ABSTRACT

Adherence to antiretroviral therapy (ART) is important for preventing the progression of human immunodeficiency virus (HIV), improving CD4 cell counts, reducing viral activity, and enhancing the quality of life of people living with HIV. However, maintaining consistent adherence among adolescents and young adults (AYA) remains difficult due to several factors, including long distances to treatment centres, increased CD4 counts that may create a false sense of security and reduce commitment to treatment, and the influence of the environment in which patients live. This study adopted a quantitative, retrospective, correlational, cross-sectional research design and was guided by the Transtheoretical Model to examine how selected predictive factors influenced ART adherence among the study population.

Secondary data were obtained from patients' medical records at the Federal Medical Centre (FMC), Owerri, Imo State, Nigeria. Descriptive statistics were used for univariate analysis. The study involved 656 patients aged between 15 and 24 years. Independent-samples t-tests revealed a statistically significant difference in adherence rates between AYA living in rural areas (94%) and those residing in urban areas (89%), t(424) = -3.280, p = .001. A statistically significant difference was also observed between patients who lived within 50 kilometres of the hospital and those who lived beyond 50 kilometres, t(509) = -2.37, p = .018. In addition, a statistically significant correlation was identified between ART adherence and CD4 counts below 500 cells/mm³, R = .214, p = .003.

The findings of this research provide useful information for HIV implementing partners and relevant healthcare professionals in Nigeria. The results can support the development of appropriate interventions and strategies aimed at improving adherence to antiretroviral treatment among adolescents and young adults living with HIV.

ADHERENCE TO ANTIRETROVIRAL MEDICINES AMONG ADOLESCENTS AND YOUNG ADULTS IN IMO STATE, NIGERIA

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

According to the World Development Indicators, Nigeria's per capita Gross Domestic Product (GDP) was approximately $2,980 in 2013, placing the country at the 131st position globally (Ajakaiye, Jerome, Nabena, & Alabi A. Olufunke, 2015). Nigeria is classified among low- and middle-income countries. The first officially reported case of HIV in Nigeria occurred in Lagos State in 1986. Following this initial diagnosis, the number of reported cases increased considerably, from two cases in 1987 to 33 in 1988 and approximately 9,715 by the year 2000. During the early period of the HIV outbreak, some Nigerians questioned the existence of the disease and regarded it as a possible strategy by Western countries to discourage sexual activity and restrict the perceived population growth of African countries. Some individuals even interpreted AIDS as an abbreviation for an alleged "American idea of discouraging sex" (Zeleza & Kakoma, 2003).

Before the introduction of the first sentinel survey in Nigeria, HIV prevalence continued to increase. Available statistics indicated that the prevalence rate rose from 1.8% in 1991 to 3.8% in 1993, 5.4% in 1999, and 5.8% in 2001 (National Agency for the Control of AIDS [NACA], 2015). In 2011, Nigeria had an estimated population of 180 million people, with an HIV prevalence rate of 3.3% (Bashorun et al., 2014). By 2015, the country's projected population had increased to 185 million, comprising approximately 49% females and 51% males, while the reported HIV prevalence rate was 3.1% (PEPFAR, 2016). Furthermore, the 2012 National HIV/AIDS and Reproductive Health Survey (NARHS), which covered a broader population than the antenatal clinic sentinel survey, recorded an HIV prevalence rate of 3.4% (NACA, 2015).

Nigeria is divided into six geopolitical zones: South-South, South-East, South-West, North-East, North-West, and North-Central (The Federal Republic of Nigeria, 1999). HIV prevalence is not evenly distributed across these geographical regions. Although the southern part of the country initially recorded relatively higher prevalence rates, the situation gradually changed, with parts of the Middle Belt, particularly areas within the North-East and North-Central regions, experiencing increasing prevalence (Bashorun et al., 2014). In 2012, the South-South geopolitical zone recorded the highest HIV prevalence rate of 5.5%, while the South-East had the lowest rate of 1.8%.

When compared with the national HIV prevalence rate of 3.0% in 2012, only the South-West and South-East recorded rates below the national figure, with prevalence rates of 2.8% and 1.8%, respectively, as presented in Figure 1 (NACA, 2015). During the same year, four states recorded HIV prevalence rates above 8%. These states were Rivers State, with 15.2%; Taraba State, with 10.5%; Kaduna State, with 9.2%; and Nasarawa State, with 8.1% (NACA, 2015).

Differences in HIV prevalence have also been observed between rural and urban communities, with urban settlements recording higher prevalence rates than rural areas (Mahy et al., 2014). Gender differences have similarly been reported, as HIV prevalence among females was higher than among males. In 2007, the prevalence rate was 4.0% among females and 3.2% among males. By 2012, the rate among females had declined to 3.5%, while the male rate stood at 3.3% (NACA, 2015). The age group of 35–39 years recorded the highest HIV prevalence in 2012, at 4.4%. However, people aged 15–24 years accounted for approximately 42% of new HIV infections worldwide (Kharsany & Karim, 2016; Wang et al., 2016).

In Nigeria, the number of new HIV infections reached its highest recorded level in 2009, with 278,061 cases. Thereafter, the number declined to 262,238 in 2011, 239,155 in 2013, and 227,518 in 2014 (NACA, 2015). Table 1 presents the pattern of HIV incidence in the country between 2009 and 2014. Despite this decline, Nigeria accounted for more than 30% of new HIV infections among children globally in 2015 (President's Emergency Plan for AIDS Relief [PEPFAR], 2016).

The exact number of HIV-related deaths in Nigeria during the early years of the epidemic is difficult to establish because proper records were not maintained at the initial stage of the outbreak. Nevertheless, available statistics indicated that the number of deaths declined from more than 210,000 in 2013 to slightly above 174,000 in 2014 (PEPFAR, 2016). The National Agency for the Control of AIDS, the government institution responsible for coordinating HIV control activities in Nigeria, estimated that approximately 180,000 deaths in 2015 were associated with HIV-related causes (NACA, 2015). Across Africa, an estimated 790,000 people died from HIV-related causes in 2014. This represented a decline compared with the estimated 1.2 million deaths recorded in 2009 and 1.5 million in 2004 (Granich et al., 2015).

HIV has also contributed to maternal and child health challenges. HIV-related maternal deaths have increasingly become an important cause of pregnancy-associated mortality (Onakewhor et al., 2011). The disease is also among five preventable conditions responsible for more than 70% of the leading causes of approximately one million annual deaths among children under five years worldwide. The other conditions include malaria, diarrhoea, measles, and pneumonia (NACA, 2015). In addition, an estimated 1.7 million children were orphaned by HIV in 2013 (PEPFAR, 2016).

The major routes of HIV transmission differ across geographical regions. In Eastern Europe, South America, and Central Asia, transmission has been associated with sexual contact, drug use, and sexual relationships between men (Shaw & Hunter, 2012). In Nigeria, several studies conducted over the past two decades have examined the major routes through which the virus spreads. Research has identified sexual contact, including transmission among men who have sex with men (MSM), intravenous drug use, and sexual relationships involving commercial sex workers as important routes of transmission (The Joint United Nations Programme on HIV and AIDS [UNAIDS], 2010). Other routes include infected blood transfusions, blood products, and mother-to-child transmission (Shubber, Mishra, Vesga, & Boily, 2014; UNAIDS, 2010).

The distribution of HIV among populations considered to be at increased risk has also changed over time. These groups include female sex workers, men who have sex with men, long-distance travellers, and injecting drug users (IDUs) (NACA, 2015). Reported prevalence rates include 27.4% among brothel-based female sex workers, 21.7% among female sex workers who operate outside brothels, and 17.2% among men who have sex with men (NACA, 2015). Although sex workers were previously considered the population with the highest HIV prevalence, available evidence indicates a changing pattern. For example, HIV prevalence among MSM increased from 13.5% in 2007 to 23% in 2015 (Entonu & Agwale, 2007).

1.2 Problem Statement

Adherence refers to the degree to which a patient's behaviour in relation to medical treatment corresponds with the treatment plan agreed upon by the patient and the healthcare provider (Bello, 2011). Poor adherence to antiretroviral therapy can result in treatment failure, while consistent adherence is necessary for achieving important treatment outcomes, including improved quality of life and increased chances of survival (Akahara, Nwolisa, Odinaka, & Okolo, 2017). In many countries where HIV is widespread, including Nigeria, patients are required to obtain their antiretroviral medicines from designated treatment centres according to scheduled appointments (Mori & Owenya, 2014).

Consequently, patients are expected to attend their clinic appointments regularly to obtain prescription refills and maintain uninterrupted access to their medication. In Nigeria and other countries in sub-Saharan Africa, antiretroviral medicines are provided free of charge through the support of the United States government and other international organisations (OGAC, 2014). Despite this arrangement, many patients do not achieve complete adherence to their scheduled pharmacy refills. Pharmacy refill records are commonly used as an indirect measure of adherence to antiretroviral treatment (Sangeda et al., 2014a, 2014b).

Several factors have been identified as obstacles to consistent ART adherence. These include transportation expenses, forgetfulness, adverse reactions to antiretroviral medicines, and the stigma associated with HIV infection (Arnet, Walter, & Hersberger, 2013; Groh et al., 2011; Hatah, Lim, Ali, Mohamed Shah, & Islahudin, 2015). Although antiretroviral medicines play a vital role in preserving the lives and health of people living with HIV, maintaining consistent adherence remains a major challenge, particularly among adolescents and young adults (Ankrah et al., 2016).

Globally, approximately 83% of adolescents living with HIV are found in sub-Saharan Africa. However, treatment outcomes among this population are generally poorer than those recorded among adults (Ankrah et al., 2016; Maskew et al., 2016). Individuals receiving antiretroviral medicines are expected to maintain good adherence in order to achieve and sustain positive health outcomes (Heestermans, Browne, Aitken, Vervoort, & Klipstein-Grobusch, 2016). Nevertheless, studies have shown that even patients who previously maintained good adherence can experience a decline in their treatment commitment (Ngarina, Popenoe, Kilewo, Biberfeld, & Ekstrom, 2013). Factors contributing to poor adherence among adolescents and young adults include financial difficulties, adverse drug reactions, forgetfulness, and HIV-related stigma (Gare et al., 2015; Shigdel et al., 2014).

Although several studies have investigated factors associated with poor ART adherence, there has been limited research in developing countries comparing adherence among patients living in rural and urban environments. A study conducted in Uganda found that patients receiving treatment from rural health facilities experienced poor adherence when measured through hospital prescription refill records (Nabukeera-Barungi et al., 2015). This creates a need to further examine whether the residential environment influences adherence among patients who live in rural communities but obtain treatment from health facilities located in distant urban areas.

Distance from a treatment facility has also been identified by patients as a possible barrier to maintaining regular treatment appointments (Conley et al., 2012). However, there is limited evidence from studies that have used hospital records to examine the relationship between the actual distance patients travel to obtain treatment and their level of adherence.

Therefore, this study seeks to address these gaps by examining ART adherence among adolescents and young adults receiving treatment at the Federal Medical Centre, Owerri, Imo State. It specifically investigates whether adherence differs between patients living in rural and urban areas, whether distance from the treatment centre is associated with adherence, and whether CD4 cell counts are related to patients' adherence patterns.

1.3 Purpose of the Study

The main purpose of this research was to investigate differences in adherence to antiretroviral therapy between adolescents and young adults living in rural and urban communities. Since distance to treatment facilities has been identified as a potential barrier to adherence, the study also classified participants according to their distance from the treatment centre to examine its relationship with adherence. Furthermore, the research investigated the relationship between CD4 cell counts and adherence among patients.

Specifically, the quantitative study was designed to achieve the following objectives:

1. Examine differences in ART adherence among adolescents and young adults receiving antiretroviral medicines from the same treatment centre but residing in rural and urban communities.

2. Investigate the association between distance from the treatment centre and ART adherence among adolescents and young adults.

3. Determine the relationship between ART adherence and CD4 cell counts among adolescents and young adults who have attained CD4 counts above 500 cells/mm³.

1.4 Research Questions

The following research questions were developed to guide the study:

Research Question 1 (RQ1): What difference exists in ART adherence between adolescents and young adults who obtain antiretroviral medicines from the same treatment centre but live in rural and urban communities?

• Null Hypothesis (H₀1): There is no statistically significant difference in ART adherence between adolescents and young adults receiving antiretroviral medicines from the same treatment centre but residing in rural and urban communities.

• Alternative Hypothesis (Hₐ1): There is a statistically significant difference in ART adherence between adolescents and young adults receiving antiretroviral medicines from the same treatment centre but residing in rural and urban communities.

Research Question 2 (RQ2): What is the relationship between distance from the treatment centre and ART adherence among adolescents and young adults?

• Null Hypothesis (H₀2): There is no statistically significant association between distance from the treatment centre and ART adherence among adolescents and young adults.

• Alternative Hypothesis (Hₐ2): There is a statistically significant association between distance from the treatment centre and ART adherence among adolescents and young adults.

Research Question 3 (RQ3): What relationship exists between high CD4 cell counts (above 500 cells/mm³) and ART adherence among adolescents and young adults?

• Null Hypothesis (H₀3): There is no statistically significant relationship between high CD4 cell counts (above 500 cells/mm³) and ART adherence among adolescents and young adults.

• Alternative Hypothesis (Hₐ3): There is a statistically significant relationship between high CD4 cell counts (above 500 cells/mm³) and ART adherence among adolescents and young adults.

1.5 Definitions of Study Variables and Other Terms

The following terms are defined according to their use and relevance in this research:

Acquired Immunodeficiency Syndrome (AIDS): AIDS refers to a group of symptoms and health conditions that develop as a result of advanced HIV infection. It is a syndrome caused by the human immunodeficiency virus (Sharp & Hahn, 2011).

Adherence: This describes the extent to which a patient's actions and behaviour regarding medical treatment correspond with the treatment instructions and arrangements agreed upon with the healthcare provider (Bello, 2011).

Adolescent: An adolescent is generally described as an individual between the ages of 10 and 18 years. However, defining adolescence solely through age has attracted criticism because the transition into adulthood also involves biological, psychological, and social changes (Curtis, 2015).

CD4 Count: This refers to a laboratory measurement of the number of CD4 cells present in an individual's blood. CD4 cells, also known as T cells, are white blood cells that play an important role in protecting the body against infections. Although a CD4 count does not directly measure the amount of HIV in the body, it serves as an important indicator of immune-system function and the extent to which HIV has affected the body's immunity (Nwokedi, Ochicha, Mohammed, & Saddiq, 2007).

Distance to Treatment Centre: This refers to the physical distance between the antiretroviral treatment facility and the residential location of a study participant.

Geopolitical Zone: This refers to the geographical divisions created in Nigeria based on geographical and political considerations. These zones provide a framework for the distribution and sharing of economic, political, and educational resources across the country (Ibrahim & Ibrahim, 2014).

HIV Treatment Centre: This is a designated healthcare facility responsible for providing medical care, treatment, and other management services to individuals living with HIV/AIDS.

Human Immunodeficiency Virus (HIV): HIV is a virus transmitted through certain bodily fluids. It attacks the body's CD4 cells, weakening the immune system and potentially leading to AIDS if the infection progresses without effective treatment.

Mortality: Mortality refers to the occurrence or frequency of deaths within a particular population over a specified period.

Pharmacy Refill: This refers to the process through which a patient obtains additional supplies of prescribed medicines from a pharmacy or designated treatment facility.

Rural: In this study, rural refers to a settlement characterised as a village or hamlet rather than a town or city.

Self-Disclosure: This refers to the act of sharing personal information about oneself with another individual (Nöstlinger, Bakeera-Kitaka, Buyze, Loos, & Buvé, 2015).

Self-Report: This refers to information about a patient's condition, behaviour, or experiences as provided directly by the patient.

Serodiscordance: This term describes a situation in which two partners in a relationship have different HIV statuses, meaning that one partner is HIV-positive while the other is HIV-negative (Irungu et al., 2016).

Urban: This refers to a settlement classified as a town or city.

Young Adult: According to the definition adopted in the original study, a young adult is an individual between the ages of 12 and 24 years (Geiger & Castellino, 2011).

1.6 Scope and Delimitations

This research examined ART adherence among adolescents and young adults living with HIV in Nigeria who received antiretroviral treatment between 2011 and 2014. The study focused on differences in adherence in relation to participants' residential environment, distance from the treatment centre, and CD4 cell counts. Consistent adherence is a major requirement for the successful management of HIV because patients are expected to remain on antiretroviral medicines throughout their lives. Adolescents and young adults represent an important link between paediatric and adult HIV care. Therefore, poor adherence within this age group may create serious public health concerns.

Failure to maintain proper adherence can also encourage the development of HIV resistance to antiretroviral medicines. When the virus becomes resistant to a particular antiretroviral drug or treatment regimen, the available treatment options may become more limited. This can make the management of HIV more difficult and create additional public health challenges.

The study was limited to secondary data obtained from the medical records of adolescents and young adults living with HIV/AIDS and enrolled in antiretroviral treatment at the Federal Medical Centre, Owerri, Imo State, Nigeria. A quantitative, retrospective, correlational, cross-sectional research design was employed to analyse the available information (Gordis, 2009).

This research design is appropriate when the purpose of a study is to examine relationships between variables without attempting to establish direct cause-and-effect relationships (Campbell & Stanley, 1963; C. Frankfort-Nachmias & Nachmias, 2015; Mann, 2003). Accordingly, the study does not claim that the identified factors directly caused changes in adherence. Rather, it examines the associations between adherence rates and selected predictive variables, namely CD4 cell counts, distance from the antiretroviral treatment centre, and the type of residential environment among adolescents and young adults.

The use of a cross-sectional approach was also appropriate because the secondary information used for the analysis was obtained from existing patient records within the specified study period. One advantage of this research design is that it allows researchers to examine the distribution of health conditions and estimate measures such as odds ratios, absolute risks, and relative risks based on prevalence data (Thompson, Myers, & Kriebel, 1998).

1.7 Significance of the Study

Adherence to antiretroviral therapy contributes significantly to improved quality of life, reduced hospital admissions, lower healthcare expenses, and decreased HIV-related illness and death (Falang et al., 2012). When adherence falls below 85%, it can become a serious public health concern because inadequate medication use may encourage the development of resistance to the limited antiretroviral treatment regimens available (Kadhiravan, 2013).

For example, when a patient develops resistance to first-line antiretroviral medicines, the remaining treatment options may be restricted to second-line regimens and salvage therapy. This can make treatment more complicated and expensive (Masikini & Mpondo, 2015). Poor adherence may also increase the overall cost of healthcare because of declining health conditions, more frequent hospital visits, higher transportation expenses, and the additional burden of taking alternative medicines. Furthermore, failure to adhere to prescribed treatment has been associated with unsuccessful treatment outcomes (Inzaule, Hamers, Kityo, Rinke De Wit, & Roura, 2016).

Adolescents and young adults represent an important population in global HIV prevention and treatment efforts. In 2012, approximately two-thirds of new HIV infections were recorded among individuals aged 15–24 years (Bekker & Hosek, 2015). Between 2002 and 2012, AIDS-related deaths declined by 30% across all age groups, except among adolescents and young adults, where mortality increased by 50% during the same period (Bekker et al., 2015).

The importance of this research lies in its examination of factors that have received limited attention in previous studies on ART adherence among adolescents and young adults. Although several researchers have investigated the challenges that prevent patients from adhering to treatment, comparatively little attention has been given to the influence of residential environments, particularly the differences between rural and urban settings.

The study also considers the role of distance from treatment facilities. If the findings show that distance is not significantly associated with adherence, this may provide useful evidence for reviewing existing treatment-support strategies and identifying other factors that require greater attention. On the other hand, if distance is found to be an important factor, the findings may support the development of interventions that make treatment services more accessible to patients who live far from healthcare facilities.

In addition, identifying factors that contribute to poor adherence can help healthcare professionals and HIV implementing partners develop appropriate interventions. Such interventions are important for supporting the global treatment targets established by UNAIDS, which aimed to achieve viral suppression among 90% of people living with HIV worldwide (UNAIDS, 2014). Achieving high levels of viral suppression is an important step towards reducing HIV transmission and working towards a generation free from HIV.