ABSTRACT
Retention in HIV care or the continuous and uninterrupted
receipt of comprehensive HIV care and treatment services is a health behaviour essential
in reducing AIDS related morbidity/mortality, prolonging survival of persons
living with HIV/AIDS (PLHIV) as well as achieving epidemic control by
minimizing viral transmission and the incidence of new HIV infections. It is a
health promoting behaviour that is of particular importance in countries with
the highest HIV disease burden including Nigeria, with over 10% of the global
HIV disease burden. Although studies have confirmed that retention ratesare
sub-optimal both in developed and developing countries, there is limited
information on how retention rates vary with time in Nigeria. This study was
therefore conducted to determine the percentage of HIV-infected adults that
were continuously retained in HIV care 36 months after starting antiretroviral
treatment (ART) as well as identify barriers and facilitators of retention.
This study employed a mixed-method research design and was
conducted at State Specialist Hospital, Akure in Ondo state, Nigeria. A total
of 420 HIV-infected persons who started antiretroviral treatment between
January and December 2013 were purposively selected and retrospectively
followed up for a total of 36 months in order to determine retention rates (operationalized
using the 4-month hospital visit constancy measure); by 12, 24 and 36 months
post-treatment initiation. Additionally, 12 in-depth interviews were conducted
with HIV-infected persons receiving treatment at the facility in order to
elicit barriers and facilitators of retention in HIV care. The socio-ecological
framework of health promotion guided the coding of qualitative research data
while grounded and density analysis was used in identifying the most
significant barriers and facilitators of retention in HIV care.
In this study, retention rates were observed to decline
significantly among both males and females. Retention rates at 12, 24 and 36
months were 57.95%, 50.00% and 40.22% for males and 77.24%, 63.31% and 49.74%
for females, respectively. Stigma, poor health literacy and clinic
distance/lack of transportation fare were the most important barriers to
retention while good health literacy and a positive healthcare worker – client
relationship were the most significant facilitators of retention identified by
study participants.
In conclusion, the study highlights the need for novel
strategies to promote retention especially among men. These strategies include
prioritization and allocation of resources by HIV program planners to
facilitate implementation of health promotion interventions; the development of
a national HIV/AIDS patient education curriculum to promote health literacy;
the conduct of regular mass media campaigns to address HIV-related stigma in
the community. There is also a need for large-scale studies that better characterizing the barriers of retention particularly the dimensions
of HIV-related stigma in Nigeria.
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
The Human
Immunodeficiency Virus (HIV) belongs to the family of ‘retroviruses’and
possesses the ability to transform its genetic material from viral ribonucleic
acid (RNA) into deoxyribonucleic acid (DNA) and then subsequently integrate the
latter into the genome of an infected human cell(Maartens, Celum, & Lewin, 2014) . These processes,
referred to as reverse transcription and integration, combined with a high
mutagenicity currently constitute significant barriers to the creation of a
cure for the virus. Antiretroviral medications (ARVs) interfere with
replication of the virus in specific cells of the immune system (expressing CD4
receptors on their cell surfaces) through varying mechanisms resulting in virologic
suppression; characterized by an undetectable level of the virus in the human circulatory
system and represents the primary goal of antiretroviral therapy. Indirect
benefits that follow virologic suppression include recovery of the immune
system; a reduction in AIDS related morbidity; an improved life expectancy and
a significant reduction in the risk of transmission of the virus(Cohen, et al., 2016) .
The receipt of
antiretroviral medications is therefore a lifelong process and for HIV-infected
persons to benefit maximally from ARV therapy, they must be optimally retained
in care. Retention in HIV care describes the continuous and uninterrupted receipt
of comprehensive HIV care and treatment services following HIV diagnosis and successful
linkage to care and is an important health behaviour necessary to ensure
continuous receipt of antiretroviral medications; evaluation of drug
toxicities; early identification of treatment failure(Geng, et al., 2010) ; and ongoing receipt
of comprehensive health education that in turn promotes medication adherence.
From an individual
standpoint, retention in care is important as it is a strong predictor of
virologic suppression and prolonged survival for persons living with HIV/AIDS
(PLHIV)(Colasanti, et al., 2016) . Countries of
sub-Saharan Africa, particularly South Africa and Nigeria are
disproportionately affected by HIV(UNAIDS, 2016) ; and in these countries, retention in
HIV care is a public health priority as intimated by a study that observed that
HIV-infected persons who are poorly retained were the most significant source
of new HIV infections in the United States(Skarbinski, et al., 2015) . From a health
promotion standpoint however, retention in care provides an indirect reflection
of the readiness of HIV-infected persons to increase control over, and improve
their health. Several studies however, suggest that retention in HIV
care is sub-optimal both in developed and developing countries(McCutchan, 2009) .
In a recent study
conducted in the United States, retention rates were observed to decline from
84% to 60% and 49% at 12, 24 and 36
months post-initiation of antiretroviral therapy, respectively (Colasanti, et al., 2016) . In sub-Saharan
Africa, the earliest systematic review of retention in HIV care observed that
among 74,000 HIV-infected persons across 13 countries, the proportion of
persons who were alive and receiving ARVs 24 months post-initiation of
treatment was approximately 60%(Rosen, Fox, & Gill, 2007) . In an updated
meta-analysis published in 2010, the authors observed that 24- and 36-month
retention rates for 226,307 persons from 39 patient-cohorts was 70% and 64.6%
respectively(Fox & Rosen, 2010) . In Nigeria, most
studies conducted to assess retention rates have been cross-sectional in
nature. In one study, 75% of 3,878 HIV-infected adults who
started ARVs between 2005 and 2009 across 37 treatment facilities in Nigeria
were retained in care by 2010 (Ugoji, et al., 2015) . In another
cross-sectional study conducted in Ekiti state, only 63% of HIV-infected
persons who started ARVs between 2005 and 2011 at a large tertiary hospital
were retained in care by 2012(Babatunde, et al., 2015) .Cross-sectional analyses
typically over-estimate retention rates and do not provide information on changes
in retentionrates over time.
Several studies have also been conducted to determine factors
that predict retention in HIV care including demographic factors such as
younger age, male gender, lower level of education and socio-economic status;
availability of social support; adherence counselling; disclosure of HIV
status; presence of severe mental illness; clinic related factors; HIV disease
progression and HIV sero-discordance(Bulsara, Wainberg, & Newton-John, 2016) . In the study of
factors influencing this important health behaviour (retention in HIV care);
most studies failed to conceptualize their research using a theory of health behaviour.
It is therefore on the premise of the large disease burden in
sub-Saharan Africa particularly Nigeria; coupled with limitations of existing
studies that this study sort to determine how retention rates varied over time while
also determining barriers and facilitators of retention in HIV care in Nigeria.
The
specific objectives are to:
1. determine
the percentage of HIV-infected adults that are continuously retained in care
after 36 months of initiating antiretroviral treatment;
2. identify
barriers to retention in care among HIV infected adults on antiretroviral treatment
and
3. identify
facilitators of retention in care among HIV infected adults on antiretroviral
treatment
Research questions that
guided this study were the following:
1. What
percentage of HIV-infected adults is continuously retained in care after 36
months of initiating antiretroviral treatment?
2. What
are the barriers to retention in care among HIV infected adults on
antiretroviral treatment?
3.
What are the
facilitators of retention in care among HIV infected adults on antiretroviral
treatment?
Sub-optimal retention
in HIV care has deleterious effects both from the individual and public health
perspective. Poor retention in HIV care has been linked with poor medication
adherence, development of antiretroviral drug resistance and an increased risk
of death from Acquired Immunodeficiency Syndrome (AIDS) – the hallmark of HIV
infection characterized by severe, debilitating and life-threatening opportunistic
infections. From a public health standpoint, interventions to promote retention
in HIV care are needed in order to reduce the transmission and incidence of new
HIV infections within communities; reduce the burden placed on an already weak
healthcare system as well as reduce healthcare costs associated with HIV
treatment, prevention and control. HIV-infected
persons who are poorly retained in care typically have higher viral loads and
are significantly more likely to transmit the virus to others. In high burden
settings like Nigeria, there is therefore an important need to employ health
promotion strategies that promote health literacy through health education both
for infected individuals and the communities they reside in.
This study is unique
as it is one of a few studies conducted in Nigeria to estimate retention rates
longitudinally, over a 36-month period thus, providing a more accurate estimate
of retention among HIV-infected persons on antiretroviral treatment.
Furthermore, this study conceptualized using the socio-ecological model also elicited
barriers and facilitators of optimal retention in HIV care in Nigeria. The
results of this study contribute new knowledge that will act as a roadmap guiding
the design and implementation of effective interventions to improve retention
in HIV care in Nigeria.
Antiretroviral
Treatment (ART):is a combination of
at least 3 potent antiretroviral medications used in the lifelong management of
HIV
HIV
Continuum of Care:
is a framework that describes the various steps that persons living with HIV
must proceed through in order to achieve virologic suppression namely
diagnosis, linkage to HIV care and ART eligibility assessment, initiation and
maintenance of ART and the achievement of viral suppression.
Virologic
Suppression: is the suppression
of HIV viral load to levels below 1,000 viral copies per millilitre (ml) of
blood due to inhibition of replication by antiretroviral medications.
Retention
in HIV Care:the continuous and uninterrupted receipt of
comprehensive HIV care and treatment services following successful linkage to
care; operationalized in this study, as ‘4-month
hospital visit constancy’ or the ‘number
of 4-month intervals with at least 1 clinic visit’.
HIV
Treatment Naive: refers to HIV-positive persons who have never been initiated on or taken
any antiretroviral medications for HIV.
HIV
Treatment Experienced:refers
to HIV-positive persons who have been initiated on antiretroviral medications
at any time since they were diagnosed with HIV.
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