ETD Collection

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Subject: search.filters.subject.Patient Compliance

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Now showing 1 - 5 of 5
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    Markers of adherence among HIV-positive adults on antiretroviral therapy at Themba Lethu Clinic
    (2015-05-05) Nnambalirwa, Maria Tegulifa
    Introduction: The prevalence of the Human Immunodeficiency Virus (HIV) in South Africa was 17.8% among 15 to 49 year olds in 2010. Antiretroviral therapy (ART) has thus played a crucial role in mitigating the impact of the HIV epidemic. Themba Lethu Clinic is one of the largest single clinics providing ART in South Africa. One of the challenges of ART provision is ensuring adherence to taking the medication. To date there has been no clear consensus on the ideal way to measure adherence in resource limited settings (RLS). Viral load is perhaps the best and most reliable indicator of poor adherence but is expensive and not easily accessible or available in many RLS. Surrogate markers such as mean cell volume (MCV), CD4 cell count, self-reported adherence and missed visits have been shown to be useful to measure adherence but their reliability remains unclear. The aim of the study was to identify other markers that can be used to measure adherence using viral load as the gold standard. Materials and methods: The study was a retrospective analysis of HIV-positive ART-naïve adults (≥ 18 years) initiating standard first-line ART at the Themba Lethu Clinic in Johannesburg, South Africa between April 2004 and January 2012. The association between the last self-reported adherence, change in MCV calculated from baseline to 6 months, change in CD4 count calculated from baseline to 6 months (≥ or < the expected increase of 50 cells/mm3 at 6 months) and missed visits (defined as a scheduled appointment that had been missed by ≥ 7 days but not by more than 3 months) and poor adherence (defined as a viral load ≥ 400copies/ml after 6 months on ART) was tested using Poisson regression models with robust error variance to estimate incidence rate ratio (IRR) and 95% confidence interval (CI). The IRR was used to approximate the relative risk (RR) of poor adherence. Interacting variables were stratified by each other, to create a new variable. The diagnostic accuracy of each identified marker of adherence was also tested using sensitivity, specificity, positive predictive values and negative predictive values. Results: 7160 patients were eligible for the study and of these 63.2% were female. The median age was 36.7 years. The median CD4 count was 101 cells/mm3 at baseline and 18.9% of the patients had poor adherence at 6 months. Variables associated with poor adherence at 6 months were change in CD4 count stratified by change in MCV at 6 months (change in CD4 count ≥ expected and change in MCV ≥ 14.5fL; adjusted relative risk (aRR) 1, change in CD4 count ≥ expected and change in MCV < 14.5fL; aRR 3.11 95% CI 2.41 – 4.02, change in CD4 < expected and change in MCV ≥ 14.5fL; aRR 1.23 95% CI 0.76 – 2.00 and change in CD4 count < expected and change in MCV < 14.5fL; aRR 6.98 95% CI 5.35 – 9.09), CD4 count at baseline (> 200 cells/mm3; aRR 1, 101 – 200 cells/mm3; aRR 1.05 95% CI 0.80 – 1.38, 51 – 100 cells/mm3; aRR 1.08 95% CI 0.80 – 1.47 and ≤ 50cells/mm3; aRR 1.34 95% CI 1.02 – 1.76) , WHO stage at baseline (stage I; aRR 1, stage II; aRR 1.16 95% CI 0.90 – 1.48, stage III; aRR 1.27 95% CI 1.04 – 1.55 and stage IV; aRR 1.44 95% CI 1.12 – 1.84) and MCV at baseline (< 80fL; aRR 1, 80 – 100fL; aRR 1.33 95% CI 1.01 – 1.75 and > 100fL aRR 0.98 95% CI 0.62 – 1.55). Sensitivity and specificity of the change in CD4 stratified by change in MCV at 6 months to predict poor adherence were 86.5% and 37.3% respectively for all eligible patients. For patients on AZT-based regimens the variables associated with poor adherence at 6 months were change in CD4 count at 6 months (≥ expected; aRR 1 and < expected; aRR 7.66 95% CI 0.98 – 59.91) and pregnancy during the first 6 months on ART (Never pregnant; aRR 1 and pregnant during follow up; aRR 9.11 95% CI 2.17 – 38.25). Sensitivity and specificity of the change in CD4 count at 6 months to predict poor adherence were 64.7% and 75.2% respectively for all eligible patients on AZT-based regimens. Sensitivity and specificity of pregnancy during the first 6 months on ART to predict poor adherence were 20% and 97.6% respectively for all eligible patients on AZT-based regimens. Discussion: Change in CD4 count stratified by change in MCV at 6 months was an expected marker of adherence as CD4 count is expected to rise in adherent patients on ART and since most patients (62.9%) were on d4T or AZT-based regimens. Pregnancy during the first 6 months on ART appeared as a marker of adherence for patients on AZT-based regimens before multiple imputation possibly due to missing data hence results for this variable should be interpreted with caution. Contrary to previous studies, self-reported adherence was not associated with poor adherence at 6 months before multiple imputation. This could have been due to the fact that that > 50% of patients had missing data for this variable. The variable is also vulnerable to recall and reporting bias so even after multiple imputation, the area under the receiver operating characteristic (ROC) curve remained < 0.55. The number of missed medical visits and regimen change were also markers of adherence in a few of the models after multiple imputation and require further investigation. In conclusion, the markers of adherence to ART are change in CD4 count stratified by change in MCV at 6 months and pregnancy during the first 6 months on ART for patients on AZT-based regimens. These could help health workers identify poor adherence in the absence of viral load testing and target patients for adherence interventions to prevent virological failure.
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    WHO staging, adherence to haart and abnormal cervical smears amongst HIV-infected women attending Dr Yusuf Dadoo Hospital
    (2014) Katumba, Appolinaire Ciamalenga
    Introduction South Africa has more people living with HIV than any other country in the world.1 Women infected with HIV have a high risk in the development of cervical dysplasia and cancer of the cervix more so than women who are not infected.2,3 Methods A cross-sectional descriptive study was carried out by reviewing cervical smears of HIV positive women in a district hospital. Three hundred and ninety cervical Pap smears were classified according to the Bethesda system. Adherence was measured by the patient’s report and viral load. Data was collected through the use of self administered questionaire and data capture sheet. Results The prevalence of abnormal Pap smears was 57 per cent and LSIL was the commonest abnormality seen (142/390, 36%). Eighty-four per cent (328/390) had stage 1 WHO-HIV classification. WHO stage 3 participants seemed to be three times more likely to have abnormal Pap smears than those with WHO stage 1 (OD 3.3, STD. error 1.70, p=0.018, 95% CI 1.23-9.04). Abnormal pap smears were seen more in participants with CD4 cell count ≤ 350 cells/μL as compared to participants with CD4 cell count ≥ 500 cells/μL { 122/172, (71.00 %) vs 48/117, (41.03%), p-0.000, 95% CI : 0.09-0.37}. Similarly, participants who did not use HAART had more abnormal results as compared to those who used HAART {42/60(70.00%) vs 180/330 (55.00%), p-0.028, 95% CI 0.28-0.93}.Adherence to HAART did not show any link with abnormal smears. Conclusion The more immune-suppressed a woman is, the higher the risk of developing cervical cancer precursors. The high risk group in this study was found to be the participants with the CD4 cell count of ≤ 350 cells/μL and the viral load ≥1000 copies/mm3. The self-reported adherence level did not show any impact.
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    Beliefs and perceptions that influence utilization of HIV/AIDS services by newly HIV diagnosed men in rural Mbashe Sub-District in the Eastern Cape Province of South Africa
    (2014) Mubuyayi, Clever
    Introduction: HIV/AIDS services are now given freely at public health facility level. They have been decentralized to the formal primary health facilities in the rural areas. Despite the efforts by the South African government, the utilization of those services remains a challenge. There are gender disparities in utilisation of HIV/AIDS services as females utilize the services in greater numbers compared to their male counterparts. The newly diagnosed seropositive men tend to disappear soon after HIV testing, only to appear in a formal health system when their immune system is seriously suppressed and at a more advanced WHO stage of disease. Therefore, the overall aim of this study was to explore the underlying perceptions and beliefs that influence utilization of HIV/AIDS services by newly diagnosed HIV positive men in Mbashe Sub-District of the Eastern Cape between January 2010 and March 2011 Methods: The study was conducted in the rural Mbashe Sub-District of the Eastern Cape Province and utilized a qualitative methodology. This qualitative approach relied on semi-structured in-depth interviews with newly diagnosed HIV positive men of 18-49 years of age who were either accessing or not accessing the HIV/AIDS services during January 2010 and March 2011.The participants were recruited through purposive sampling and 18 interviews were conducted in 6 different facilities at three different service levels. Interviews were audio-recorded and transcripts were subjected to thematic content analysis based on the Health Belief Model. Results: The results show that both groups of men reacted negatively to HIV positive status. The experiences during HIV Counselling and Testing were not linked to whether men could access services. The barriers to utilizing the available HIV/AIDS services included fear of stigma and discrimination, need for an alternative quick cure which delayed utilization of the services, the clinic as gendered space, compromised Provider-Initiated Counselling and Testing (PICT) model implementation, shortage of food, physical fitness and alcoholism. The facilitators for access included the need for survival, disclosure and social support, and cues to action like witnessing a relative dying due to HIV/AIDS related illness. However, the HBM model could not squarely explain the trends in accessing HIV service since few constructs were found to be relevant and also some issues that are outside the HBM model emerged. Conclusions: The study demonstrates that newly diagnosed men‟s utilization of the subsequent free HIV/AIDS services at the primary health care level is influenced by many factors . There are those factors that trigger men to utilize the services and those that deter them from accessing necessary HIV/AIDS services. The factors that influence their access to services are mainly within the multilevel framework which ranges from individual, family, community and societal factors. Therefore, the targeted interventions to address the issue should focus on addressing stigma and discrimination, policy change on training, recruitment and deployment of male nurses, integration of traditional/spiritual interventions within the mainstream of health services, correct implementation of the PICT model and encouraging couple counselling and testing. The Health Belief Model constructs, especially perceived severity, were not strongly linked to whether men accessed services or not.
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    Drug delivery problems to TB patients in Gauteng
    (2014-05-20) Mabena, Confidence
    After declining for many years, the incidence of tuberculosis (TB) is on the increase again. With TB resurgence there is also resistance of some TB strains to the commonly used TB drugs. This condition is kno wn as multi-drug resistance tuberculosis (MDR TB). Among all factors that increase TB and MDR TB, treatment compliance and completion is the greatest challenge. MDR TB is mainly caused by poor adherence to TB treatment by either the patient or the prescriber. In order to improve patient adherence to treatment. Directly Observed Therapy (DOT) has been implemented in many countries including South Africa. DOT means that each consumption of TB drugs by the patient is observed by a reliable person. Even with DOT in place, many patients still do not adhere to the prescribed treatment. This study aimed at determining from health workers the following: • Problems experienced by the health workers when giving treatment to TB patients, • causes for non-adherence to TB treatment, and • what could be done to make DOT more effective. A questionnaire was used to gather information. Ail clinics rendering TB services in Gauteng were considered in this study. Two questionnaires were sent to each of the 138 participating clinics and had to be completed by any two health workers involved in the treatment of TB patients. Only 69 of the 276 questionnaires sent, were returned completed (25%). Information gathered from the questionnaires revealed that patients seen at TB clinics in Gauteng came from various residential areas including townships, suburban rural and informal settlement. The Pearson chi squared test showed that there was no association between the percentage of patients who completed treatment and the number of patients seen at a clinic, or between the percentage of patients who completed treatment and the working hours at a particular clinic. The main cause of non-compliance shown by the results of this study was that patients discontinued treatment as soon as they felt better. Other causes of non-compliance mentioned by health workers included patient denial of having TB, ignorance, long treatment periods and many drugs that were to be taken during treatment. Health workers revealed that the main problem experienced in giving treatment to TB patients was that of deiaulting. The majority of these respondents suggested education as one way of making DOT more effective. In terms o f this study, it can be concluded that education on TB at various levels namely the patient, the health care worker and the community, is recommended. Education on the disease TB and its optimal treatment will improve patient compliance, decrease defaulting in delivering TB drugs to patients and make DOT more effective.
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