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Adherence to antiretroviral therapy among HIVinfected children attending a donor-funded clinic at a tertiary hospital in Nigeria a
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Edna Iroha , Christopher Imokhuede Esezobor , Chinyere Ezeaka , Edamisan Olusoji a
Temiye & Adebola Akinsulie
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Department of Paediatrics, College of Medicine , University of Lagos , PMB 12003, Lagos, Lagos State, Nigeria Published online: 19 May 2010.
To cite this article: Edna Iroha , Christopher Imokhuede Esezobor , Chinyere Ezeaka , Edamisan Olusoji Temiye & Adebola Akinsulie (2010) Adherence to antiretroviral therapy among HIV-infected children attending a donor-funded clinic at a tertiary hospital in Nigeria, African Journal of AIDS Research, 9:1, 25-30, DOI: 10.2989/16085906.2010.484543 To link to this article: http://dx.doi.org/10.2989/16085906.2010.484543
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ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2010.484543
Adherence to antiretroviral therapy among HIV-infected children attending a donor-funded clinic at a tertiary hospital in Nigeria Edna Iroha, Christopher Imokhuede Esezobor*, Chinyere Ezeaka, Edamisan Olusoji Temiye and Adebola Akinsulie
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Department of Paediatrics, College of Medicine, University of Lagos, PMB 12003, Lagos, Lagos State, Nigeria *Corresponding author, e-mail address: [email protected] The success of antiretroviral therapy (ART) depends on a high level of adherence to a life-long regimen of antiretroviral drugs (ARVs). Since the scale-up of access to ARVs in Nigeria, few studies have determined the level of adherence of ART among children. This study was undertaken to determine the level of ART adherence among paediatric patients at an outpatient clinic, the reasons for non-adherence, and the factors associated with adherence, according to caregivers’ reports. Out of a total of 212 children, 183 (86%) were adherent in the three days preceding the interview, while 29 (14%) were not adherent. Drug exhaustion at home (16 children), followed by ‘child slept through’ (7 children) and ‘caregiver away’ were the most common reasons for a child having missed one or more ARV doses. Independent factors for adherence were male gender (odds ratio [OR] = 2.85; 95% confidence interval [CI]: 1.17–6.92) and attendance at last scheduled clinic appointment (OR = 4.76; 95% CI: 1.73–13.04). The caregiver’s highest educational attainment, distance travelled to the clinic, use of medication reminders, formulation of ARVs, duration of HAART usage, age of the child and orphan status were not significantly associated with adherence to drug treatment. The overall level of adherence was high and similar to the rate reported prior to free access to ART services in Nigeria. Among child patients on HAART, there is a need to identify factors affecting clinic attendance and drug exhaustion at home. Keywords: caregivers, compliance, drug treatment, HAART, HIV/AIDS, paediatrics, questionnaires, sub-Saharan Africa
Introduction The chronicity of HIV and AIDS places on the patient a lifelong burden of adherence to a highly complex regimen of drugs with multiple adverse effects, overlapping toxicities, and several dietary requirements (Ferguson, Stewart, Funkhouser, Tolson, Westfall & Saag, 2002). Adherence to antiretroviral drugs (ARVs) in the paediatric population assumes a wider dimension (Shah, 2007). First, medication-related factors such as volume, taste, diet prescription, intake of drugs, dosing interval and side effects are difficult to overcome in treating children (Ferris & Kline, 2002; Van Dyke, Lee, Johnson, Wiznia, Mohan, Stanley et al., 2002; Shah, 2007). Second, children depend on caregivers, who might be living with HIV/AIDS, to administer their medication (Steele, Anderson, Rindel, Dreyer, Perrin, Christensen et al., 2001). Because the success of antiretroviral therapy (ART) rests on a high level of adherence to the medication, centres offering ART services are required to assess the level of individual patient adherence (Hardon, Davey, Gerrits, Hodgkin, Irunde, Kgatlwane et al., 2006). However, earlier studies characterising ART adherence among HIV-infected children in Africa (e.g. Laniece, Ciss, Desclaux, Diop, Mbodj, Ndiaye et al., 2003; Akam, 2004; MukhtarYola, Adeleke, Gwarzo & Ladan, 2006) were done at a time when ARVs had to be bought by the caregivers. The prohibitive cost of ARVs was the most significant cause of non-adherence to treatment (Laniece et al., 2003; Mukhtar-
Yola et al., 2006). With the recent scale-up in ART services, many centres in developing countries, including Nigeria, are now offering free ART services. One such centre in Nigeria is the Paediatric Special Clinic at Lagos University Teaching Hospital (LUTH), which offers comprehensive ART services. After about four years since its commencement no assessment of ART adherence had been undertaken in the cohort of children attending the clinic. This study aimed to assess the level of adherence to ARVs among child patients, as reported by their caregivers, in a clinic population of HIV-infected children, and also to identify factors associated with drug compliance. Methods The study was carried out between July and September 2008 in the Paediatric Special Clinic at Lagos University Teaching Hospital (LUTH), the largest tertiary hospital in Lagos, in southwest Nigeria. The clinic is one of several centres in Nigeria providing free, comprehensive ART services for HIV-infected children. The clinic is open one day per week. Children are started on highly active antiretroviral therapy (HAART) at clinical stage 3 or 4 of HIV disease or when they exhibit advanced/severe immunosuppression. Also, prior to the commencement of HAART, the paediatric patient’s caregiver is counselled on the benefits, risks, and limitations of HAART and the need for long-term adherence. This message is usually reinforced, prior to consultation, by
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the nurses, and during consultation with physicians and at the pharmacy. Ethical clearance was obtained from the hospital’s research and ethics committee. The questionnaire for caregivers was developed to capture common factors associated with either non-adherence or adherence to ART among paediatric patients, as identified by several other studies, such as age and gender of the child, orphan status, medication-related characteristics, use of medication reminders, remoteness of the clinic from the patient’s residence, and other sociodemographic data. The initial questionnaire was pretested by interviewing 20 caregivers of HIV-infected children attending another state-run ART centre similar to the study site, and the limitations identified were rectified during preparation of the final questionnaire. Caregivers of children who had been on HAART for at least 30 days and who consented to participate in the study were administered the questionnaire in an interview format during a scheduled clinic visit. Caution was exercised during the interview to avoid inadvertently disclosing the child’s HIV status to the child because about 98% of the children in the cohort were not aware of their HIV status. Before administration of the questionnaire, each participating caregiver was reminded that their child’s doctors understood that taking all the doses of prescribed drugs is difficult, and thus that the interview was aimed at identifying hurdles to drug adherence and providing solutions. To reduce recall bias each participating caregiver was asked about drug administration for each day of the previous three days, starting with the immediate past day. The data was analysed using SPSS version 14. Continuous variables were summarised using means/ median and categorical data as percentages. Bivariate analysis (odd ratios [OR] with a 95% confidence interval [CI]) was performed to identify variables associated with adherence to treatment. To control for the effect of confounders, multiple logistic regression was done using only those factors found to have a significant association with drug adherence, based on the bivariate analysis. The level of statistical significance was set at p < 0.05. Operational definitions Adherence was defined as having taken all doses of the ARVs during the past three days. HAART is the administration of at least three ARV drugs from at least two classes. ART is the administration of ARVs either as prophylaxis or treatment. Results Sociodemographic characteristics of the children Two hundred and twelve children out of a total of 223 of children (95.1%) who were registered at the clinic and were on HAART were included in the study. Seven of the 11 children who did not participate had missed their clinic appointments for at least three months prior to the study and could not be contacted; they were otherwise similar to the participants in their sociodemographic characteristics. Of the 212 children included, 172 (81.1%) were aged less than ten years, with a male to female ratio of 1.08:1.
Iroha, Esezobor, Ezeaka, Temiye and Akinsulie
Of the caregivers, 154 (72.6%) were the mother of the child patient and 100 (47.2%) were of the Yoruba tribe. The level of education attained by the caregivers was: none or primary school (44; 20.8%), secondary school (104; 49.1%) or post-secondary education (64; 30.2%). The great majority of the children (203; 95.8%) took a regimen consisting of zidovudine, lamivudine and nevirapine; three children were on a regimen consisting of zidovudine, lamivudine and efavirenz, while six were on second-line drugs, including kaletra. The median duration of use of HAART among the children was 18 months (Table 1). In the three days prior to the interview, 183 children (86.3%) were reported as adherent while 29 (13.7%) did not attain adherence. Reasons for non-adherence The most commonly reported reason for non-adherence was drug exhaustion at home, followed by ‘child sleeping through’ the drug administration time (Figure 1). Factors associated with adherence Male gender and keeping the last clinic appointment were significantly associated with adherence to the treatment, according to both the univariate and multivariate analyses: the male children were more likely than the female children to have adhered to HAART in the three days prior to the interview (OR = 2.85; 95% CI: 1.17–6.92), while those children who had kept their last clinic appointment were more likely to have adhered as compared to those who had missed their last appointment (OR = 4.76; 95% CI: 1.73–13.04) (Tables 2 and 3). The age of the child, duration and formulation of HAART, use of other drugs besides HAART, medication reminders, orphan status, highest educational status of the caregiver, and distance needed to
Table 1: Sociodemographic characteristics of the children studied (n = 212) Variables Age (months): 0–59 60–119 ≥120 (age 10+) Gender: Females Males Tribe: Yoruba Igbo Other Caregiver’s relationship to the child: Mother Father Grandparent/other Caregiver’s highest educational level: None or primary school Secondary school Post-secondary school Duration of HAART (months): 1–11 12–59 ≥60 (≥5 years)
n (%) 80 (37.7) 92 (43.4) 40 (18.9) 110 (51.9) 102 (48.1) 100 (47.2) 55 (25.9) 57 (26.9) 154 (72.6) 18 (8.5) 40 (18.9) 44 (20.8) 104 (49.1) 64 (30.2) 72 (34) 127 (59.9) 13 (6.1)
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Figure 1: Reasons given by the caregivers for a child’s non-adherence to HAART medication during the last three days (n = 29 non-adherent children)
Vomiting
1
Child away
1
Caregiver forgot
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Caregiver away
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Child slept through
7
Drugs were finished
16
0
5
10 Frequency
15
travel to the clinic were not found to be significantly associated with adherence to treatment. Discussion A high level of adherence was found in this clinic population of children receiving ARVs, according to the caregivers’ reports on adherence during the preceding three days. This high level of adherence among children in a Nigerian ART centre is encouraging when viewed against the fears and concerns expressed about drug adherence in developing countries prior to the global efforts at scaling up access to ART (cf. Harries, Nyangulu, Hargreaves, Kaluwa & Salaniponi, 2001; Liechty & Bangsberg, 2003). The high level of adherence documented in this study could be due partly to the provision of ARVs free of user costs in a country where less than 10% of those who need ART have access to it, and to the short duration of HAART usage in the cohort, as well as the availability of counselling services at multiple points during a single clinic visit (see Laniece et al., 2003; Akam, 2004; Vreeman, Wiehe, Ayaya, Musick & Nyandiko, 2008). Conversely, the high adherence level found in his study could be due to overestimation in the caregivers’ reports. Compared to electronic drug monitoring and unannounced pill counts, caregivers’ self-reports tend to overestimate drug adherence (Arnsten, Demas, Farzadegan, Grant, Gourevitch, Chang et al., 2001; Nabukeera-Barungi, Kalyesubula, Kekitiinwa, Byakika-Tusiime & Musoke, 2007; Davies, Boulle, Fakir, Nuttall & Eley, 2008). Overestimation is even more likely to have occurred in our study as the clinicians running the clinic administered the questionnaire — thus, the caregivers might have overestimated adherence to please the investigators. However, the level of drug adherence found here is similar to adherence rates observed in other studies among children in both developing and developed countries (e.g. Reddington, Cohen, Baldillo, Toye, Smith, Kneut et al., 2000; Giacomet, Albano, Starace, Franciscis, Giaquinto, Gattinara et al., 2003; Eley, Nuttall,
Davies, Smith, Cowburn, Buys et al., 2004; Mukhtar-Yola et al., 2006; Biadgilign, Deribew, Amberbir & Deribe, 2008). A study in Cote d’Ivoire (Arrivé, Anak, Wemin, Diabate, Rouet, Salamon & Msellati, 2005) reported 67% adherence among the participants in the preceding three days, a level far lower than that recorded in this study; however, the most frequent reason cited for non-adherence in that study was ‘drug stock exhaustion’ at the facility level. Similarly, a recent study in Cape Town, South Africa, reported only 79% adherence (Davies et al., 2008), but this could be due to assessment over a one-year period, which would have increased the odds of encountering non-adherence. Published works from developed countries (e.g. Byrne, Honig, Jurgrau, Heffernan & Donahue, 2002; Farley, Hines, Musk, Ferrus & Tepper, 2003) have reported higher levels of adherence than that observed in this study, but they involved smaller study populations and some were carried out as part of the rigorous process of clinical trials. We found two independent factors to be associated with increased odds of drug adherence. Not surprisingly, keeping the last scheduled clinic appointment was significantly associated with adherence to treatment. This association corroborates that found by Farley et al. (2003), who demonstrated that not missing a clinic appointment was significantly associated with a viral load below the threshold of detection, implying high adherence. Being a donor-funded programme in which request forms for drug refill are usually completed during the monthly clinic visits, coupled with the prohibitive cost of ARVs in the open market, it is apparent that missing a clinic appointment where drugs are provided at no cost is likely to result in drug exhaustion at home. However, the distance caregivers had to travel to get to the clinic was, inexplicably, not associated with adherence, as similarly reported in a study in Uganda (Nabukeera-Barungi et al., 2007). Although, the factors that may be associated with clinic attendance were not investigated in this study, efforts aimed at improving adherence to treatment should identify these factors. Significantly, the gender of the child was associated with adherence in this study. Our finding in this regard is consistent with the report of a large study in the United States (Williams, Storm, Montepiedra, Nichols, Kammerer, Sirois et al., 2006) involving 2 088 children, with a median age of 11.5 years and about 60% African-American, which found that female children had an estimated odds ratio of 1.25 in multiple logistic regressions for non-adherence. Similar observations were made in a recent study in Lomé, Togo, by Polisset, Ametonou, Arrivé, Aho & Perez (2009). However, in a review of 32 studies among paediatric populations receiving HAART, Simoni, Montgomery, Martin, New, Demas & Rana (2007) observed that the gender of the child was not significantly associated with adherence to medication. Greater adherence among the male children in this study may reflect the higher premium the study population places on male children. Similarly, male child preference has been observed in other aspects of children’s life in Nigeria, such as food-sharing at home, school entry and completing an education. Not surprisingly, we did not find a significant association between adherence to treatment and orphan status (one or both parents deceased), age of the child, taking
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Iroha, Esezobor, Ezeaka, Temiye and Akinsulie
Table 2: Univariate factors associated with adherence to HAART among children attending the Paediatric Special Clinic at Lagos University Teaching Hospital, 2008 (n = 212) Drug adherence in the past three days
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Variables Age of children (months): 1–59 60–119 ≥120 (age 10+) Gender of children: Males Females HAART duration (months): 1–11 12–59 ≥60 (≥5 years) Formulation of ARVs: Liquid Tablet Both Cotrimoxazole prophylactic therapy (CPT): Yes No Drugs other than ARVs and CPT: Yes No Caregiver’s highest educational level: None or primary school Secondary school Post-secondary school Attended last scheduled clinic appointment: Yes No Use of medication reminders: Yes No Distance travelled to clinic: ≤10 km 11–20 km >20 km Orphan status: Both parents deceased Father deceased Mother deceased Either father or mother dead *NA = not applicable
‘Yes’ (n = 183) n (%)
‘No’ (n = 29) n (%)
Odds ratio (95% confidence interval)
p-value
68 (85) 80 (87) 35 (87.5)
12 (15) 12 (13) 5 (12.5)
0.84 (0.38–1.86) 1.10 (0.5–2.44) 1.14 (0.40–3.18)
0.663 0.814 0.810
94 (92.2) 89 (80.9)
8 (7.8) 21 (19.1)
2.77 (1.17–6.58) 1.00
0.017
62 (86.1) 108 (85) 13 (100)
10 (13.9) 19 (15) 0
0.97 (0.43–2.22) 0.76 (0.33–1.72) NA*
0.949 0.507 NA
69 (85.2) 55 (91.7) 59 (83.1)
12 (14.8) 5 (8.3) 12 (16.9)
0.86 (0.39–1.90) 2.06 (0.75–5.69) 0.67 (0.30–1.50)
0.705 0.155 0.333
174 9
29 0
NA NA
NA NA
58 125
11 18
0.76 (0.34–1.71) 1.00
0.505
38 (86.4) 92 (88.5) 53 (82.8)
6 (13.6)) 12 (11.5) 11 (17.2)
0.81 (0.31–2.56) 1.43 (0.65–3.17) 1.18 (0.33–4.24)
0.676 0.373 0.543
169 (88.9) 14 (63.6)
21 (11.1) 8 (36.4)
4.60 (1.73–12.25) 1.00
0.001
53 (85.5) 130 (86.7)
9 (14.5) 20 (13.3)
1.04 (0.43–2.50) 1.00
0.927
69 (90.8) 71 (89.9) 50 (87.7)
7 (9.2) 8 (10.1) 7 (12.3)
0.85 (0.39–1.85) 1.47 (0.64–3.42) 0.69 (0.24–1.99)
0.675 0.363 0.490
NA 2.04 (0.46–9.12) 0.61 (0.22–1.64) 0.76 (0.31–1.84)
NA 0.272 0.320 0.539
8 24 25 41
0 2 6 8
Table 3: Factors associated with the children’s adherence to HAART, based on logistic regression
Variables Attendance at last scheduled clinic appointment Male gender
drugs besides ARVs, use of medication reminders, or the duration and formulation of HAART. The effects of these factors on adherence to medication schedules have been inconsistent in various studies of adherence (e.g. Eley et al., 2004; Williams et al., 2006; Nyandiko, Ayaya, Nabakwe,
Odds ratio (95% confidence interval) 4.76 (1.73–13.04) 2.85 (1.17–6.92)
p-value 0.002 0.021
Tenge, Sidle, Yiannoutsos et al., 2006; Vreeman et al., 2008; Wamalwa, Farquhar, Obimbo, Selig, Mbori-Ngacha, Richardson et al., 2009). However, consistent with the findings of several studies (e.g. Orrell, Bangsberg, Badri & Wood, 2003; Weiser, Wolfe, Bangsberg, Thior, Gilbert,
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African Journal of AIDS Research 2010, 9(1): 25–30
Makhema et al., 2003) this study found no association between a child’s adherence to treatment and the educational attainment of the caregiver, which should further help to dispel fears about the success of ART scale-up in developing countries. Drug stock exhaustion at home was the most frequently given reason for not being adherent; this finding was buttressed by the increased odds of drug adherence among those keeping the last clinic appointment. The next most common reasons reported for non-adherence were ‘the child slept through’ and ‘caregiver was away’ during the drug administration time. A recently published study by Biadgilign et al. (2008), carried out at several ART centres in Ethiopia, identified drug exhaustion at home and the child sleeping through the time for administration as the most common reasons for non-adherence, a finding similar to ours. Although, this study was not designed to identify the factors associated with drug exhaustion at home (such as caregivers sharing the drugs with other children needing them), missing one’s clinic appointment appears to be a major determinant. Therefore, we recommend that caregivers are made aware that a drug refill could be obtained even after the child/caregiver misses a scheduled clinic appointment, and that logistics should be put in place to satisfy this. However, this introduces the possibility that children will miss their clinical assessment and that the effects of HAART will not be monitored. The low frequency of ‘forgetfulness’ in this study (see Figure 1) is dissimilar to the findings of several other studies (i.e. Arrivé et al., 2005; Osterberg & Blaschke, 2005; Mukhtar-Yola et al., 2006) and cannot be readily explained, especially considering that only about 30% of the caregivers reported using medication reminders, and that the use of reminders was not associated with adherence to medication. In tandem with several other studies (e.g. Paterson, Swindells, Mohr, Brester, Vergis, Squier et al., 2000; Gibb, Goodall, Giacomet, Mcgee, Compagnucci & Lyall, 2003), a change in daily routine (‘child away’; ‘caregiver away’) or difficulty incorporating drug administration into one’s lifestyle (‘child slept through’) were common reasons for non-adherence. Integrating medication administration into the lifestyle of the child and the other family members is important to achieving adherence among children on ARVs. Among the limitations of our study was the use of caregiver reports to assess children’s adherence to treatment. Caregivers’ reports have been shown to overestimate drug adherence; however, its advantages are low staff burden, ease of administration, and high specificity (see Osterberg & Blaschke, 2005). While we are not able to report on the viral load of the participants because of the cross-sectional nature of the study design, systematic reviews have demonstrated good correlation between drug adherence as assessed by caregiver reports (or self-reports) with patients’ virologic response (Nieuwkerk & Oort, 2005; Simoni, Kurth, Pearson, Pantalone, Merrill & Frick, 2006). Also, we were not able to investigate the reasons for caregivers and children not keeping their clinic appointments or the reasons for drug exhaustion at home. However, the fairly large sample size, high response rate (95%), and inclusion of several variables are some of the strengths of the investigation.
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Conclusions This study has demonstrated a fairly high level of adherence among children on HAART in a centre offering free ART services in Nigeria. Drug exhaustion at home was the most commonly cited reason for non-adherence. Keeping the clinic appointment and male gender were significantly associated with adherence to drug treatment. Acknowledgments — We are grateful to the caregivers and children who agreed to participate in this study. The authors — Edna Iroha is an associate professor and consultant paediatrician, as well as head of the Paediatric HIV/AIDS Group at LUTH, with specialisation in perinatology and neonatology. Christopher I. Esezobor is a lecturer in the Department of Paediatrics, College of Medicine, at the University of Lagos. His areas of interest are infectious diseases, paediatric nephrology and public health. Chinyere Ezeaka is a senior lecturer and consultant paediatrician, with special interests in neonatology and public health. Edamisan O. Temiye is a senior lecturer and consultant paediatrician; his areas of interest are haematology, oncology and infectious diseases. Adebola Akinsulie is an associate professor and consultant paediatrician specialising in haematology, oncology and infectious diseases.
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refill, provider assessment, caregiver self-report, and appointment keeping. Journal of Acquired Immune Deficiency Syndromes 33, pp. 211–218. Ferguson, T.F., Stewart, K.E., Funkhouser, E., Tolson, J., Westfall, A.O. & Saag, M.S. (2002) Patient-perceived barriers to antiretroviral therapy. Associations with race. AIDS Care 14, pp. 607–617. Ferris, M.G. & Kline, M.W. (2002) Challenges to pediatric adherence to antiretroviral medications. The AIDS Reader 12, pp. 162–163. Giacomet, V., Albano, F., Starace, F., Franciscis, A., Giaquinto, C., Gattinara, G.C., Bruzzese, E., Gabiano, C., Galli, L., Viganò, A., Caselli, D. & Guarino, A. (2003) Adherence to antiretroviral therapy and its determinants in children with human immunodeficiency virus infection: a multicentre, national study. Acta Paediatrica 92, pp. 1398–1402. Gibb, D.M., Goodall, R.L., Giacomet, V., Mcgee, L., Compagnucci, A. & Lyall, H. (2003) Adherence to prescribed antiretroviral therapy in human immunodeficiency virus-infected children in PENTA 5 trial. Pediatric Infectious Disease Journal 22, pp. 56–62. Hardon, A., Davey, S., Gerrits, T., Hodgkin, C., Irunde, H., Kgatlwane, J., Kinsman, J., Nakiyemba, A. & Laing, R. (2006) From Access to Adherence: The Challenges of Antiretroviral Treatment. Studies from Botswana, Tanzania and Uganda. Geneva, World Health Organization (WHO). Harries, A.D., Nyangulu, D.S., Hargreaves, N.J., Kaluwa, O. & Salaniponi, F.M. (2001) Preventing antiretroviral anarchy in sub-Saharan Africa. The Lancet 358, pp. 410–414. Laniece, I., Ciss, M., Desclaux, A., Diop, K., Mbodj, F., Ndiaye, B., Sylla, O., Delaporte, E. & Ndoye, I. (2003) Adherence to HAART and its principal determinants in a cohort of Senegalese adults. AIDS 17, pp. S103–S108. Liechty, C.A. & Bangsberg, D.R. (2003) Doubts about DOT. AIDS 17, pp. 1383–1387. Mukhtar-Yola, M., Adeleke, S., Gwarzo, D. & Ladan, Z.F. (2006) Preliminary investigation of adherence to antiretroviral therapy among children in Aminu Kano Teaching Hospital, Nigeria. African Journal of AIDS Research (AJAR) 5(2), pp. 141–144. Nabukeera-Barungi, N., Kalyesubula, I., Kekitiinwa, A., ByakikaTusiime, J. & Musoke, P. (2007) Adherence to antiretroviral therapy in children attending Mulago Hospital, Kampala. Annals of Tropical Paediatrics 27, pp. 123–131. Nieuwkerk, P.T. & Oort, F.J. (2005) Self-reported adherence to antiretroviral therapy for HIV-1 infection and virologic treatment response: a meta-analysis. Journal of Acquired Immune Deficiency Syndromes 38, pp. 445–448. Nyandiko, W.M., Ayaya, S., Nabakwe, E., Tenge, C., Sidle, J.E., Yiannoutsos, C.T., Musick, B., Wools-Kaloustian, K. & Tierney, W.M. (2006) Outcomes of HIV-infected orphaned and non-orphaned children on antiretroviral therapy in western Kenya. Journal of Acquired Immune Deficiency Syndromes 43, pp. 418–425. Orrell, C., Bangsberg, D., Badri, M. & Wood, R. (2003) Adherence is not a barrier to successful antiretroviral therapy in South Africa. AIDS 17, pp. 1369–1375. Osterberg, L. & Blaschke, T. (2005) Drug therapy: adherence to medications. New England Journal of Medicine 353, pp. 487–497.
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Paterson, D.L., Swindells, S., Mohr, J., Brester, M., Vergis, E.N., Squier, C., Wagener, M.M. & Singh, N. (2000) Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine 133, pp. 21–30. Polisset, J., Ametonou, F., Arrivé, E., Aho, A. & Perez, F. (2009) Correlates of adherence to antiretroviral therapy in HIV-infected children in Lomé, Togo, West Africa. AIDS and Behavior 13(1), pp. 23–32. Reddington, C., Cohen, J., Baldillo, A., Toye, M., Smith, D., Kneut, C., Demaria, A., Bertolli, J. & Hsu, H. (2000) Adherence to medication regimens among children with human immunodeficiency virus infection. Pediatric Infectious Disease Journal 19, pp. 1148–1153. Shah, C.A. (2007) Adherence to highly active antiretroviral therapy in pediatric patients infected with HIV: issues and intervention. Indian Journal of Pediatrics 74, pp. 55–60. Simoni, J.M., Kurth, A.E., Pearson, C.R., Pantalone, D.W., Merrill, J.O. & Frick, P.A. (2006) Self-report measures of antiretroviral therapy adherence: a review with recommendations for HIV research and clinical management. AIDS and Behavior 10, pp. 227–245. Simoni, J.M., Montgomery, A., Martin, E., New, M., Demas, P.A. & Rana, S. (2007) Adherence to antiretroviral therapy for pediatric HIV infection: a qualitative systematic review with recommendations for research and clinical management. Pediatrics 119(6), pp. e1371–e1383 (doi:10.1542/peds.20061232). Steele, R.G., Anderson, B., Rindel, B., Dreyer, M.L., Perrin, B., Christensen, R., Tyc, V. & Flynn, P.M. (2001) Adherence to antiretroviral therapy among HIV-positive children: examination of the role of caregiver health beliefs. AIDS Care 13(5), pp. 617–629. Van Dyke, R.B., Lee, S., Johnson, G.M., Wiznia, A., Mohan, K., Stanley, K., Morse, E.V., Krogstad, P.A. & Nachman, S. (2002) Reported adherence as a determinant of response to highly active antiretroviral therapy in children who have human immunodeficiency virus infection. Pediatrics 109(4), p. e61. Vreeman, R.C., Wiehe, S.E., Ayaya, S.O., Musick, B.S. & Nyandiko, W.M. (2008) Association of antiretroviral and clinic adherence with orphan status among HIV-infected children in western Kenya. Journal of Acquired Immune Deficiency Syndromes 49, pp. 163–170. Wamalwa, D.C., Farquhar, C., Obimbo, E.M., Selig, S., Mbori-Ngacha, D.A., Richardson, B.A., Overbaugh, J., Egondi, T., Inwani, I. & John-Stewart, G. (2009) Medication diaries do not improve outcomes with highly active antiretroviral therapy in Kenyan children: a randomized clinical trial. Journal of the International AIDS Society 12, p. 8. Weiser, S., Wolfe, W., Bangsberg, D., Thior, I., Gilbert, P., Makhema, J., Kebaabetswe, P., Dickenson, D., Mompati, K., Essex, M. & Marlink, R. (2003) Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana. Journal of Acquired Immune Deficiency Syndromes 34, pp. 281–288. Williams, P.L., Storm, D., Montepiedra, G., Nichols, S., Kammerer, B., Sirois, P.A., Farley, J. & Malee, K. (2006) Predictors of adherence to antiretroviral medications in children and adolescents with HIV infection. Pediatrics 118(6), pp. e1745–e1757 (doi:10.1542/peds.2006-0493).
African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20
Adherence to antiretroviral therapy among HIVinfected children attending a donor-funded clinic at a tertiary hospital in Nigeria a
a
a
Edna Iroha , Christopher Imokhuede Esezobor , Chinyere Ezeaka , Edamisan Olusoji a
Temiye & Adebola Akinsulie
a
a
Department of Paediatrics, College of Medicine , University of Lagos , PMB 12003, Lagos, Lagos State, Nigeria Published online: 19 May 2010.
To cite this article: Edna Iroha , Christopher Imokhuede Esezobor , Chinyere Ezeaka , Edamisan Olusoji Temiye & Adebola Akinsulie (2010) Adherence to antiretroviral therapy among HIV-infected children attending a donor-funded clinic at a tertiary hospital in Nigeria, African Journal of AIDS Research, 9:1, 25-30, DOI: 10.2989/16085906.2010.484543 To link to this article: http://dx.doi.org/10.2989/16085906.2010.484543
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African Journal of AIDS Research 2010, 9(1): 25–30 Printed in South Africa — All rights reserved
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ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2010.484543
Adherence to antiretroviral therapy among HIV-infected children attending a donor-funded clinic at a tertiary hospital in Nigeria Edna Iroha, Christopher Imokhuede Esezobor*, Chinyere Ezeaka, Edamisan Olusoji Temiye and Adebola Akinsulie
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Department of Paediatrics, College of Medicine, University of Lagos, PMB 12003, Lagos, Lagos State, Nigeria *Corresponding author, e-mail address: [email protected] The success of antiretroviral therapy (ART) depends on a high level of adherence to a life-long regimen of antiretroviral drugs (ARVs). Since the scale-up of access to ARVs in Nigeria, few studies have determined the level of adherence of ART among children. This study was undertaken to determine the level of ART adherence among paediatric patients at an outpatient clinic, the reasons for non-adherence, and the factors associated with adherence, according to caregivers’ reports. Out of a total of 212 children, 183 (86%) were adherent in the three days preceding the interview, while 29 (14%) were not adherent. Drug exhaustion at home (16 children), followed by ‘child slept through’ (7 children) and ‘caregiver away’ were the most common reasons for a child having missed one or more ARV doses. Independent factors for adherence were male gender (odds ratio [OR] = 2.85; 95% confidence interval [CI]: 1.17–6.92) and attendance at last scheduled clinic appointment (OR = 4.76; 95% CI: 1.73–13.04). The caregiver’s highest educational attainment, distance travelled to the clinic, use of medication reminders, formulation of ARVs, duration of HAART usage, age of the child and orphan status were not significantly associated with adherence to drug treatment. The overall level of adherence was high and similar to the rate reported prior to free access to ART services in Nigeria. Among child patients on HAART, there is a need to identify factors affecting clinic attendance and drug exhaustion at home. Keywords: caregivers, compliance, drug treatment, HAART, HIV/AIDS, paediatrics, questionnaires, sub-Saharan Africa
Introduction The chronicity of HIV and AIDS places on the patient a lifelong burden of adherence to a highly complex regimen of drugs with multiple adverse effects, overlapping toxicities, and several dietary requirements (Ferguson, Stewart, Funkhouser, Tolson, Westfall & Saag, 2002). Adherence to antiretroviral drugs (ARVs) in the paediatric population assumes a wider dimension (Shah, 2007). First, medication-related factors such as volume, taste, diet prescription, intake of drugs, dosing interval and side effects are difficult to overcome in treating children (Ferris & Kline, 2002; Van Dyke, Lee, Johnson, Wiznia, Mohan, Stanley et al., 2002; Shah, 2007). Second, children depend on caregivers, who might be living with HIV/AIDS, to administer their medication (Steele, Anderson, Rindel, Dreyer, Perrin, Christensen et al., 2001). Because the success of antiretroviral therapy (ART) rests on a high level of adherence to the medication, centres offering ART services are required to assess the level of individual patient adherence (Hardon, Davey, Gerrits, Hodgkin, Irunde, Kgatlwane et al., 2006). However, earlier studies characterising ART adherence among HIV-infected children in Africa (e.g. Laniece, Ciss, Desclaux, Diop, Mbodj, Ndiaye et al., 2003; Akam, 2004; MukhtarYola, Adeleke, Gwarzo & Ladan, 2006) were done at a time when ARVs had to be bought by the caregivers. The prohibitive cost of ARVs was the most significant cause of non-adherence to treatment (Laniece et al., 2003; Mukhtar-
Yola et al., 2006). With the recent scale-up in ART services, many centres in developing countries, including Nigeria, are now offering free ART services. One such centre in Nigeria is the Paediatric Special Clinic at Lagos University Teaching Hospital (LUTH), which offers comprehensive ART services. After about four years since its commencement no assessment of ART adherence had been undertaken in the cohort of children attending the clinic. This study aimed to assess the level of adherence to ARVs among child patients, as reported by their caregivers, in a clinic population of HIV-infected children, and also to identify factors associated with drug compliance. Methods The study was carried out between July and September 2008 in the Paediatric Special Clinic at Lagos University Teaching Hospital (LUTH), the largest tertiary hospital in Lagos, in southwest Nigeria. The clinic is one of several centres in Nigeria providing free, comprehensive ART services for HIV-infected children. The clinic is open one day per week. Children are started on highly active antiretroviral therapy (HAART) at clinical stage 3 or 4 of HIV disease or when they exhibit advanced/severe immunosuppression. Also, prior to the commencement of HAART, the paediatric patient’s caregiver is counselled on the benefits, risks, and limitations of HAART and the need for long-term adherence. This message is usually reinforced, prior to consultation, by
African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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the nurses, and during consultation with physicians and at the pharmacy. Ethical clearance was obtained from the hospital’s research and ethics committee. The questionnaire for caregivers was developed to capture common factors associated with either non-adherence or adherence to ART among paediatric patients, as identified by several other studies, such as age and gender of the child, orphan status, medication-related characteristics, use of medication reminders, remoteness of the clinic from the patient’s residence, and other sociodemographic data. The initial questionnaire was pretested by interviewing 20 caregivers of HIV-infected children attending another state-run ART centre similar to the study site, and the limitations identified were rectified during preparation of the final questionnaire. Caregivers of children who had been on HAART for at least 30 days and who consented to participate in the study were administered the questionnaire in an interview format during a scheduled clinic visit. Caution was exercised during the interview to avoid inadvertently disclosing the child’s HIV status to the child because about 98% of the children in the cohort were not aware of their HIV status. Before administration of the questionnaire, each participating caregiver was reminded that their child’s doctors understood that taking all the doses of prescribed drugs is difficult, and thus that the interview was aimed at identifying hurdles to drug adherence and providing solutions. To reduce recall bias each participating caregiver was asked about drug administration for each day of the previous three days, starting with the immediate past day. The data was analysed using SPSS version 14. Continuous variables were summarised using means/ median and categorical data as percentages. Bivariate analysis (odd ratios [OR] with a 95% confidence interval [CI]) was performed to identify variables associated with adherence to treatment. To control for the effect of confounders, multiple logistic regression was done using only those factors found to have a significant association with drug adherence, based on the bivariate analysis. The level of statistical significance was set at p < 0.05. Operational definitions Adherence was defined as having taken all doses of the ARVs during the past three days. HAART is the administration of at least three ARV drugs from at least two classes. ART is the administration of ARVs either as prophylaxis or treatment. Results Sociodemographic characteristics of the children Two hundred and twelve children out of a total of 223 of children (95.1%) who were registered at the clinic and were on HAART were included in the study. Seven of the 11 children who did not participate had missed their clinic appointments for at least three months prior to the study and could not be contacted; they were otherwise similar to the participants in their sociodemographic characteristics. Of the 212 children included, 172 (81.1%) were aged less than ten years, with a male to female ratio of 1.08:1.
Iroha, Esezobor, Ezeaka, Temiye and Akinsulie
Of the caregivers, 154 (72.6%) were the mother of the child patient and 100 (47.2%) were of the Yoruba tribe. The level of education attained by the caregivers was: none or primary school (44; 20.8%), secondary school (104; 49.1%) or post-secondary education (64; 30.2%). The great majority of the children (203; 95.8%) took a regimen consisting of zidovudine, lamivudine and nevirapine; three children were on a regimen consisting of zidovudine, lamivudine and efavirenz, while six were on second-line drugs, including kaletra. The median duration of use of HAART among the children was 18 months (Table 1). In the three days prior to the interview, 183 children (86.3%) were reported as adherent while 29 (13.7%) did not attain adherence. Reasons for non-adherence The most commonly reported reason for non-adherence was drug exhaustion at home, followed by ‘child sleeping through’ the drug administration time (Figure 1). Factors associated with adherence Male gender and keeping the last clinic appointment were significantly associated with adherence to the treatment, according to both the univariate and multivariate analyses: the male children were more likely than the female children to have adhered to HAART in the three days prior to the interview (OR = 2.85; 95% CI: 1.17–6.92), while those children who had kept their last clinic appointment were more likely to have adhered as compared to those who had missed their last appointment (OR = 4.76; 95% CI: 1.73–13.04) (Tables 2 and 3). The age of the child, duration and formulation of HAART, use of other drugs besides HAART, medication reminders, orphan status, highest educational status of the caregiver, and distance needed to
Table 1: Sociodemographic characteristics of the children studied (n = 212) Variables Age (months): 0–59 60–119 ≥120 (age 10+) Gender: Females Males Tribe: Yoruba Igbo Other Caregiver’s relationship to the child: Mother Father Grandparent/other Caregiver’s highest educational level: None or primary school Secondary school Post-secondary school Duration of HAART (months): 1–11 12–59 ≥60 (≥5 years)
n (%) 80 (37.7) 92 (43.4) 40 (18.9) 110 (51.9) 102 (48.1) 100 (47.2) 55 (25.9) 57 (26.9) 154 (72.6) 18 (8.5) 40 (18.9) 44 (20.8) 104 (49.1) 64 (30.2) 72 (34) 127 (59.9) 13 (6.1)
African Journal of AIDS Research 2010, 9(1): 25–30
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Figure 1: Reasons given by the caregivers for a child’s non-adherence to HAART medication during the last three days (n = 29 non-adherent children)
Vomiting
1
Child away
1
Caregiver forgot
2
Caregiver away
6
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Child slept through
7
Drugs were finished
16
0
5
10 Frequency
15
travel to the clinic were not found to be significantly associated with adherence to treatment. Discussion A high level of adherence was found in this clinic population of children receiving ARVs, according to the caregivers’ reports on adherence during the preceding three days. This high level of adherence among children in a Nigerian ART centre is encouraging when viewed against the fears and concerns expressed about drug adherence in developing countries prior to the global efforts at scaling up access to ART (cf. Harries, Nyangulu, Hargreaves, Kaluwa & Salaniponi, 2001; Liechty & Bangsberg, 2003). The high level of adherence documented in this study could be due partly to the provision of ARVs free of user costs in a country where less than 10% of those who need ART have access to it, and to the short duration of HAART usage in the cohort, as well as the availability of counselling services at multiple points during a single clinic visit (see Laniece et al., 2003; Akam, 2004; Vreeman, Wiehe, Ayaya, Musick & Nyandiko, 2008). Conversely, the high adherence level found in his study could be due to overestimation in the caregivers’ reports. Compared to electronic drug monitoring and unannounced pill counts, caregivers’ self-reports tend to overestimate drug adherence (Arnsten, Demas, Farzadegan, Grant, Gourevitch, Chang et al., 2001; Nabukeera-Barungi, Kalyesubula, Kekitiinwa, Byakika-Tusiime & Musoke, 2007; Davies, Boulle, Fakir, Nuttall & Eley, 2008). Overestimation is even more likely to have occurred in our study as the clinicians running the clinic administered the questionnaire — thus, the caregivers might have overestimated adherence to please the investigators. However, the level of drug adherence found here is similar to adherence rates observed in other studies among children in both developing and developed countries (e.g. Reddington, Cohen, Baldillo, Toye, Smith, Kneut et al., 2000; Giacomet, Albano, Starace, Franciscis, Giaquinto, Gattinara et al., 2003; Eley, Nuttall,
Davies, Smith, Cowburn, Buys et al., 2004; Mukhtar-Yola et al., 2006; Biadgilign, Deribew, Amberbir & Deribe, 2008). A study in Cote d’Ivoire (Arrivé, Anak, Wemin, Diabate, Rouet, Salamon & Msellati, 2005) reported 67% adherence among the participants in the preceding three days, a level far lower than that recorded in this study; however, the most frequent reason cited for non-adherence in that study was ‘drug stock exhaustion’ at the facility level. Similarly, a recent study in Cape Town, South Africa, reported only 79% adherence (Davies et al., 2008), but this could be due to assessment over a one-year period, which would have increased the odds of encountering non-adherence. Published works from developed countries (e.g. Byrne, Honig, Jurgrau, Heffernan & Donahue, 2002; Farley, Hines, Musk, Ferrus & Tepper, 2003) have reported higher levels of adherence than that observed in this study, but they involved smaller study populations and some were carried out as part of the rigorous process of clinical trials. We found two independent factors to be associated with increased odds of drug adherence. Not surprisingly, keeping the last scheduled clinic appointment was significantly associated with adherence to treatment. This association corroborates that found by Farley et al. (2003), who demonstrated that not missing a clinic appointment was significantly associated with a viral load below the threshold of detection, implying high adherence. Being a donor-funded programme in which request forms for drug refill are usually completed during the monthly clinic visits, coupled with the prohibitive cost of ARVs in the open market, it is apparent that missing a clinic appointment where drugs are provided at no cost is likely to result in drug exhaustion at home. However, the distance caregivers had to travel to get to the clinic was, inexplicably, not associated with adherence, as similarly reported in a study in Uganda (Nabukeera-Barungi et al., 2007). Although, the factors that may be associated with clinic attendance were not investigated in this study, efforts aimed at improving adherence to treatment should identify these factors. Significantly, the gender of the child was associated with adherence in this study. Our finding in this regard is consistent with the report of a large study in the United States (Williams, Storm, Montepiedra, Nichols, Kammerer, Sirois et al., 2006) involving 2 088 children, with a median age of 11.5 years and about 60% African-American, which found that female children had an estimated odds ratio of 1.25 in multiple logistic regressions for non-adherence. Similar observations were made in a recent study in Lomé, Togo, by Polisset, Ametonou, Arrivé, Aho & Perez (2009). However, in a review of 32 studies among paediatric populations receiving HAART, Simoni, Montgomery, Martin, New, Demas & Rana (2007) observed that the gender of the child was not significantly associated with adherence to medication. Greater adherence among the male children in this study may reflect the higher premium the study population places on male children. Similarly, male child preference has been observed in other aspects of children’s life in Nigeria, such as food-sharing at home, school entry and completing an education. Not surprisingly, we did not find a significant association between adherence to treatment and orphan status (one or both parents deceased), age of the child, taking
28
Iroha, Esezobor, Ezeaka, Temiye and Akinsulie
Table 2: Univariate factors associated with adherence to HAART among children attending the Paediatric Special Clinic at Lagos University Teaching Hospital, 2008 (n = 212) Drug adherence in the past three days
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Variables Age of children (months): 1–59 60–119 ≥120 (age 10+) Gender of children: Males Females HAART duration (months): 1–11 12–59 ≥60 (≥5 years) Formulation of ARVs: Liquid Tablet Both Cotrimoxazole prophylactic therapy (CPT): Yes No Drugs other than ARVs and CPT: Yes No Caregiver’s highest educational level: None or primary school Secondary school Post-secondary school Attended last scheduled clinic appointment: Yes No Use of medication reminders: Yes No Distance travelled to clinic: ≤10 km 11–20 km >20 km Orphan status: Both parents deceased Father deceased Mother deceased Either father or mother dead *NA = not applicable
‘Yes’ (n = 183) n (%)
‘No’ (n = 29) n (%)
Odds ratio (95% confidence interval)
p-value
68 (85) 80 (87) 35 (87.5)
12 (15) 12 (13) 5 (12.5)
0.84 (0.38–1.86) 1.10 (0.5–2.44) 1.14 (0.40–3.18)
0.663 0.814 0.810
94 (92.2) 89 (80.9)
8 (7.8) 21 (19.1)
2.77 (1.17–6.58) 1.00
0.017
62 (86.1) 108 (85) 13 (100)
10 (13.9) 19 (15) 0
0.97 (0.43–2.22) 0.76 (0.33–1.72) NA*
0.949 0.507 NA
69 (85.2) 55 (91.7) 59 (83.1)
12 (14.8) 5 (8.3) 12 (16.9)
0.86 (0.39–1.90) 2.06 (0.75–5.69) 0.67 (0.30–1.50)
0.705 0.155 0.333
174 9
29 0
NA NA
NA NA
58 125
11 18
0.76 (0.34–1.71) 1.00
0.505
38 (86.4) 92 (88.5) 53 (82.8)
6 (13.6)) 12 (11.5) 11 (17.2)
0.81 (0.31–2.56) 1.43 (0.65–3.17) 1.18 (0.33–4.24)
0.676 0.373 0.543
169 (88.9) 14 (63.6)
21 (11.1) 8 (36.4)
4.60 (1.73–12.25) 1.00
0.001
53 (85.5) 130 (86.7)
9 (14.5) 20 (13.3)
1.04 (0.43–2.50) 1.00
0.927
69 (90.8) 71 (89.9) 50 (87.7)
7 (9.2) 8 (10.1) 7 (12.3)
0.85 (0.39–1.85) 1.47 (0.64–3.42) 0.69 (0.24–1.99)
0.675 0.363 0.490
NA 2.04 (0.46–9.12) 0.61 (0.22–1.64) 0.76 (0.31–1.84)
NA 0.272 0.320 0.539
8 24 25 41
0 2 6 8
Table 3: Factors associated with the children’s adherence to HAART, based on logistic regression
Variables Attendance at last scheduled clinic appointment Male gender
drugs besides ARVs, use of medication reminders, or the duration and formulation of HAART. The effects of these factors on adherence to medication schedules have been inconsistent in various studies of adherence (e.g. Eley et al., 2004; Williams et al., 2006; Nyandiko, Ayaya, Nabakwe,
Odds ratio (95% confidence interval) 4.76 (1.73–13.04) 2.85 (1.17–6.92)
p-value 0.002 0.021
Tenge, Sidle, Yiannoutsos et al., 2006; Vreeman et al., 2008; Wamalwa, Farquhar, Obimbo, Selig, Mbori-Ngacha, Richardson et al., 2009). However, consistent with the findings of several studies (e.g. Orrell, Bangsberg, Badri & Wood, 2003; Weiser, Wolfe, Bangsberg, Thior, Gilbert,
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African Journal of AIDS Research 2010, 9(1): 25–30
Makhema et al., 2003) this study found no association between a child’s adherence to treatment and the educational attainment of the caregiver, which should further help to dispel fears about the success of ART scale-up in developing countries. Drug stock exhaustion at home was the most frequently given reason for not being adherent; this finding was buttressed by the increased odds of drug adherence among those keeping the last clinic appointment. The next most common reasons reported for non-adherence were ‘the child slept through’ and ‘caregiver was away’ during the drug administration time. A recently published study by Biadgilign et al. (2008), carried out at several ART centres in Ethiopia, identified drug exhaustion at home and the child sleeping through the time for administration as the most common reasons for non-adherence, a finding similar to ours. Although, this study was not designed to identify the factors associated with drug exhaustion at home (such as caregivers sharing the drugs with other children needing them), missing one’s clinic appointment appears to be a major determinant. Therefore, we recommend that caregivers are made aware that a drug refill could be obtained even after the child/caregiver misses a scheduled clinic appointment, and that logistics should be put in place to satisfy this. However, this introduces the possibility that children will miss their clinical assessment and that the effects of HAART will not be monitored. The low frequency of ‘forgetfulness’ in this study (see Figure 1) is dissimilar to the findings of several other studies (i.e. Arrivé et al., 2005; Osterberg & Blaschke, 2005; Mukhtar-Yola et al., 2006) and cannot be readily explained, especially considering that only about 30% of the caregivers reported using medication reminders, and that the use of reminders was not associated with adherence to medication. In tandem with several other studies (e.g. Paterson, Swindells, Mohr, Brester, Vergis, Squier et al., 2000; Gibb, Goodall, Giacomet, Mcgee, Compagnucci & Lyall, 2003), a change in daily routine (‘child away’; ‘caregiver away’) or difficulty incorporating drug administration into one’s lifestyle (‘child slept through’) were common reasons for non-adherence. Integrating medication administration into the lifestyle of the child and the other family members is important to achieving adherence among children on ARVs. Among the limitations of our study was the use of caregiver reports to assess children’s adherence to treatment. Caregivers’ reports have been shown to overestimate drug adherence; however, its advantages are low staff burden, ease of administration, and high specificity (see Osterberg & Blaschke, 2005). While we are not able to report on the viral load of the participants because of the cross-sectional nature of the study design, systematic reviews have demonstrated good correlation between drug adherence as assessed by caregiver reports (or self-reports) with patients’ virologic response (Nieuwkerk & Oort, 2005; Simoni, Kurth, Pearson, Pantalone, Merrill & Frick, 2006). Also, we were not able to investigate the reasons for caregivers and children not keeping their clinic appointments or the reasons for drug exhaustion at home. However, the fairly large sample size, high response rate (95%), and inclusion of several variables are some of the strengths of the investigation.
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Conclusions This study has demonstrated a fairly high level of adherence among children on HAART in a centre offering free ART services in Nigeria. Drug exhaustion at home was the most commonly cited reason for non-adherence. Keeping the clinic appointment and male gender were significantly associated with adherence to drug treatment. Acknowledgments — We are grateful to the caregivers and children who agreed to participate in this study. The authors — Edna Iroha is an associate professor and consultant paediatrician, as well as head of the Paediatric HIV/AIDS Group at LUTH, with specialisation in perinatology and neonatology. Christopher I. Esezobor is a lecturer in the Department of Paediatrics, College of Medicine, at the University of Lagos. His areas of interest are infectious diseases, paediatric nephrology and public health. Chinyere Ezeaka is a senior lecturer and consultant paediatrician, with special interests in neonatology and public health. Edamisan O. Temiye is a senior lecturer and consultant paediatrician; his areas of interest are haematology, oncology and infectious diseases. Adebola Akinsulie is an associate professor and consultant paediatrician specialising in haematology, oncology and infectious diseases.
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