Background: Botswana has the highest rate of HIV infection in the world, estimated at 36% among the population aged 15-49 years. To improve antiretroviral (ARV) treatment delivery, we conducted a cross-sectional study of the social, cultural, and structural determinants of treatment adherence.
Methods: We used both qualitative and quantitative research methodologies, including questionnaires and interviews with patients receiving ARV treatment and their health care providers to elicit principal barriers to adherence. Patient report and provider estimate of adherence (≥95% doses) were the primary outcomes.
Results: One hundred nine patients and 60 health care providers were interviewed between January and July 2000; 54% of patients were adherent by self-report, while 56% were adherent by provider assessment. Observed agreement between patients and providers was 68%. Principal barriers to adherence included financial constraints (44%), stigma (15%), travel/migration (10%), and side effects (9%). On the basis of logistic regression, if cost were removed as a barrier, adherence is predicted to increase from 54% to 74%.
Conclusions: ARV adherence rates in this study were comparable with those seen in developed countries. As elsewhere, health care providers in Botswana were often unable to identify which patients adhere to their ARV regimens. The cost of ARV therapy was the most significant barrier to adherence.
AIDS is the leading cause of death in sub-Saharan Africa. According to 2001 estimates, there are 28.5 million people living with AIDS in Africa, comprising >70% of the world's HIV-infected population. Botswana currently has the highest estimated prevalence of HIV infection in the world. According to the 2002 UNAIDS update, >330,000 people of a population of 1.5 million in Botswana have been infected with HIV, and there were 26,000 estimated deaths due to AIDS in 2001 alone. Statistics from 2002 indicate that 38.8% of the economically productive and sexually active adults (aged 15-49 years) have HIV infection/AIDS. 1 In 1997, it was estimated that AIDS patients occupied 60% of hospital beds in medical wards. The large-scale effects of the AIDS epidemic in Botswana transcend the health care sector and impact upon virtually all aspects of society. According to estimations and projections by the US Bureau of the Census, the life expectancy in Botswana in 1996 was down from a projected 61 years in the absence of AIDS to 45 years as a result of the HIV/AIDS epidemic. By 2010, it is estimated that the life expectancy in Botswana will decline further to 33 years. 2 The HIV epidemic has had large macroeconomic repercussions due to the loss of lives of many individuals during their productive years. Households have been facing large financial burdens due to loss of income support from family members who die of the disease as well as increasing costs of treatment of HIV infection/AIDS and associated opportunistic infections. 3
Lack of strict adherence to highly active antiretroviral (ARV) therapy is considered to be one of the key challenges to AIDS care worldwide. Estimates of average rates of nonadherence with ARV therapy range from 50% to 70% in many different social and cultural settings, and the risks associated with nonadherence are extensive at both individual and societal levels. 4,5 Treatment adherence has been closely correlated with viral suppression, 6-8 while nonadherence has contributed to progression to AIDS, 9 the development of multidrug resistance, and death. 10-12 Even short-term nonadherence (as little as 1 week) may result in rapid rebound of plasma viremia, leading to treatment failure. 13 Adherence is perceived as a significant barrier to the delivery of ARV therapy in sub-Saharan Africa. 14,15 Little is known about rates of adherence or predictors of adherence in Africa. Therefore, we investigated the level of adherence and the social, cultural, economic, and structural determinants of adherence among HIV-positive patients receiving ARV therapy in Botswana.
Unfortunately, at the present time, most patients in Africa do not have access to subsidized or affordable ARVs. In Botswana, at the time of the study, <1% of HIV-infected patients received subsidized ARV treatment. Of those patients who received medical aid, individuals were typically subsidized from only one quarter to one half of the cost of triple-drug therapy. Consequently, most patients using ARV therapy were receiving suboptimal regimens and underwent forced treatment interruptions due to these financial constraints. As a result of these forced treatment interruptions, we hypothesized that the patterns of adherence would be different in Botswana than in industrialized settings and that gaps in treatment would be at least as significant a problem as day-to-day nonadherence.