aInfectious Disease Institute, Kampala, Uganda
bEpidemiology and Prevention Interventions Center, Division of Infectious Diseases and The Positive Health Program UCSF, San Francisco, California, USA
cMakerere University, Kampala, Uganda.
Received 30 March, 2007
Accepted 12 April, 2007
Although recent data suggest high levels of adherence to expanding antiretroviral therapy (ART) programmes in resource-limited settings, the culture-specific barriers to adherence are poorly understood. In a prospective observational study, we found that 1.2% of patients discontinued ART because of a belief in spiritual healing. Spiritual beliefs should be an important part of ART adherence counselling in resource-limited settings, requiring close collaboration between HIV care programmes and religious leaders to identify common goals and ensure successful treatment.
Uganda has been heralded as one of the world's earliest and most compelling AIDS prevention success stories as a result of its unprecedented decline in the prevalence of HIV from a national average of 18% in 1992 to 6.4% currently . ART has been rapidly scaled up over the past 3 years with 85 000 patients currently on treatment . Free antiretroviral therapy (ART) is provided through programmes such as the Multicountry AIDS Program and the President's Emergency Plan for AIDS Relief (PEPFAR) to clinically eligible patients. Early studies suggest excellent adherence and treatment response among individuals receiving care in these programmes .
In spite of these successes, many challenges remain including a better understanding of the cultural interpretation of HIV treatment. Uganda is a highly religious country where 85.1% of the population identifies themselves as Christian and 12.1% as Muslims. One cultural misunderstanding is that HIV/AIDS can be cured by spiritual healing. We set to determine how common this belief is among individuals who miss ART refill appointments in a prospective observational cohort at the Makerere University Infectious Diseases Institute (IDI) HIV treatment programme.
IDI provides expanded HIV care, training and research at Makerere University Medical School and Mulago teaching hospital in Kampala, Uganda. At the time of this study more than 4000 adults among the 8000 active patients are receiving free ART.
From April 2004 to April 2005, patients starting their first course of ART were enrolled into a prospective observational cohort to evaluate the clinical, immunological and virological outcomes of naive patients starting ART. Patients were enrolled if they fulfilled all of the following eligibility criteria: (i) confirmed HIV-1 infection; (ii) regular attendance; (iii) stable residence within a 20 km radius of Kampala; (iv) willingness to be followed and exclusively receive HIV-1 care at IDI for at least 2 years; and (v) provision of written informed consent. Clinical data were completed for each patient at baseline and every 3 months. Information on loss to follow-up, transfer, and death was kept for all patients. Laboratory measurements included complete blood counts, CD4 lymphocyte counts and plasma HIV-1-RNA levels (viral load) every 6 months.
From August to September 2006, we carried out a chart review for patients who had missed their last study appointment and their antiretroviral drugs refill. Phone calls or home visits were conducted to investigate the reason for missing appointments. Discontinuing ART because of ‘spiritual healing’ was defined as patients' discontinuation of ART as a result of the belief that they had been cured of HIV infection after prayers by religious leaders.
Of 558 patients enrolled, the majority (69.4%) were women and 88.4% were in an advanced stage of disease by the time they started ART [World Health Organization (WHO) stage III or IV]. The median CD4 cell count at baseline was 104 cells/μl and the median viral load was 5.4 log copies/ml. By the time of the analysis 13.8% of patients had died. Six patients (1.2%) discontinued HAART because of spiritual healing. Five were women, mean age 32 years; four were at WHO stage III at baseline and two were WHO stage IV. The median baseline CD4 cell count was 109 cells/μl and the median baseline viral load was 87 206 copies/ml. All of them were started on a generic fixed combination of stavudine, lamivudine and nevirapine (Table 1). The median duration from initiation to discontinuation of HAART was 30 weeks (mean 31.3, range 12–56). Whereas most patients had a CD4 cell count response, only one patient had viral suppression before discontinuation.
All these patients were members of evangelical churches that believe in the sole authority of the literal bible, a salvation only through regeneration, or rebirth, and a spiritually transformed personal life. All the patients had a normal mental examination at the time of discontinuation of ART. One patient died and one patient was lost to follow-up. The remaining four patients were called back to the clinic by the study counsellors and had symptomatic HIV off ART. Two patients were diagnosed with tuberculosis relapse (after 3 and 12 months off ART), one experienced chronic diarrhea after 5 months off ART, and one was admitted for suspected tuberculosis. All initially declined to restart ART but subsequently restarted on ART after adherence counselling and education. Three of these four eventually needed to be switched to second-line salvage treatment as a result of virological failure.
We found that 1.2% of HIV-positive individuals initiating ART in a prospective observational cohort study discontinued therapy as a result of their belief that they no longer needed therapy because they had been spiritually healed. Four of six of these individuals restarted therapy, but three required second-line salvage therapy. Treatment interruptions of a fixed dose combination have been associated with virological failure and drug resistance [4,5]. Sustaining uninterrupted ART is an important goal to sustain viral suppression, prevent drug resistance and ensure the clinical benefit of treatment Spiritual beliefs should be an important part of ART adherence counselling in resource-limited settings. Close collaboration between HIV care programmes and religious leaders will be necessary to identify common goals and ensure successful ART programmes in Uganda.
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© 2007 Lippincott Williams & Wilkins, Inc.