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(i.e. medication alert, daily frequencies and pill storage) and and minimising the number of times second-line regimen is
VLF. However, participants who relied on their memory as a taken per day (n = 1). One patient felt that healthcare workers
reminder to take medication (whilst on first-line regimen) trusting that their patients took their medication as prescribed
were almost three times more likely to interrupt their first- would promote treatment adherence. Lastly, 12 participants
line treatment than those who relied on an alarm (AOR: 2.6, did not have any recommendations (mainly because of not
95% CI = 1.0–6.4, p = 0.042). There was no association found experiencing any pill-taking challenges), as shown in the
between medication alert or frequency of taking medication following statement:
and second-line treatment interruption. Participants who ‘The current regimen is fine with me, therefore, I will suggest no
used their handbag to store their medication were the least change’. (VLS, male, 41 years old)
likely to experience second-line treatment interruption (OR:
0.2, 95% CI = 0.05–1.0, p = 0.054).
Discussion

Recommendations from participants This study sought to describe and understand treatment
adherence and possible treatment support interventions
The study participants made 175 recommendations for from patients receiving second-line ART.
improving adherence (see Table 5). Coformulation in single
tablets, only needing to take one dose of medication daily It has been reported that relationship dynamics influence
(preferably at night) and education about being adherent ART adherence and VLS in that being married or having a
were listed as the most effective mechanisms to improve committed and supportive partner tended to foster an
adherence on second-line treatment. Some examples of environment for better clinical outcomes in HIV-positive
recommendations from participants include the following: people. 17,18 Studies from South Africa and the United
‘Education should be emphasised through adherence classes. Kingdom found that HIV-positive married individuals had
Reinforce on the benefits of ART’. (VLS, female, 38 years old) better clinical outcomes compared to any other relationship
status. 19,20 Similarly, our study found that single and
‘Availing a single-dose treatment for the second-line patients
would enable them to adhere to treatment. Further ongoing unmarried people living with their partners were more likely
education would also help’. (VLF, female, 39 years old) to be virally unsuppressed.

Other recommendations included the development of Not statistically significant but important for consideration
injectable ART (n = 9, seven women and two men) and the in adherence strengthening, our study showed that being
provision of psychosocial support (particularly related to younger was a predictor of VLF, which was congruent with
We noted VLS in those participants
previous studies.
21,22,23
poverty and ensuring food supply):
who resided further away from the health facilities. This is
‘Should consider addressing the psychosocial needs of patients not in agreement with findings of studies conducted in
on second line as they have to adhere to treatment but sometimes Uganda, Ghana and Burkina Faso, 24,25,26 which reported that
they do not have enough food to eat’. (VLF, female, 45 years old) individuals who resided closer to a health facility were more
likely to seek healthcare.
Single recommendations to improve adherence included
treatment reminders (n = 1), additional counselling (n = 1) Late disclosure may hinder adherence or treatment support and
subsequently yield poor clinical outcomes. Whilst the majority
27
TABLE 5: Participants’ perspectives on how adherence can be improved amongst of participants (63%) disclosed their HIV status 1 week after
second-line patients. diagnoses, about 28% took longer than 4 weeks to disclose.
Recommendation Number of people citing the Early disclosure, particularly to a family member or partner, has
recommendation
Coformulation in single tablets 55 been strongly associated with improved adherence. 8,28,29
One dose 46 Disclosure to a family member or partner has been linked with
Education 24 adequate psychosocial support which in turn facilitates
No recommendations 12 adherence to treatment. 8,29,30,31,32 However, the findings of our
Injection 9 study suggest that disclosure and dependence on a treatment
Psychosocial support 9 supporter are likely not to produce desired adherence levels
Smaller pills 7 (and did not feature in the list of participant recommendations),
No side effects 4 indicating that disclosure and treatment support should be
Clinic operating times 2 assessed in combination with other adherence strategies instead
Counselling 1 of as a single consideration or mechanism. 33
Decreased frequency of treatment ingestion 1
Follow-up 1
Liquid 1 Unsurprisingly, the more toxic the second-line multi-pill, and
More research needed 1 regimens requiring medication to be taken multiple times a
SMS reminders 1 day, were seen as significantly harder to take than a single
Trust patients 1 tablet daily well-tolerated first-line regimen. These views
TOTAL 175 were consistent with reports from other studies that attributed
SMS, short message service. similar challenges to taking second-line regimen. 34,35,36

http://www.sajhivmed.org.za 289 Open Access