Barriers to Antiretroviral Adherence for Patients Living With HIV Infection and AIDS in Botswana

Botswana has the highest estimated HIV prevalence in the world. According to the 2002 UNAIDS update, more than 330,000 people of its 1.5 million population have HIV, and there were roughly 26,000 deaths from AIDS in 2001. The estimated rate of infection among people ages 15-49 is 36 percent.

One of the biggest challenges to HIV/AIDS care worldwide is lack of adherence to highly active antiretroviral regimens. To improve treatment delivery in Botswana, the authors conducted a cross-sectional study of the social, cultural, and structural determinants of treatment adherence. They interviewed 109 patients and 60 health care providers in three private clinics between January and July 2000. At the time, those clinics served almost all patients receiving ARV therapy in Botswana.

The researchers conducted face-to-face interviews to identify missed doses over a one-year period. They defined adherence as taking 95 percent of prescribed doses over the previous year. They also interviewed and distributed questionnaires to 60 health care providers who worked closely with patients on HAART.

An equal number of male and female patients participated in the study, and patients clustered in the 30- to 50-year age range. Fifty-three percent of participants were married or cohabiting. Forty-six percent had higher education -- many having taken brief training courses after secondary school -- and 37 percent had completed at least three years of secondary school. Participants came from a wide range of occupations. Most were well informed about HIV prevention and transmission.

Fifty-four percent of patients self-reported treatment adherence, while 56 percent were adherent by provider assessment. Observed agreement between patients and providers was 68 percent, "only modestly higher than the rate of agreement expected from chance alone," according to the study.

The investigators found that principal barriers to adherence included financial constraints (44 percent), stigma (15 percent), travel/migration (10 percent) and side effects (9 percent). They conducted logistic regression and predicted that if cost were removed as a barrier, adherence could improve to 74 percent. "This is very encouraging in Botswana," they wrote, "where there is increasing access to ARVs in the public sector. (As of April 14, 2003, >4,600 patients had received ARV therapy as part of an HIV treatment program involving 4 sites in Botswana.) Other initiatives planned by the Botswana government may further improve adherence, including improvements in the distribution of ARVs, increased availability of clinical and laboratory monitoring, and strengthened health infrastructures for delivering care."

The study found that gaps in treatment occurred due to financial difficulties, but that patients were adherent when medications were available. The finding bolsters the authors' conclusion that "patients in Botswana will achieve much higher adherence rates if structural and economic treatment barriers are minimized."

"Adherence rates in Botswana appear to be comparable with those in many developed countries, despite the fact that patients in Botswana face large structural and economic barriers to treatment," the investigators concluded. "The cost of ARVs was the most significant treatment barrier in this study. The pattern of nonadherence in Botswana - characterized by large gaps in treatment rather than day-to-day nonadherence - reflects the lack of consistent access to affordable and efficacious medication regimens. Expanded access to subsidized ARV therapy should improve adherence and, consequently, treatment outcomes for patients receiving therapy in resource-poor settings."

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