Saudi Journal of Medical and Pharmaceutical Sciences

Abbreviated Key Title: Saudi J Med Pharm Sci

ISSN 2413-4929 (Print) |ISSN 2413-4910 (Online)
Scholars Middle East Publishers, Dubai, United Arab Emirates
Journal homepage: https://saudijournals.com

Original Research Article

Influencing Factors of Adherence to Antiretroviral Drugs among People

Living with HIV in South-South Nigeria
Chijioke-Nwauche I. N1*, Akani Y2
1
Department of Clinical Pharmacy and Management, Faculty of Pharmaceutical Sciences, University of Port Harcourt, Nigeria
2
Department of Social Welfare, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria

DOI: 10.36348/sjmps.2021.v07i02.011 | Received: 25.01.2021 | Accepted: 10.02.2021 | Published: 27.02.2021

*Corresponding author: Chijioke-Nwauche I. N

Abstract
Background: A major challenge to antiretroviral therapy is poor adherence by the patients due to the multiplicity of
drugs involved. For effective outcome of therapy, a 95% adherence is advocated in patients on ARV drugs. Objectives:
Study sought to evaluate the factors that affect the adherence to their prescribed medications by people living with HIV
(PLWHIV) in the capital city of Port Harcourt, South-South, Nigeria. Methods: A descriptive cross sectional study using
pretested questionnaire was used to collect information on adherence among HIV adult patients. Socio-demographic
factors were evaluated as possible factors associated with adherence. Reasons for missing medications were also obtained
and described. Results: Participants comprised of 109 (31.8%) males and 231 (67.3%) females (mean age 37.3 ± 8.9)
years. Study revealed a poor level (58%) of adherence among participants. Patient factors (forgetfulness, personal travels
and work schedule), were major reasons given for missing their medications. Others are economic (lack of transport,
poverty) and socio-cultural (stigma, spiritual) factors. Social support in the form of treatment supporter was found to be a
significant (p<0.05) positive influencing factor to adherence by patients as well as disclosure of status to spouse.
Conclusion: Strategies to improve adherence should be focused on the ways to address the negative influencing factors.
Improved awareness in terms of counselling, education and orientation of the patients is strongly advocated. Social
support systems (family, community, treatment supporter) and societal acceptance of PLWHIV should be put in place to
encourage adherence.
Keywords: Adherence, Antiretroviral drugs, HIV, Infection, Non-adherence, South-South Nigeria.
Copyright © 2021 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International
License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original
author and source are credited.

to decreased morbidity and mortality such that many

INTRODUCTION infected people now live for extended period making
Since the first case of HIV was reported in HIV a chronic disease [4, 5]. Despite this revolution in
1986, HIV has remained a major public health the life of the HIV persons in reducing morbidity and
challenge in Nigeria [1]. Even though there is a mortality, there are associated challenges of adherence
reduction of national prevalence from 4.1% in 2015 to and adverse drug reactions. The drug treatment for HIV
the current 1.4%, HIV still remains a public health disease is tripartite comprising antiretroviral therapy,
challenge in Nigeria despite the advancement in the management of opportunistic infections or malignancies
area of drug therapy. Nigeria has the highest number of and symptomatic control. Antiretroviral drugs are
new infections in sub-Saharan Africa and bears the usually given as a combination of a minimum of three
second highest burden of HIV globally after South drugs from different classes so as to prevent resistance.
Africa with an estimated number of about 3.6 million So even in cases where there is no opportunistic
people living with HIV [2]. Current epidemiology data infections and malignancies, the combined regimen of
according to zones, shows that the South-South zone of the ARV drugs on its own is burdensome to the patients
the country have the highest prevalence rate of 3.1% which many times result to poor or non-adherence to
[3]. Rivers State, which is part of South-South zone the drugs by the patients. Furthermore, there is
ranks third in the country with a prevalence rate of increased burden of adverse drug reactions due to the
3.8% [3]. multiplicity of drugs taken by these patients as well as
the safety profile of the ARV drugs [6].
The introduction of antiretroviral (ARV) drugs
for the treatment of HIV infection changed the whole Adherence as defined by the World Health
course of HIV/AIDS disease and management, leading Organization is the ability of patients to follow
Citation: Chijioke-Nwauche I. N & Akani Y (2021). Influencing Factors of Adherence to Antiretroviral Drugs among People 145
Living with HIV in South-South Nigeria. Saudi J Med Pharm Sci, 7(2): 145-152.
 Chijioke-Nwauche I. N & Akani Y., Saudi J Med Pharm Sci, Feb, 2021; 7(2): 145-152

treatment plans, take medications at prescribed times treatment. A pretested 25-point questionnaire form was
and frequencies and also follow restrictions regarding used as the tool for the study. Based on calculated
lifestyles, food and other medications. It is the degree to sample size, 350 questionnaires were distributed to
which a person’s behaviour corresponds with agreed persons attending the adult antiretroviral (ARV) clinic
recommendations from a health care provider [7, 8]. in the University of Port Harcourt Teaching Hospital
Medication adherence is crucial for successful (UPTH). Patients were recruited consecutively on clinic
treatment, particularly in chronic disease management days until the calculated sample size was obtained.
[9]. Poor adherence to ARVs leads to increased risk of
resistance to the drugs. Reports have shown that Inclusion Criteria
adherence rates of <80% are associated with detectable Patients were recruited if they met the
viremia in a majority of patients [10]. The following eligibility criteria: 18 years and above,
recommended adherence rate by the WHO is 95% [11]. registered and receiving highly active antiretroviral
treatment (HAART) from the ARV adult clinic for a
Poor adherence has been attributed to many period > 6 months and willingness to provide informed
factors like patient-related factors (forgetfulness, consent. Participating respondents were patients on
inconvenient dosing and pill burden, side effects of the fixed dose combination of various HAART regimens
drugs; finance/economic factors such as poverty, consisting of different combinations of any of the
insecurity, socio-cultural factors (stigma and following drugs: TDF: Tenofovir; FTC: Emtricitabine;
discrimination); inability to disclose status, weak health 3TC: Lamivudine; DTG: Dolutegravir; NVP:
systems such as drug stock outs, strike action by health Nevirapine; EFV: Efavirenz; LPV/r:
workers and poor services especially in developing Lopinavir/ritonavir; ATV/r: Ritonavir boosted
countries [12-17]. These factors however differ from Atazanavir; AZT: Zidovudine. Dosage frequency of the
country to country or with different societies. Poor drugs are either once or twice daily.
adherence to therapies increases health costs and poor
health outcomes while on the other hand, patients’ Exclusion Criteria
safety is enhanced with improved adherence [8]. The Patients below 18 years; those who have been
present study was designed to evaluate the factors that on ARV drugs for less than six months, pregnant
affect the adherence to their prescribed ARV drugs by women and patients unwilling to participate in the
people living with HIV (PLWHIV) in the capital city of study.
Port Harcourt, Rivers State, Nigeria as well as
determine the reasons for non-adherence. Using the pretested structured questionnaire,
information obtained include: knowledge of ARV
drugs, disclosure of their status, reasons for non-
MATERIALS AND METHODS adherence, challenges to non-adherence and its
Study design and area implications, social and family support, financial
A prospective–descriptive study was carried challenges, access to the hospital and availability of the
out between March-May 2017 to evaluate factors that medications to the participants. Additional information
influence adherence among HIV patients that attend the obtained was the demographic status of the patients
antiretroviral clinic (ARV) in the University of Port ranging from age, sex, education, marital as well as
Harcourt Teaching Hospital (UPTH). The hospital has employment status. Participants were asked to give
about 800-bedded capacity and serves as a referral reasons for non-adherence to their medications.
centre being the largest hospital in the Niger Delta
region. Many of the HIV patients that attend the clinic Data obtained were entered into excel
come from different parts of the region to fill their spreadsheet and transferred to SPSS version 21 for
prescriptions. analysis. Association between factors and adherence or
non-adherence were analysed and confounding factors
Port Harcourt is the capital city of Rivers State were noted. A confidence interval of 95% was used and
in the Niger Delta region and is very rich in the nation’s p-values < 0.05 was considered significant.
oil and gas resources which attracts many migrant and
international workforce with commercial workers Ethical Consideration
following the camp [18]. Rivers State, which is part of Prior to the study, ethical approval was
South-South zone ranks third in the country with a obtained from the Ethics Committee of the University
prevalence rate of 3.8% which is higher than the of Port Harcourt Teaching Hospital after thorough
national prevalence of 1.4% [3]. screening and review of the study proposal which
included information on the study as well as consent
Before initiating therapy, patients were form to be signed voluntarily by the participants.
normally counselled by different persons which include
physicians, pharmacists, nurses and social
workers/counsellors to enable them understand the
disease and the importance of adhering to their

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compared to single or divorced (Table-1). Majority

RESULTS (49.9%) of the respondents had secondary education,
Out of a total of 350 questionnaires 12.2% had primary education, 31.2% had tertiary
administered, 343 (98%) were retrieved. Demographic education, and only 3% had no formal education.
information showed the respondents were made up of Analysis of the occupation of the respondents showed
109 (31.8%) males and 231 (67.3%) females, 3 persons traders and business men/women had the highest
did not indicate their gender. Participants were aged number (30.9%), unemployed persons accounted for
between 18 and 70 years (mean age 37.3 ± 8.9), with 24.5% while self- employed and civil servants
the age range of 31-40 years being the highest (39.3%) accounted for 21% and 14.3% respectively (Table-1).
while the least was among those above 60 years (1.2%). The respondents were on HAART fixed-dose
Other demographic information include marital status combination drugs.
with more (46.1%) of the participants married

Table-1: Demographic statistics of participants

Variables Frequency Percentage
Age
≤ 20 15 4.4
21-30 77 22.4
31-40 135 39.3
41-50 84 24.5
51-60 26 7.6
≥ 60 4 1.2
Unknown 2 0.6
Sex
Male 109 31.8
Female 231 67.3
Unknown 3 0.9
Marital Status
Married 158 46.1
Single 128 37.3
Divorced 24 7
Widowed 19 5.5
Separated 13 3.8
Unknown 1 0.3
Educational level
No formal education 13 3.8
Primary education 42 12.2
Secondary education 171 49.9
Tertiary education 107 31.2
Unknown 10 2.9
Occupation
Trading/Business 106 30.9
Civil servant 49 14.3
Self employed 72 21
Unemployed 84 24.5
Others 18 5.2
Unknown 14 4.1

Less than half of the 343 respondents: 139 Evaluation of the knowledge of the drugs by
(40.5%) knew the drugs they were taking while 175 the respondents indicated that 64.1% knew that the
(51.0%) did not know, 29 (8.5%) persons did not drugs do not cure, while 18.7% believe the drugs cure,
indicate. Analysing duration the respondents have been 13.1% indicated they did not know. There were varied
on their drugs, I94 (56.6%) of the respondents have answers to the knowledge of specific function of the
been on ART between 1-6 years, 66 (19.2%) for more drugs with only 35.3% of the respondents aware that
than 7 years while 71 (20.7%) have been on ART for the HAART reduces viral load. Other answers obtained
less than one year while 12 (3.5%) of the respondents in response to the implications of non-adherence are
could not tell the duration they have been on the drugs. shown in Table-2.

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Table-2: Knowledge of HIV drugs

Do HIV drugs cure?
Yes 64 918.7)
No 220 (64.1)
Don't know 45 (13.1)
No response 14 (4.1)
Can you stop HIV drugs once you start?
Yes 34 (9.9)
No 261 (76.1)
Don't know 17 (5.0)
No response 31 (9.0)
What do HIV drugs do to the body?
Reduce viral load 121 (35.3)
Makes you grow fat 22 (6.4)
Reduces risk of transmission 35 (10.2)
Don't know 3 (0.9)
Makes you stop falling sick 1 (0.3)
Can be used to treat other illness in the body 1 (0.3)
No response 160 (46.6)
What are the implications of non-adherence?
My doctors will be angry 15 (4.4)
The drugs may no longer work 13 (3.8)
I will become sick again 35 (10.2)
I will not get cured 8 (2.3)
Virus will become resistance 51 (14.9)
My viral load will increase 53 (15.5)
Pharmacy may no longer give me drugs 2 (0.6)
I may need to change my drugs 7 (2.0)
I might die from the disease 9 (2.6)
I will loose weight 1 (0.3)
No response 148 (43.1)

Only 198 (58%) of respondents reported that Demographic factors were also found to be
they have never missed their drugs while 42% admitted among influencing factors of significance. Marital and
to have missed their drugs at one time or the other. educational status have significant influence (p<0.05)
Statistical analysis showed some influencing factors on on adherence with married persons being more adherent
adherence to be significant. Social support in the form to their medications compared to single or separated
of treatment supporter was found to be an important (81.2% vs 3.4% vs 30%) respectively. Respondents
influencing factor to adherence by patients. This factor with tertiary education showed higher level of
was found to have significant (p < 0.05) influence on adherence with 84.6% in this category adhering to their
adherence to treatment by the respondents, with 75.3% drugs as prescribed. The test of relationship shows that
of persons acknowledging a positive influence to educational attainment influences the level of adherence
adherence through the help of their treatment supporter. by respondents (p<0.05).
On the contrary, in persons without treatment supporter,
over 90% of the respondents have missed their Influence of age on adherence was significant
medications one time or the other. Treatment supporters (p<0.05) but dependent on age range. Respondents in
comprised mostly of spouse (50%), with others as the age range of 31-40 reported highest adherence
family relations, friend, pastor, community volunteer (83.2%) followed by 41-50 (60%), while the age range
and persons living positively with the virus. 21-30 and 51-60 had very low adherence of 18.4% and
10% respectively. On gender influence, there was a
Respondents admitted to disclosure of their close relationship between the numbers of those who
HIV status in this order: spouse (48%), family have in one time or the other missed their prescription
member/sibling (32%), sexual Partner (6%), pastor between the males and females. Hence, from the test of
(8%), friend (3%) and medical personnel (3%). relationship obtained (p=0.323), it can be concluded
Analysis of the results showed that disclosure to spouse that gender does not have a significant influence on
had a significant positive influence (p<0.05), however, their adherence to treatment.
disclosure to other persons did not have any significant
influence on adherence (p >0.06).

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On the impact of duration of HIV treatment, which was a major factor in the earlier study compared
the analysis showed varied results as follows: with to the fixed dose combination that is obtained in present
patients who had been on medication for 4-6 years study. The 58% adherence level reported in present
demonstrating the highest rate of adherence (84%). This study is very low compared to the recommended level
was closely followed by those that had been on by WHO [11, 19], and it is even lower than 70.4%
medication for a period above 9 years (78.9%), others obtained in an Indian study [21]. Adherence levels
are 1-3 years (26.9%) and 7-9 years (23.8%). <80% have been associated with detectable viremia in
many patients [10]. Poor adherence is very closely
Responding to questions on personal reasons related to poor treatment outcome and can lead to cross
for missing their drugs, responses were classified under resistance to other antiretroviral drugs which can
five different categories according to a study in South invariably complicate treatment of HIV infection [22].
Africa [17], and based on WHO, 2003 [8] classification
(Table-3). Many factors have been attributed to the poor
adherence of patients to their therapy and these factors
Table-3: Categories of reasons for missing could be patient-related, drug-related such as side
medications effects of the drugs, inconvenient dosing and pill
Variable Responses (343) burden [10]. Other factors include belief systems, socio-
Patient factors 221 (64.5) cultural behaviours such as fear of stigma and
Economic factors 41 (12) discrimination, economic factors such as poverty and
Socio-cultural factors 31 (9) insecurity, inability to disclose the status, weak health
Drug-related factors 19 (5.5) facility management such as drug stock outs and strike
Health system factors 19 (5.5) action by health workers [23, 24, 13, and 12]. The
Others 12 (3.5) present study has also established some of these factors
A. Patient Factors N= 221 to be influential on patients’ non-adherence.
Forgetfulness 90 (40.7)
The positive influence of social support as
Tight work schedule 47 (21.3)
evidenced by spouse, family, friends acting as treatment
Travelled out of town 45 (20.3)
supporters on adherence observed from our study has
Drugs got finished 24 (10.8)
been reported in other studies [25, 21, 26]. Community
Too ill to take drugs 7 (3.2) support or organizations as well as persons living
No longer feeling sick 5 (2.3) positively with the virus also accounted for positive
Suspicious of treatment 2 (0.9) influences of adherence. The negative influence of
Tired of taking drugs 1 (0.5) socio-cultural aspects as reported in present study
B. Economic Factors N=41 include rejection as a result of stigma, where persons
Lack of transport 31 (75.6) living with HIV are not well integrated in the
No food to eat 10 (24.4) community. This has been reported in a previous study
C. Socio-cultural factors N=31 in South Africa [27]. Social and community support
Spiritual healing 20 will minimize this feeling of rejection and thereby
Stigma 6 empower the PLWHIV to adhere to their medication. In
Sharing drugs 3 relation to this is the importance of disclosure
Taking native drugs 2 especially to the spouses. Fear of disclosure has been a
D. Health System factors N= 19 major limitation to adherence [28, 29]. Results of
Strike in the hospital 13 positive significant influence of disclosure to spouse is
Poor attitude of workers 6 in consonance with previous studies [30, 31].
E. Drug-related Factors N=19
Fear of side effects 15 Education as an important influence that
Too many drugs 4 encourages adherence has been reported in many
F. Others 12 (3.5) studies with people of higher education being more
adherent to their medications [32, 33]. The present
study is in consonance with these reports establishing
DISCUSSION higher education as a positive influence for better
Adherence to medication is a very important adherence. However, a South African study among
factor in patient’s management particularly among pregnant women on HIV treatment reported that women
people living with HIV. To achieve maximal viral with lower level of education were more likely to report
suppression, an adherence of 95% is required [19]. The complete adherence when compared to those with
study reported an adherence of 58%, which is an tertiary education [34].
improvement from the 49.2% obtained from the same
centre in an earlier study [20]. The increase in
adherence could be as result of reduced pill burden

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Gender influence was found to be insignificant being rejected were also among reasons given for non-
in the present study. There are varied results of gender adherence as observed in previous studies [17, 21].
influence with some studies reporting women to be
more adherent [35, 21], while in other studies males
have been reported to be more adherent [36, 37].
CONCLUSION
The study reveals patient factors (primarily
The present study has shown the reasons for forgetfulness) as the main reasons for missing their
non-adherence as admitted by the study participants to medications. Other negative influencing factors are
be majorly patient-related accounting for 64.5% of the lower education level, lack of disclosure, social stigma
reasons. Among these factors, forgetfulness was the and lack of treatment supporters. Poor adherence to
greatest reason given, followed by work schedule and ARV drugs constitutes a deterrent to efficient therapy
personal travels, being tired of taking the drugs and also leading to poor health outcomes, increased health care
too ill to take the drugs (Table-3). An earlier study by costs and generally increases greater burden on public
Maduka and Tobin-West [38] which was targeted at health. Strategies to improve adherence should be
non-adherent patients in the same Centre, established focused on the ways to address the negative influencing
being away from home as major reason for non- factors. A combination of many strategies should be
adherence as against forgetfulness that was obtained in employed to achieve this. A major point of importance
the present study. Previous study in South Eastern is education, counselling and orientation of the patients.
Nigeria reported forgetfulness as a major factor A well-informed patient will be more committed to
responsible for non-adherence [39]. This was equally adhere to his medication knowing that non-adherence
identified in studies from South Africa and Ethiopia could result to poor outcome of his/her treatment.
[17, 40]. In an Indonesian study, forgetfulness was Positive behavioural changes by patients should be
responsible for 67% of non-adherence among urban encouraged to enable improved adherence. Social
population of HIV-patients [25]. support systems (family, community and treatment
supporter) should be put in place to encourage
Economic factors were shown to be another adherence and societal acceptance of PLWHIV will
important factor. Even though the medications were help to reduce the stigma syndrome. Strengthening the
made available free to the patients, the respondents weak health system in terms of reduced stock out of
were required to go to the hospitals to collect them. The drugs, improved training and welfare of personnel and
lack funds constituted a constraint to achieving this as healthcare practitioners will all work together to
some could not afford the transport cost to go for the improve adherence.
drugs as was observed in a similar study in South-
Eastern Nigeria and other parts of Africa [39, 17]. Conflicting interests: The authors declare no
While transport cost was a hindrance to some, for conflicting interests in publishing the paper.
others, their financial constraint meant no food to eat
and as such they could not take their medications. Funding: This research received no grant or fund from
These factors were also established among HIV- any agency.
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