Factors Associated With Adherence To Anti-Retroviral Therapy Among People Living With HIV/AIDS At Wangaya Hospital In Denpasar, Bali, Indonesia: A Cross-Sectional Study

Introduction

The Health Ministry of the Republic of Indonesia reported that the number of HIV cases from 2005 to 2017 increased from the annual number. The cumulative number of HIV infections released until December 2017 was 280,623. The highest number of infections were DKI Jakarta (51,981), East Java (39,633), Papua (29,083), West Java (28,964) and Central Java (22,292). In 2017, there were 48,300 people living with HIV in Indonesia, in Bali 2,441 people were confirmed with HIV infection. The number of AIDS released from 2005 to 2017 was relatively stable every year. The cumulative number of AIDS from 1987 to December 2017 totaled 102,667 people. The highest number of AIDS were from Papua (19,729), East Java (18,243), Jakarta City (9,215), Central Java (8,170), Bali (7,441) and West Java (6,502).

The use of combination Anti Retroviral (ARV) initiated in the late 1990s. It was proven effective in suppressing viral replication and had changed the natural course of the disease, had decreased morbidity and mortality.^1–6 Both Human Immunodeficiency Virus (HIV) infection and Acquired Immunodeficiency Syndrome (AIDS) remained as the major public health problem in the world.^3,7 Currently, HIV infection is proven to be a disease with chronic inflammation and potentially controllable. Thus, new issues related to the manageable disease have appeared, including the adherence to ART.⁸ Indeed, adherence to ART is an essential for long-term therapeutic success and is therefore this therapy becomes a major concern.⁴ On the other hand, medical knowledge around HIV/AIDS has increased significantly over the years and a good progress has been made in the treatment of HIV as a manageable life-threatening chronic condition using ART.^2–5,9,10 The ART program progress beyond knowledge development among PLWHA; a partnership between them and healthcare providers is required, with the HIV-infected person assuming the major responsibility of self-care that will result in adherence and a good clinical outcome. To achieve and to maintain controlled HIV infection, the absence of viral resistance, one of the most important aspects is the client’s adherence to the ART program.^6–12 Improving adherence requires collaboration with the patients in order to understand and to improve the individual impediments to adherence.^13,14

This study explores the rates and the factors associated with ART adherence among adult PLWHA at Wangaya Hospital, in Denpasar, Bali, Indonesia.

Methodology

Study Population And Design

A hospital-based cross-sectional study was conducted among 202 adult PLWHA (aged ≥ 18 years) taking ART for at least 6 months. Biopsychosocial approach (comprehensive care support treatment) should be provided to all adult PLWHA during the visit generally every 30 days routinely and who were given a written informed consent. The participants were interviewed about the socio-demographic characteristics, the duration of taking ART. The associated factors with ART adherence among PLWHA such as: age, sex, education, employment status/occupation, address (travel burdens), type of ARV and support.

Measurement Of Adherence

The used method for measuring adherence in this study is by using the pill counts. Pill counts, by counting the number of pills that remain in the patients’ bottles. The patients bring back the actual pill containers in order for the clinicians to physically count the leftover pills. Pill counts were assessed retrospectively based on 30 days recall. The adherence index was calculated by the formula:

PLWHA with ≥95% of adherence were considered as having high adherence and those with less than 95% were considered as having low adherence.^15–20

Statistical Analysis

The data were collected and analyzed using Statistical Package for Social Sciences (SPSS). Statistics for windows version 24.0. To verify the association among the independent variables such as socio-demographic characteristics and others to ART adherence, crude odds ratio (OR) with 95% CI was calculated by chi-square test, with p value of < 0.05 was considered statistically significant.

Ethical Clearance

The study procedure was approved by Ethical Committee of Wangaya Hospital in Denpasar, Bali, Indonesia with register number: 02/RSUDW/Litbang/2015. The study was conducted in accordance with the Declaration of Helsinki. We collect the data from the patients who visited Wangaya Hospital, in Denpasar, Bali, Indonesia. Written informed consent was obtained from all the participants.

Results

Characteristics Of The Study Participant

This study goal is to assess the factor associated with ART adherence among people living with HIV/AIDS (PLWHA) at Wangaya Hospital, in Denpasar, Bali, Indonesia. The ART adherence was assessed by interviewing and pill counts within the past 30 days prior. Reported with high adherence if as taking ≥95% of their pills during the previous 30 days and low adherence if as taking <95% of their pills during the previous 30 days. On this study, 202 participants analyzed, the overall adherence levels 170 (84.16%) participants were reported with high adherence but 32 (15.84%) participants with low adherence.

Data characteristics and associated factors to ART adherence among PLWHA of the study participant are shown in Table 1.

Table 1 Associated Factors To Adherence Levels Among PLWHA (N=202)

We found that 100 (49.50%) of the study participants were in the age group below 35 years old and 102 (50.50%) the age group above 35 years old. They were male 123 (60.89%) and 79 (39.11%) were female. Regarding education status, mostly, 115 (56.93%) of the participants were graduated from high school followed by junior high school 37 (18.32%), elementary school 28 (13.86%), graduated from university 19 (9.40%) and the uneducated 3 (1.49%). The participants were employed 174 (86.14%), unemployed 28 (13.86%), they were majority 151 (74.75%) live in Denpasar and 51 (25.25%) live out of Denpasar. Participants taking Fixed Dose Combination (FDC) were equal to participants taking non-FDC. Most 75 (37.13%) of the participants were supported by their family, followed by no support 64 (31.69%) and 63 (31.18%) supported by Non-Government Organization (NGO).

In this study, we found statistically significant association between ART adherence with employment status/occupation (p=0.011), type of ARV (due to adverse effect) (p=0.002), family support (p<0.001). There was no association between ART adherence with age (p=0.099), sex (p=0.326), education (p=0.928) and address (travel burdens) (p=0.356).

Mostly the participants took their ARV drugs showed the high adherence but 32 (15.84%) of them were with low adherence. The reasons for missing the adherence were feeling healthy: 12 (5.94%), adverse effects of ARV: 9 (4.46%), busy: 5 (2.48%), and far from home: 3 (1.48%) (Figure 1).

Figure 1 The reason for missing the adherence to ART.

Discussion

Adherence is a major issue in management of chronic disease, such as in management of HIV patients.^14,21 In HIV, studies indicate that high levels of ART adherence are necessary for viral suppression, prevention of ART resistance, disease progression and reduce the transmission risk.^9,14 ART adherence is influenced by a number of factors, including regimen complexity and drug toxicity.^15,22,23

A total of 202 participants in this study, 84.16% (170 participants) were high adherence but 32 (15.84%) participants reported low adherence. We found statistically significant association between ART adherence with employment status/occupation, type of ARV (due to adverse effect), family support but no association with age, sex, education and address (travel burdens).

The statistically significant association between employment status/occupation and ART adherence (p=0.011). Another study: Prah et al (2018) reported that occupation/employment status was significantly associated with adherence to ART (p<0.0031).¹⁴ Safira et al (2016) reported that occupation/employment status was significantly associated with adherence to ART (p=0.003).¹⁵ Suleiman et al (2016) found that occupation/employment status was significantly associated with adherence to ART (p=0.0008).¹⁶ Ibrahim et al (2014) found that those who were unemployed are more likely to be associated with poor adherence to ART (p = 0.011).¹⁷ A study conducted by Talam et al (2008) showed that employment status associated with adherence to ART (p=0.000).¹⁸

Furthermore, other aspects contribute to the effectiveness of ART, such as the capacity of the patients in adhering to special instructions regarding dose intervals due to ARV taking routinely.²

This study found that type of ARV (due to adverse effect of ARV) was statistically significantly associated with ART adherence (p=0.002). Another study: Cheng et al (2018) reported that type of ARV (side effect of treatment) associated with adherence to ART (p < 0.001).²⁴ Achappa et al (2013) reported that side effect of treatment associated with adherence to ART (p = 0.001).²⁵ Oliveira et al (2018) found that adverse effects of the drugs associated with adherence to ART (p = 0.0009).¹ A study conducted by Shigdel et al (2014) showed that adverse effects of treatment associated with adherence to ART (p = 0.005).²⁶

Family support boosts the patients self-esteem and it becomes easy for the patient to adhere to ART and to believe that the patients will have a long and healthy life. In contrast, if a patient does not have the support from their family, it becomes difficult for the patient because the situation brings them to be hopeless, to be potential to refuse the treatment and to be low adherence.⁹ This study has shown that family support was statistically significantly associated with ART adherence (p<0.001). Achappa et al (2013) found that a good family care/support statistically significant associated with ART adherence (p=0.0001). A meta-analysis reported that adherence is 1.74 times higher in participants from cohesive families.²⁵ Yathiraj et al (2016) reported that the participants with a good family care (74.0%; OR = 3.0, CI=1.2, 5.2) were found to be adherent to ART (p <0.05).²⁷ Joseph et al (2018) found that partners/family support statistically significant associated with ART adherence (p<0.001).²⁸

Koyra HC (2018) reported that the major reasons for not adhering to ART in PLWHA at Dubbo St. Marry Hospital, Southern Ethiopia were forgetting to take medications 48 (36.00%) followed by fear of adverse effects 32 (24.00%), hopelessness 23 (17.00%), being busy 17 (13.00%), distance from home 11 (8.00%) and others 3 (2.20%).²⁹ This study found that the major reasons for not adhering to ART were feeling healthy: 12 (5.94%), adverse effects of ARV: 9 (4.46%), busy: 5 (2.48%), and far from home: 3 (1.48%).

This study found that there is no association between adherence to ART and age, sex, education, address (travel burdens). Other studies found no association between adherence to ART and age, sex, education.^30–40 Byabene et al (2017) reported that adherence to ART was not associated with time to clinic (travel burdens) (p = 0.07).⁴¹

Conclusion

Mostly the participants are in high adherence. A statistically significant association was observed between ART adherence with employment status/occupation, type of ARV (due to adverse effect) and family support. The reasons for missing the adherence were mostly due to feeling healthy and followed by adverse effects, busy, and far from home.

Limitations Of Study

The limitations of this study included its small sample size. This study was conducted at Wangaya Hospital in Denpasar, Bali-Indonesia during January 2015–December 2017. Since this is a hospital-based study which only included PLWHA who attended the Wangaya Hospital in Denpasar, Bali-Indonesia during the study period, so the result cannot be generalized to all PLWHA in Indonesia. The Secondary data were reviewed to identify the clinical markers in addition to primary data. Patient self-report was used and it was subject to recall bias and overestimate adherence level. The use of a cross-sectional design limited the degree to which causal inferences and generalizations could be made from the research findings.