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Factors Associated with  ART Non-adherence in  Rural Achham, Nepal

Factors Associated with ART Non-adherence in Rural Achham, Nepal






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    Factors Associated with  ART Non-adherence in  Rural Achham, Nepal Factors Associated with ART Non-adherence in Rural Achham, Nepal Presentation Transcript

    • Achieving Millennium Development Goals Through Universal Access Factors Associated with ART Non-adherence in Rural Achham, Nepal Dr. Bibhusan Basnet ,MBBS Nyaya Health Nepal , B Dr. Bayalpata Hospital Badelgada-2, Achham Organization Organization logo logo
    • IntroductionBackground • Worldwide: 40.3 million (WHO 2005) • Asia: 4.7 million, of which newly infected/year :350,000 (WHO 2008) • Situation in Nepal: 50,200 (UNAIDS/NCASC 2012) • Far west accounts for 16% of total HIV infections (UNAIDS 2005) • For successful treatment , medication adherence for patients on ART is critical. (Sethi et al.2003) www.nepalaids2012.org.np
    • Statement of the problem • ART is the cornerstone of treatment for HIV and AIDS. • Non-adherence is a major, if not the most important factor contributing to treatment failure and development of resistance(Turner 2002) www.nepalaids2012.org.np
    • Rationale / Justification • Adherence is essential for successful treatment and sustained viral control( Carter 2005) • Failure to ART increases risk of transmission of resistant viruses. • Limited future treatment options due to poor adherence makes adherence a public health concern . • Bayalpata hospital operating in far west Accham has recently been upgraded to an ART center.• The following study was devised as an asset for quality improvement,thus enhancing the impact of ART services www.nepalaids2012.org.np
    • Objectives General •To evaluate the adherence to ART. •To determine the factors associated with ART adherence Specific 1. To determine the adherence rate 2. To determine facilitating factors and barrier to adherence 3. To assess the Karnofsky performance scale of the patient www.nepalaids2012.org.np
    • Research Design and Methodology • Cross-sectional quantitative study carried out over a 8 weeks period • Sampling technique: Convenient sampling • Sample size: 105 patients, attending the Out patient clinic of the hospital. • Inclusion criteria: Patients <18 years and who have been on ART for at least 6 months. www.nepalaids2012.org.np
    • Study Site : Bayalpata Hospital, Achham. www.nepalaids2012.org.np
    • Data collection: • Data collection was done using structured questionnaire on the following variables: • Socio-economic demographics • Adherence rate • Facilitating factors and barriers associated with adherence • Health system factors • Coping strategy www.nepalaids2012.org.np
    • Data Collection Tools:•Visual Analog scale(VAS) was similar to pain evaluation used for assessingadherence. (Walsh et al.2002 ,Giordano et al.2004)• Score of 10 was considered as to never missed any medication in the last 4weeks. i.e absolute adherence•≤9 for missed medications in the last month.•Any answer different from 10 was considered to represent non adherence. www.nepalaids2012.org.np
    • Data Collection Tools Continued:•Karnofsky Performance Scale was used.• Assess a patients performance on a regular basis, especially as the effects ofHIV progress.•Karnofsky scores over time allows patients to be classified as to theirfunctional impairment(EM Painline 2012)•Lower the Karonfsky score, the worse the survival for most serious illnesssuch as HIV/AIDS. www.nepalaids2012.org.np
    • Ethical Consideration • The research received approval from NHRC. • Verbal informed consent was taken from each study participant. • Questionnaire was accessed by only the researcher, thus maintaining the confidentiality of the participants. www.nepalaids2012.org.np
    • Research Findings www.nepalaids2012.org.np
    • Socio Demographics•Among the respondents,37 were males and 68 females.•56.2% of the patients surveyed were married, while the remainder werewidowed (43.8%).•65.7% of the patients led a nuclear family or a joint family (30.5%).•Median number of dependents was found to be 3. Marital Status of patients Type of family60.0% 70.0% 65.7% 60.0%50.0% 50.0%40.0% 40.0%30.0% 30.5% 56.2% 30.0%20.0% 43.8% 20.0%10.0% 10.0% 3.8%0.0% 0.0% Married Widowed Nuclear Joint Living alone www.nepalaids2012.org.np
    • Socio Demographics•Majority of patients were either of the Dalit (51.4%) or chhettri(44.8%) castes.•78.1% of the respondents had farming as their most common occupationfollowed by shopkeeper (6.7%) and housewife (5.7%). Caste Occupation60.0% 90.0% 51.4% 80.0%50.0% 44.8% 70.0%40.0% 60.0% 50.0%30.0% 40.0%20.0% 30.0% 20.0%10.0% 2.9% 10.0% 1.0%0.0% 0.0% Brahmin Chhetri Vaishya Dalit Farming Housewife Shopkeeper Teacher Laborer Other www.nepalaids2012.org.np
    • Socio Demographics: • 82.9% were on first-line WHO regimen or a substituted first line regimen (17.1%). • Median individual monthly income: NRs 2000 (range 300-10000) • Median family expenditure/year :NRs 20000 (3000-150000) www.nepalaids2012.org.np
    • Socio Demographics • Educational attainment was low with 70.5% indicating they could not read or write Education 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Cannot read Read, but Primary SLC High school University or write cannot write school www.nepalaids2012.org.np
    • Adherence•With respect to measures of adherence 90 (85.7%) reported a VAS of 10 and15 (14.3%) gave a score <10.• Rates of missed doses in the past week were 6.7%, 15.2% in the past monthand 25% in the past 6 months.•Of those reporting a missed dose in the past month 70.6% missed less than 3 doses 17.6% 3 to 12 doses 11.8% more than 12 doses www.nepalaids2012.org.np
    • Adherence rate by VAS<10 (n=15) VAS score <10 (n=15) Factors associated with poor n OR 95% CI p-value adherenceAny medication side-effects 12 1.71 0.45-6.6 0.5466 100% 90% VAS Score <10 (n = 15)Field work or family 8 32.40 6.98-150.2 <0.0001 80%obligations 70%Travel by both bus and on 0.0152 60% 6 4.79 1.42-16.1foot 50% 40%Depressed mood past month 7 3.07 1.00-9.36 0.0567 30%Literacy 14 4.53 0.56-36.4 0.1815 20%Living alone 2 6.77 0.88-52.3 0.0968 10%Help at home 7 0.38 0.12-1.14 0.1362 0%Socioculture factors 5 4.50 1.26-16.1 0.0279Time waiting, spent at clinic 12 3.66 0.97-23.6 0.0527or timing of ART clinicOpportunistic infection last 6 6 2.19 0.70-6.87 0.205monthsCoping mechanisms 8 0.76 0.25-2.23 0.778 www.nepalaids2012.org.np
    • Adherence by missed dose in last 1 week Missed dose in last week (n=7) n OR 95% CI p-value Factors associated with poor 100% adherence (n = 7)Any medication side-effects 5 1 0.18-5.46 1Field work or family 80% 5 27.5 4.58-165.1 0.0003obligations 60%Travel by both bus and on 4 8.72 1.75-43.5 0.0125foot 40%Depressed mood past month4 3.69 0.77-17.6 0.1007 20%Literacy 6 1.58 0.18-13.9 1 0%Living alone 1 5.28 0.48-58.7 0.2443Help at home 3 0.35 0.07-1.65 0.2183Sociocultural factors 2 2.87 0.50-16.5 0.2343Time waiting, spent at clinic 5 1.88 0.35-10.1 0.6963or timing of ART clinicOpportunistic infection last 6 0.37 3 2.31 0.48-11.1monthsCoping mechanisms 2 0.25 0.05-1.37 0.1196 www.nepalaids2012.org.np
    • Adherence by missed dose in last 1 month Missed dose in last month (n=16) n OR 95% CI p-value Factors associated with poor adherence(n=16)Any medication side-effects 12 1.24 0.37-4.20 0.7771 100%Field work or family 9 17.4 4.78-63.0 <0.0001 80%obligationsTravel by both bus and on 60% 6 4.26 1.29-14.0 0.0219foot 40%Depressed mood past month 7 2.23 0.75-6.68 0.227 20%Literacy 15 4.93 0.62-39.5 0.1162Living alone 2 6.21 080-47.8 0.1091 0%Help at home 7 0.32 0.11-0.95 0.0455Sociocultural factors 7 9.11 2.6-31.9 0.001Time waiting, spent at clinic 12 2.45 0.73-8.18 0.1739or timing of ART clinicOpportunistic infection last 6 7 2.68 0.89-8.11 0.1163monthsCoping mechanisms 9 2.08 0.71-6.1 0.269 www.nepalaids2012.org.np
    • Adherence by missed dose in last 6 months Missed dose in last 6 months (n=26) Factors associated with poor adherence n OR 95% CI p-value (n = 26)Any medication side-effects19 1.12 0.41-3.01 1 100%Field work or family 80% 11 56.5 6.77-470 <0.0001obligationsTravel by both bus and on 60% 7 2.83 0.93-8.58 0.112foot 40%Depressed mood past month 13 3.59 1.40-9.17 0.0112 20%Literacy 24 4.42 0.96-20.4 0.055Living alone 2 3.17 0.42-23.7 0.57 0%Help at home 14 0.49 0.20-1.21 0.1516Socioculture factors 8 5.33 1.64-17.3 0.006Time waiting, spent at clinic 19 2.45 0.93-6.49 0.1089or timing of ART clinicOpportunistic infection last 6 10 2.42 0.93-6.34 0.1143monthsCoping mechanisms 13 0.63 0.26-1.53 0.3602 www.nepalaids2012.org.np
    • Karnofsky Performance Scale•Respondents were relatively asymptomatic•34.3% (score of 100)- Normal; no complaints; no evidence of disease•30.5%(score of 90)- Able to carry on normal activity; minor signs or symptoms ofdisease•24.8%(score of 80)-Normal activity with effort; some signs or symptoms of disease•only 4 patients required considerable assistance or disability related to the HIVdisease•Non significant with respect to adherence. www.nepalaids2012.org.np
    • Socio Cultural Factors•Socio-cultural factors and alternative treatments besides ART as a factor fornon adherence were uncommon with only 13.3% and 14.3%, respectively.•Though uncommon, it was found to be a significant factor associated with nonadherence: VAS Score <10 (p=0.0279) missed dose in the last month (p=0.001) missed dose in the last 6 months (p=0.006) 100.0% 86.7% 80.0% 60.0% 40.0% 20.0% 8.6% 2.9% 1.9% 1.9% 0.0% Stigma and Fear of disclosure Fear of stigma in Fear of stigma in None discrimination to of status in the the family the workplace oneself community www.nepalaids2012.org.np
    • Individual Factors 40% Individual Factors 20% 0% dizziness vomiting headache fever rash diarrohea candidiasis TB vaginal discharge Most common side effects Most common opporutnistic infectionsNote: No statistical significance found with non- adherence www.nepalaids2012.org.np
    • Individual factors•98.1% of those surveyed stated their family was aware of their HIV status.•Spouses of nearly all subjects (104/105) were aware of their HIV status(63.8%) or deceased (35.2%).•Seventy-two subjects reported use of electronic reminders. Use of electronic reminders 60.0% 51.9% 50.0% 40.0% 31.7% 30.0% 20.0% 10.6% 10.0% 2.9% 2.9% 0.0% Watch Clock Mobile Radio None www.nepalaids2012.org.np
    • Hospital Based Factors•Twenty-five of 105 respondents (23.8%) indicated distance was a reason fornon adherence.•97.1% of the respondents reported sufficient counseling provided. Hospital based non adherent factors 25% 21.9% 20.0% 20% 15.2% 15% 10% 5% 0% Time spent waiting to see a Time spent at the hospital Timing of the ART clinic clinician and www.nepalaids2012.org.np
    • Hospital Based Factors•Median amount of travel time required to get to clinic was 3 hours•17 persons reported required travel both by foot and bus.•Most reported travelling by foot (73.3%) compared to travel by bus (10.5%)•Travel by both foot and bus were significant for: VAS of <10 (p=0.0152) missed dose in the last week(p=0.0125) missed dose in the last month(p=0.0219) www.nepalaids2012.org.np
    • Trend towards significance:A trend toward significance was observed for:• VAS score and depressed mood in the past month(p=0.0567)• VAS score and time waiting for physician/time spent at hospital/timing of ART clinic (p=0.0527)• Missed dose in the last 6 months and literacy (p=0.055)• Median values for monthly and yearly income was not found to be significant www.nepalaids2012.org.np
    • Limitations of the study: • The study could not be generalized. • Cross-sectional design, which correlated unique time frames of adherence. • Recall bias • Patient’s viral load as well as CD4 count is not included in the study secondary to unavailability of this data. www.nepalaids2012.org.np
    • Conclusion • The correlation between the four assessments of adherence was high. • Rates of missed doses in the past week were 6.7%, 15.2% in the past month and 25% in the past 6 months. • Among those with a missed dose in the past month, most were less than 3 doses. • Factors consistently associated with non-adherence across all methods of adherence were the presence of field work or family obligations. • The presence of socio-cultural factors affecting adherence and travel by both foot and bus were significant for 3 out of 4 measures of adherence. www.nepalaids2012.org.np
    • Conclusion •Despite the availability of free ART services, accompanied by counseling, patient adherence is still an issue. •There are individual, socio-cultural and health system factors that all influence how successful treatment of HIV with ARVs will be. • Addressing these issues by creating a more collaborative relationship between the patient and the health care provider may be the key to achieving a 100% adherence rate. www.nepalaids2012.org.np
    • Recommendations• Timing of the ART clinic should be made more flexible.•Electronic reminders as watches was seen to be used extensively. So, couldbe promoted by the government.•Socio cultural factors related to stigma have been changing , yet is a factorrelated to non adherence.•Distance is seen as one of the major barriers so decentralization of ARTcenters should be increased. www.nepalaids2012.org.np
    • References•Carter, M (2005). Adherence Information series for HIV positive people. NAM.Available from: http://www.aidsmap.com [Accessed 15/5/2012]•Emergency medicine painline (2012)Availablefrom:http://www.empainline.org/linked_site_content/pdf/KarnofskyPerformanceStatusScale.pdf [Accessed 13/8/2012]•Giordano ,TP, Guzman, D, Clark, R et al.(2004) Measuring adherence toantiretroviral therapy in a diverse population using a visual analogue scale,HIVClin Trials, vol. 5,no.2,pp.74-79•National Centre for AIDS and STD Control (2009). Cumulative HIV/AIDSsituation of Nepal. Monthly Report on HIV/AIDS Statistics. Kathmandu. www.nepalaids2012.org.np
    • References•National Centre for AIDS and STD Control (2010). HIV Treatment and Care(Anti-Retroviral Therapy - ART) Centers, 2010. Availablefrom:http://www.ncasc.gov.np/uploaded/SDP/ART_Sites_in_Nepal_2010.pdf[Accessed 15/5/2012]•Sethi, AK, Celentano, DD, Gange ,SJ, Moore, RD, Gallant, JE et al.(2003)Association between adherence to antiretroviral therapy and humanimmunodeficiency virus drug resistance. Clin Infect Dis vol.37,no.(8),pp.1112-8.•Turner, BJ (2002) .Adherence to antiretroviral therapy by HIV-infected patients.Journal of Infectious Disease, vol.185, no. 2, pp. 143-51.•outcome. AIDS Care, vol.16, pp. 269–277 www.nepalaids2012.org.np
    • References•United Nations Program on HIV/AIDS /National Centre for AIDS and STDControl(2012).Nepal country progress report ,2012.Available from:http://www.unaids.org/en/dataanalysis/knowyourresponse/countryp•Walsh, JC, Mandalia, S, Gazzard BG (2002) Responses to a 1 month self-report on adherence to antiretroviral therapy are consistent with electronic dataand virological treatment www.nepalaids2012.org.np
    • THANKYOU!!! www.nepalaids2012.org.np