Impact of antiretroviral therapy regimens adherence on perceived health and wellbeing status among adults living with HIV in Ghana

Introduction

HIV remains a major global public health issue since its emergence, having claimed an estimated 36.3 million (27.2–47.8 million) lives and over 38 million people living with HIV (PLHIV) by the end of 2020 (World Health Organization, 2021). Of these numbers, over two-thirds (25.4 million) are in the WHO African Region (World Health Organization, 2021). In Ghana, there were an estimated 342,307 PLHIV (36% male, 64% female) by the end of 2019, with 20,068 new infections, and 13,616 AIDS-related deaths (Ghana AIDS Commission, 2019).

Due to significant advancement in the development and access to more effective therapeutics, improvement in the care and management of PLHIV today is different from three decades ago. WHO reported that in 2020, 27.5 million (26.5–27.7 million) PLHIV were receiving antiretroviral therapy (ART). This equates to a global ART coverage rate of 73% (56–88%) (World Health Organization, 2021). This has led to an almost 59% suppression of the virus with minimal risk of infecting others in 2019 (UNAIDS, 2020). In Ghana, close to 68% of PLHIV receiving ART have achieved viral suppression (Ghana AIDS Commission, 2016). Between 2000 and 2019, new HIV infections fell by 39% and HIV-related deaths fell by 51%, with 15.3 million lives saved due to ART (World Health Organization). These improvements have been attributable to increased concerted efforts of national interventional programs and international funding. Thus, this indicates a remarkable improvement in the health and longevity of HIV-diagnosed persons compared with the 1980s and early 1990s.

Improvements in ARTs, counseling and other HIV/AIDS care have been game-changers in the fight against the HIV pandemic. There is sufficient evidence that ART adherence and maintenance of viral suppression improve the health of PLHIV who maintain viral suppression; however, viral suppression also prevents infection from positive partners to negative sexual partners (World Health Organization, 2018). However, for ART to lead to viral suppression and overall improvement in health and quality of life for PLHIV, there must be sustained adherence to ART regimens; be it first- or second-line prescribed treatment. This is because adherence to the prescribed treatment regimen improves clinical outcomes and reduces chances of mortality (World Health Organization, 2018) while non-adherence is associated with poor health outcomes, frequent hospitalizations, and increased rates of mortality (Vrijens et al., 2012). Promoting ART adherence has, therefore, become one of the main goals of clinicians and professionals who are directly or indirectly caring for PLHIV (DiMatteo, 2004). With consistent adherence to ART, economic wellbeing improved significantly among adults in study participants in South Africa. This reduced their inability to perform required job activities from 56% to 6% and reduced dependence on caretakers from 81% to less than 1% over a five-year period (Rosen et al., 2014). Also, among other factors, poor ART adherence has been linked to malnutrition, under-nutrition, and food insecurity among PLHIV in different settings (Gebremichael et al., 2018; Negessie et al., 2019; Weldehaweria et al., 2017). On the other hand, non-adherence is associated with poor health outcomes, frequent hospitalizations, and increased rates of mortality (DiMatteo, 2004). Promoting ART adherence has, therefore, become one of the main goals of clinicians and professionals who are directly or indirectly caring for PLHIV (Weiser et al., 2017).

Many studies have been conducted to evaluate ART adherence in various countries and there have been mixed results. While some studies reported good adherence, others report poor adherence. For instance, it was reported that only 55% of PLHIV globally adhere to ART indicating a poor global adherence index (Saberi et al., 2015). Poor ART adherence, ranging between 30% and 50% has also been reported in the USA (Marcum et al., 2013). Dalmida and colleagues indicated that among adults in the US receiving ART, only 25% have viral suppression, which suggests that poor ART adherence may partly be to blame for the low viral suppression (Dalmida et al., 2017). However, Kim et al. and Yu et al. have reported 70.4% and 86% adherence rates among PLHIV in Korea and China respectively (Kim et al., 2018; Yu et al., 2018).

In Ghana, the Ghana Aids Commission (GAC) reported a 77% sustained ART adherence among PLHIV leading to 68% viral suppression (GAC, 2019). Lokpo et al., and Afrane et al. have also reported 69% and 61.6% viral suppression among adults and children respectively in two cities in Ghana (Afrane et al., 2021; Lokpo et al., 2020). However, other studies in Ghana have reported lower ART adherence among various groups of PLHIV in the country (Abrokwah, 2018; Anokye-Kumatia et al., 2018; Nichols et al., 2019).

Varying factors have been reported for adherence and non-adherence of ART among PLHIV in different parts of the world. The most common factors reported for non-adherence to ART included fear of stigma, gender, non-disclosure of HIV status, younger age, and depression among PLHIV (Kim et al., 2018; Madiba & Josiah, 2019; Yu et al., 2018). Other predictors of non-adherence reported include race, alcohol use, and low socio-economic status (SES) (Amirkhanian et al., 2018; Corless et al., 2017). In Ghana, similar factors, such as gender, age, and fear of stigma in addition to financial difficulties, clinic attendance, educational status, and shortage of antiretroviral medications have also been reported to predict ART adherence (Anokye-Kumatia et al., 2018; Nichols et al., 2019; Poku et al., 2020).

In recent years, there has been an increasing interest in ART adherence and the issues of quality of life and wellbeing among PLHIV (Ghiasvand et al., 2019). However, in Ghana, and the Volta and Oti regions, in particular, there has been little quantitative analysis of ART adherence and perception of wellbeing among PLHIV. This study sets out to assess the self-reported adherence of ART and perceptions of wellbeing among PLHIV receiving ART at three HIV clinics in the Volta and Oti regions of Ghana.

Methods

Findings

Challenges in adhering to ART

Participants were asked about challenges they encounter in their adherence to ART regimens as prescribed by their doctors. The majority (162 (53.8%)) indicated that they did not have a challenge in accessing and taking their medication. However, 106 (35.2%) reported that they have transportation challenge in traveling to and from their respective clinics for their medication. Other challenges included medication side effects (12 (4%)), medication shortage (11 (3.7%)), too many medications (seven (2.3%)), and cost of medication (three (1%)). These are presented in Figure 1.

Figure 1. Challenges of PLHIV in adhering to ART.

Discussion

The initiation of ART among participants in this study was in line with the WHO 2016 consolidated guidelines on ART that recommends early initiation of ART for adults with HIV and CD4 count below 500 cells/mm², regardless of the clinical stage to optimize positive HIV treatment outcomes and prevent new infections (World Health Organization, 2016). However, not many findings have reported early initiation of ART especially in developing and resource-limited countries. Meanwhile, in this study, 60%, 19.6%, and 14.6% of participants reported that they initiated ART immediately after their diagnosis, within a month, and within four months, respectively. This indicates that about 95% of the participants in this study enrolled in ART within six months after their HIV diagnosis which is consistent but higher than 53% reported in a systematic review in Australia in 2015 (McManus et al., 2019). In an analysis of a population-based sample in San Francisco to track early initiation of ART, researchers reported a steady increase from early ART initiation from 2001 to 2015 which peaked at 74% (Truong et al., 2019).

It was also found in this study that ART adherence was among the highest reported in the literature as reported by the participants in the study. A 55% global adherence rate of ART was reported a few years earlier among PLHIV (Saberi et al., 2015). In this study, most (97%) of the participants reported that they adhere to ART regimens and are consistent with their anti-retroviral medications since initiating ART. This adherence rate is higher than the 78% national adherence rate reported by the Ghana AIDS Commission in Ghana (Ghana AIDS Commission, 2019). The high adherence rate is also consistent with but higher than 70.4% and 86% reported in Korea and China, respectively (Kim et al., 2018; Yu et al., 2018). Again, the finding is higher than the 30–50% ART adherence rates reported in the USA earlier (Marcum et al., 2013).

Many factors have been reported to predict or at least to be associated with ART adherence among PLHIV in different environments. In this study, different variables were tested using different statistics and only the availability of alternatives to the current ART had a statistically significant association with ART adherence in χ² analysis. Those who took their medication because they did not have alternatives to the current ART regimen were more likely not to adhere to ART compared to those who did not worry about alternatives to the current ART regimen. However, in binary and multinomial regression analysis the same variable did show a significant relationship to ART adherence. This finding is inconsistent with findings in Ghana where gender, fear of stigma, shortage of antiretroviral drugs, and financial difficulties were reported to predict ART adherence (Anokye-Kumatia et al., 2018; Nichols et al., 2019; Poku et al., 2020). Other promoters of ART adherence reported in a teaching hospital in Accra, Ghana; included perception of benefits of ART, awareness of ART regimen, access to food, and transparency on the part of clinicians (Dzansi et al., 2020), which we did not find in this study. The finding is also inconsistent with findings of fear of HIV stigma, gender, and non-disclosure of HIV status, and lower SES (Corless et al., 2017; Kim et al., 2018; Madiba & Josiah, 2019; Yu et al., 2018).

The finding is, however, consistent with emerging evidence in the literature that PLHIV around the world are searching and showing a preference for alternative ARTs and willing to switch from the existing daily pills regimen to long-acting ARTs (LA-ART) including six months injectables, implants, and ART-free HIV remission (Dandachi et al., 2021). For example, in a study to explore the perceptions and viewpoints of PLHIV about LA-ART in France, researchers concluded that LA-ART may be the suitable mode of HIV treatment for some PLHIV (Carillon et al., 2020). In a quantitative study among 282 PLHIV in the USA, Dubé and colleagues reported that 42% and 24% indicated their preference of six-month injectables and ART-free HIV remission respectively over the daily pills (Dubé et al., 2020). Similarly, in Texas, researchers reported that 61% of study participants preferred LA-ART over the daily pills regimen and specifically, 41%, 40%, and 18% preferred a pill for six months, injectables, and implants respectively (Dandachi et al., 2021).

Therefore, the finding in this study may be a signal that alternatives to the current ART regimens in Ghana should be taken into consideration by the Ghana AIDS Commission, Ghana Health Service, and Ghana AIDS Control program in planning and updating HIV/AIDS policies in Ghana.

Many health and social benefits of ART adherence have been reported for those who have consistently adhered to ART regimen; including viral suppression and reduced risk of infecting others, improved quality of life, and reduction in AIDS-related deaths. There seems to be a consensus in the literature that ART adherence has greater health benefits for PHLIV. For instance, the WHO reported that 67% of all those estimated to be living with HIV globally were receiving ART out of which 59% achieved suppression of the HIV with no risk of infecting others (UNAIDS, 2020; World Health Organization, 2021). The Ghana AIDS Commission and Lokpo et al. have also reported 68% and 61.6% suppression among different PLHIV groups in Ghana who have sustained ART adherence (Ghana AIDS Commission, 2019; Lokpo et al., 2020). This study was not a clinical one and so viral suppression and CD4+ count were not measured to determine the health outcomes for the participants. However, self-reported health status and wellbeing were assessed whereby 90% of the participants reported being happy with their overall health and personal wellbeing. Specifically, 94%, 91%, 83%, and 75% of the participants rated their nutritional status, energy level, sleep behavior, and ability to work, respectively, significantly improved while on ART. The findings of improvement in personal wellbeing among PHLIV on ART are corroborated by the findings of other studies that show that data from various sources show improved quality of life especially when ART is initiated early such as reported in this study (Ford et al., 2018; Lifson et al., 2017). The risk of early death due to HIV-related causes has also been found to be significantly reduced with early initiation and adherence to ART (Mangal et al., 2019). The findings of improvement in physical, economic, and general wellbeing are also consistent with findings from similar studies. For instance, in a study of perceptions of the benefits of ART among PLHIV in Cote d’Ivoire, Brazil, and Ethiopia, researchers found that participants adhered to ART regimen because they perceived ART to reduce the risk of transmission of HIV, minimize job losses, and improves economic productivity among other benefits (Abebe Weldsilase et al., 2018; Dutra et al., 2019; Hendrickson et al., 2019). These findings imply that the more PLHIV perceive that adhering to ARTs has direct personal health and economic benefits, the more likely they will be consistent in their adherence to ARTs.

Conclusion

The findings from this study showed a high level of ART adherence among PLHIV in the three localities covered and corroborates reports of high and consistent ART adherence by the Ghana AIDS Commission. We also found in this study that availability and accessibility to alternatives to the current ART regimen may be a strong motivator for adherence. Finally, our findings point that initiation and adherence to ART could lead to improvement in health and wellbeing of PLHIV as demonstrated by the self-report of participants. For public health practice, we advocate continuous effort to motivate PLHIV to adhere to their ART regimen through enhanced access to a regular supply of ART. Investment in LA-ART to ensure more effective, efficient, and stress-free adherence to ART for all PLHIV need to be expedited.

Data availability

The data from which the results and conclusions of this manuscript are drawn came from PLHIV who are considered a vulnerable population. As such, every effort was made during the collection, handling, and analysis to protect the personal information and health records of the participants. To continue to ensure that we adhere to the principles of data privacy and confidentiality, we have created a limited dataset which is de-identified and have deposited it in Zenodo with the DOI: 10.5281/zenodo.5914548. A request to the principal investigator or the Head of the Department of Family and Community Health is still required for full access and use of the data.