.2 % while medication in thelast 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 ARTand immunologic success, with non-adherence increasing the risk (Obirikorang,Selleh, Abledu & Fofie, 2013). Another cross-sectional study of 229 womenby Boateng, Kwapong -Baffour, 2013) concluded that 27% of PLHIV whohad good understanding and knowledge of ART defaulted treatment. This impliesthat even knowledge about effects of non-adherence does not necessarily affectdefaulter rate.

Similarly, a Nigerian study in Aminu Kano Teaching Hospitalreported 80% were adherent to ART (Mukhtar, Adeleke,Gwarzo & Ladan (2006).  Thus, these studies disclose that ARTnon-adherence appears to be a huge challenge threatening the long-term scale upand success of the ART programme in Sub-Saharan Africa.The Tema General Hospital’s ART clinic report from 2016/2017showed 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 forthe year in review, more than a quarter was non-adherent to their drugs. Moreover, patients had reported recurrentopportunistic infections and 3% or 98 people are on second-line regimen at TemaGeneral Hospital due to non-adherence causing treatment failure and resistanceto the first line drugs.

According various studies treatment failures, whichcould result from non-adherence, can result in opportunistic infections anddeath among PLHIV (Paterson et al. 2000; DeFino etal. 2004; Sethi et al.

2003). In these studies, there is a significantassociation of less than 95% adherence to treatment and virological failure. According to an Indian study, experiencingART-related undesired effects was considerably associated with suboptimaladherence. (Mehta et al, 2015).

Kobin and Sethi, 2011 found that non-adherence couldlead to limited future treatment options, emergence of resistant strains,higher treatment costs, treatment failure, and immune suppression.Experience suggeststhat PLHIV may be aware of the adverse effects of non-adherence throughcounseling sessions, but still do not conform to the agreed commendations dueto diverse reasons. Some PLHIV do not keep to clinic appointments and givevaried reasons when they finally do attend. Apart from these challenges, there arelimited reports available on the factors affecting adherence in Ghana and inTema Metropolis. Therefore, in order to develop programs to support adherence,it is important to understand the causes, hence the need to investigate intothe factors that affect adherence to ART.  Itis for this reason the researcher want to investigate the factors contributionto non-adherence in anti retroviral therapy among adults living with HIV/AIDSin the Tema General Hospital.

   2.1 JUSTIFICATION OF THE STUDYTo ensure a patient adheres to treatment regimenthey have undergo three intense counseling sessions before starting ARVs, withthe counselor being guided by a standard counseling form. This aims atempowering the patient to understand the treatment they are to be initiated onas this treatment is taken for the rest of their lives. Patient education isprovided to ensure long-term adherence to treatment, which is associated withtreatment success (NASCOP, 2005). This study is to contribute to an understanding of thefactors affecting adherence to ART programme in the Ghanaian context. It will contributeto the body of knowledge on the effects of non-adherence of ART and givefeedback to the ART programme at Tema General Hospital and Ghana in general oneffectiveness of interventions for patients receiving ART.  SIGNIFICANCE OF STUDYInvestigations in both African and Ghanaian contexthave indicated that there is a dearth in the level of ART adherence and severalfactors have been cited to contribute to the gap. This investigation willprovide an understanding into the level of ART adherence and distinguish theimpediments to optimal ART adherence in the Ghana Context.

Again, it will provide requisite information to informpolicy and practice in scaling up ART programme, develop evidenced-basedinterventions to increase adherence to ART. PLHIVs will benefit directly orindirectly through the provision of relevant and appropriate services and thehealth care provider will be well informed about the pervasiveness of non adherence and help to PLHIVto understand the need of playing active roles in their care to achieve optimaladherence with focus on improving ART adherence.  3.0 AIMTo investigate and define the factors affecting adherenceto ART among adult PLHIVs in Ghana, Tema General Hospital3.

1 OBJECTIVES OF STUDY1.     Toinvestigate factors affecting adherence to ART2.     To determine the level of adherence of PLHIV to ART programme in TGH3.     Toestablish the association between socio-cultural, socio-demographic,socio-economic and other patient/client related factors affecting the ARTadherence.

4.     To determine patient’s lifestyle practices in relation totreatment provided at the ART clinic. ?   4.0 METHODOLOGY4.1 Study Design4.

1.1 Cross-Sectional DesignThe 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. Thisdesign is appropriate for defining the status of a phenomenon or relationshipamong 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 StudyLocationThe study will be conducted in hospital(s) in TemaMetropolitan Area, Greater Accra Region, Ghana. Ghana is a West African Country found along the coast of the Gulf ofGuinea and bounded to the south by the Atlantic Ocean, Cote d’Iviore to thewest, Togo to the east and Burkina Faso to the north.

Ghana has severalhospitals, some directly under the Ministry of Health, Ghana Health Service,Quasi Hospitals and Private owned hospitals. In addition, there arenon-governmental health agencies in Ghana helping bring good health to thepopulace. Ghana is reported to be one of the fasted growing economies and amultiethnic country with ten (10) administrative regions with varioussocio-economic groups and an uneven distribution of wealth and health. Tema isa city in Greater Accra Region.Tema is a community located on the coastof Atlantic Ocean 16 miles (25 km) east of Accra, the national capital ofGhana. It has a population of approximately 402,637 people and the 11th mostpopulated settlement in Ghana as of 2010 (Ghana Statistical Service, 2010).

Tema has acquired the nicknames meridian city and harbour town because of thepassage of longitude 00 (the Greenwich Meridian) through the town and for itsprominence as the main seaport in Ghana (GhanaDistricts.com, 2013). Thecommunity is built on a fishing settlement, which is now home to severalfactories, and it is a major trading centre. Tema is a major commercial townwith numerous factories and an oil refinery. The town has one referral hospital, Tema General, anda polyclinic with numerous private hospitals. 4.

3 Study Population And Sample SelectionThe eligible population will be adult PLHIVs on ARTthat are registered and attending ART clinic at Tema General Hospital. Eligibleparticipants must be on ARVs for at least three months with the ability to giveconsent, not take part in the pilot study, and be above 20 years of age.4.3.1 SamplingThis study will employ systematic sampling technique,which ensures some level of precision in estimating population parameters, thusreducing sampling error (Burns and Grove 2005: 365). Study participants will beselected using an ordered patient list based on their registered identificationnumbers from the ART computer database.

4.3.2 SAMPLE SIZEUsing aprecision of 5% and 95% confidence interval the sample size was determined bythe formula, N= p(1-p) z2 /d2;?Where,p = estimated proportion of patients adherent to ART, z = thecut off value of the Normal distribution and d = theprecision required on either side of the proportion. Consideringlost to follow up, transfer out, death and non-willingness, 10% of the samplesize was added to the total sample size. A pooled estimate of adherence toantiretroviral therapy in Sub-Saharan Africa was found to be 77% (Mills et al2006a:679). Therefore, the total sample size for this study was 300 using aprecision of 5% and 95% confidence interval.    4.

3 StudyMethod4.3Quantitative StudyQuantitativemethods will be used to permit a range of statistical analysis of the numericaldata. This will actually help interpret and better understand the complexreality of the situation and the implications of data collected.

 4.3.1 Data CollectionThe studyobjectives determine the scope and nature of data to be collected. A structuredquestionnaire will be used to interview participants. The questionnaire will bepiloted in a small group of PLHIVs on ARVs before data collection. Datacollectors will be trained and deployed to gather the necessary information byinterviewing participants using the structured questionnaires.Quantitativedata collection will give an extent in terms of numbers of participants whohave problems adhering to ART services.   4.

3.2 Data Collection ToolStructured questionnaires will beused to collect data. The tool will be in four sections: section A solicitinginformation on their demographic data, B, information to meet the objective offactors affecting ART adherence, section C will determine the level ofadherence. Section D will solicit information to meet howpatients’ lifestyle affects their treatment .

The questionnaire willanswer questions relating to demographics, adherence, socio-cultural,psychosocial, socio-economics, health care provider attitude, health relatedART site and setting.4.3.3Data Analysis4.3.3.1Approach To Quantitative Analysis Quantitativeanalysis software SPSS will be used to analyse the data collected. Regressionanalysis will be used to analyse data and generate a summary of statistics ofcross-sectional data.

Results will be presented in graphs, pie charts.     4.3.4 Inclusion CriteriaAll adult PLHIV on ART attending clinic for the past 3months who have agreed to participate, will be included in the study.  4.

3.5 ExclusionCriteriaPLHIV who are not interested in participating, thosebelow 20 years and those who do not attend Tema General Hospital ART clinic.4.3.6 Withdrawal CriteriaPatients canwithdraw from the study at any point in time when they no longer feel comfortablebeing part of the study. 5.

0Ethical ConsiderationsThestudy protocol will be assessed and approved by the Research Ethics Committeeof the Ghana Health Service, before commencement of data abstraction. The studywill commit to respecting the standards of good scientific practice as well asadhere to the requirements of the Helsinki Declaration. Participants would be informed before the studyto enable them makes a decision. The information given to participants willinclude the purpose of the study, details of the investigator, and addressconfidentiality and anonymity issues.

Informed consent (verbal) will be soughtfrom PLHIV who have agreed to participate in the study. Moreover, their refusalat any point will not have any effect on their care. 5.1 Quality ControlAll data collected will be doubledchecked and cleaned before analysis is made.

 5.2 Confidentialityof dataThis study will beconducted in strict accordance with the standards for protection of privacy ofidentifiable health information. Codes instead of names will be used in datacollection.

It will ensure that all study records are managed in a secure andconfidential manner so as not to expose the identity of subjects. Hard copies of data ofsubjects will be secured and restricted to principal investigator and auditorsuntil data is entered into the software, after which the hardcopies will bediscarded safely and appropriately. All computers used in the collection andsaving of data will be password protected. Excel sheets for recording patients’information will also be password protected. 5.3 LIMITATIONSThe generalisabilty ofthe study findings may be compromised because the study is single site healthfacilities.Death, transfer out andlost to follow up may affect findings.  REFERENCES       UNAIDS (2010) Joint United Nations Programme on HIV/AIDS (UNAIDS)Global report, UNAIDS report on the global AIDS epidemic.

?           Factors Influencing Adherenceto Antiretroviral Therapy among People            Living With HIV/AIDS at ARTClinic in Jimma University Teaching            Hospital, Southwest Ethiopia Abebe Abera*, BeletechFenti, Temamen Tesfaye and Fikadu Balcha Aberaet al., J Pharma Reports 2015, 1:1                  Kobin AB, Sheth NU (2011) Levels of adherence required forvirologic suppression among newer antiretroviral medications. Ann Pharmacother45: 372-379. ?    Paterson DL, Swindells S, Mohr J, Brester M, Vergis EN, et al.(2000) Adherence to protease inhibitor therapy and outcomes in patients withHIV 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 SouthIndia. AIDS Behav.                 Lewis, M. P., Colbert, A.

, Erlen, J., & Meyers, M. (2006). Aqualitative study of persons who are 100% adherent to antiretroviral therapy. AIDS Care, 18(2), 140-148. doi:10.1080/09540120500161835            Mukhtar-Yola, M., Adeleke, S.

, Gwarzo, D., & Ladan, Z. F.

(2006). Preliminary investigation of adherence to antiretroviral therapy amongchildren 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 improveadherence to HIV therapy regimens.

PatientEducation and Counseling, 50(2), 187-199. doi: 10.1016/s0738-3991(02)00127-1 ?        ?                           ?  

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