Page 349 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 6 of 8 Original Research

in North-Western Tanzania, 28.3% of the adult HIV-infected This study also considered challenges caregivers face in
patients were found to have sub-therapeutic plasma taking care of HIV-infected orphan children. Forgetfulness
antiretroviral drug concentrations. Furthermore, they found was indicated to be a challenge caregivers face in taking
that the proportion of patients with sub-therapeutic orphan children to the clinic for drug refill and was also
antiretroviral plasma concentrations had significantly higher implicated as a reason for the child missing at least one dose
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viral loads. Plasma levels have the potential to be highly (46.7%). Several other studies found similar caregiver-related
objective adherence measures and provide unequivocal reasons of forgetfulness as a major challenge together with
evidence that medication has been taken. Nevertheless, it other varied responses as the main reasons for their
should be noted that plasma drug levels are not predictive of defaults. 44,45,46 Distance to treatment centres was also of great
adherence behaviour in all patients’ due to factors unrelated concern among the caregivers, with 39.4% of them using over
to adherence such as drug interactions, individual metabolism 1 h of travel time to the treatment centre together with high
variation and poor quality of the drug. Although NVP has transportation cost. Studies have shown that patients who
a long elimination half-life, the autoinduction of its travelled more than 1 h to hospitals were more likely to be
metabolising enzymes make plasma levels unreliable as non-adherent. 47,48 Participants were found to spend
a measure of long-term adherence. 35,36 These factors may unnecessarily long periods of time from arrival at the clinic to
affect the plasma concentrations above or below a threshold getting cART; 75.5% of the study population reported
considered to represent adherence. spending more than 2 h at the clinic on account of lengthy
queues at outpatient HIV clinics. Long waiting times have
Our study found that orphans who had their HIV status also been reported in other studies, and this may discourage
disclosed had better adherence compared to those with an patients from going to clinics and remaining in care. 49,50
undisclosed status. Similar studies from around the region
found that children who had their HIV status disclosed were Appropriate HIV/AIDS knowledge may play an important
more likely to be adherent to cART. 37,38 It may be that children role in enhancing cART adherence. The lack of practical
who knew their status would be more concerned about their knowledge on HIV/AIDS and cART medications,
health and therefore understand the rationale behind taking understanding the benefit of cART for children and poor
their medications. Our study also found that older children individual adherence to treatments are among the root causes
(aged 10–14) were more likely to adhere to cART compared of ineffective cART service delivery. This study revealed a
to younger ones (aged 2–9). This finding is in keeping with varying lack of knowledge among caregivers on how cART
other studies that showed similar results where older children contributes to improvement in health and longevity, where
had better adherence. 38,39 Older children may have a better 44.4% of the respondents indicated cART decreased incidence
understanding of medications and need for adherence, and of opportunistic infections. The ramifications of not taking
they can self-medicate. Also, older children have increased cART were linked to poor immunologic response, increased
independence and improved self-care. Double orphans were risk of mortality and rapid progression into AIDS. Potent
also found to have lower adherence compared to single cART has led to a dramatic decrease in HIV-associated
orphan children in this study. This may be related to the morbidity and mortality. The majority of caregivers (91.2%)
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caregivers’ motivation, where a non-parental caregiver of a were unaware of the likelihood of drug resistance from
double orphan may be less motivated to care for the orphan inappropriate cART administration. Inappropriate use of
compared to a parental caregiver. 40 cART contributes to the development of HIV drug-
resistance. 52
The cART adherence levels established in this study by 3-day
caregiver recall exceeded the level of adherence as determined The variation in adherence by the three different measurement
by the NVP plasma concentrations. This finding can be in approaches demonstrates the critical importance in the
part due to the tendency of patients to provide socially choice of adherence assessment/measure in research and
acceptable responses or exaggerated responses to please the clinical care. The lack of a perfect measure suggests that a
provider or because of recall bias. 33,41 The average sensitivity composite of multiple measures has a value. Caregiver self-
of good adherence based on self-reported adherence, clinic report and patient clinic attendance have a role in this regard.
attendance and immunological parameters was relatively These methods are low-cost, non-invasive and practical and
high (83.5%); however, these assessments lacked the have the potential to provide clinicians with additional
specificity. Self-reported adherence is subject to bias with insights into the adherence lapses of their patients.
respondents overstating their actual adherence. Poor clinic
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attendance may also be due to one or two missed Our study had some limitations. Information collected from
appointments (but not consecutive), which might not the participants was based on self-reports and thus some bias
correlate with pill counts, where patients may have had extra is likely to have been included. Caregiver reported adherence
pills to cover the period. These results reveal that, whereas was limited to a 3-day recall bias, and NVP plasma levels
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high self-reported adherence to cART and clinic attendance only identify poor adherence in the short term. Therefore,
rates correlated well with normal therapeutic plasma drug this study could not observe change in cART adherence over
levels among these patients, these tools may still have some time nor could actual behaviour be observed. Furthermore,
limitations while identifying non-adherent patients. the cross-sectional survey design limits the application of

http://www.sajhivmed.org.za 342 Open Access