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African Journal of Biomedical Research
Ibadan Biomedical Communications Group
ISSN: 1119-5096
Vol. 11, Num. 2, 2008, pp. 221-224
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TOXICOSIS OF NON-STEROIDAL ANTI-INFLAMMATORY AGENTS IN RATS
African Journal of Biomedical Research, Vol. 11, No. 2, May, 2008, pp. 221-224
Short
communication
Default from
Anti-Retroviral Treatment Programme in Sagamu, Nigeria
Daniel
O.J, Oladapo OT, Ogundahunsi O.A, Fagbenro S, Ogun SA and Odusoga OA
Dept. of Chemical
Pathology, Obafemi Awolowo College
Health Sciences, Olabisi Onabanjo
University, Sagamu Ogun State
*Corresponding
Author
Received: July
2007
Accepted
(Revised): January
2008
Published: May
2008
Code Number: md08030
ABSTRACT
To
determine the rate and reason for default from antiretroviral treatment (ART)
program in Sagamu Nigeria, a cohort of 100 patients on ART was followed up for
12 months at the centre for special studies Olabisi Onabanjo University
Teaching Hospital Sagamu between July 2000 and September 2003. The patient
chart at the clinic were reviewed to collect the socio-demographic data of
patients who defaulted ART treatment (defined as PLWA who refused to come back
to collect ART medications for at least 6 months from the last visit). The
patients were traced to their place of residence with the address given on the
clinic chart. Where such patients were found at home, a reason for default from
treatment was inquired from them. For those who were not met at home proxy
interviewees such as a neighbour or a family member were asked if they were
available. Of the 100 patients who had enrolled in the ART treatment programme
during the study period, 36% of the study population defaulted treatment, 18%
had died while 46% were alive and well. Major reasons for default includes:
opting for spiritual/faith/alternative healing ( 8%), lost of interest in the
programme/financial (7%), moved to home town of origin (6%), changed address
(5%), untraceable home address or name (5%), side effects of ART (2%),
widowhood rites (1%). Two individuals were not met at home after repeated
visits by the Community health extension workers. About a third of PLWA
defaulted from treatment. The major reasons for default were psychosocial
factors unrelated to the treatment regimen. Ensuring adherence to therapy in
communities must take into consideration the psychosocial and cultural
practices and norms of the people to avert the emergence and transmission of
drug-resistant strains.
Key Words: HAART,
Defaulters, factors, psychosocial
INTRODUCTION
Over
40 million people have been infected with the human immune deficiency virus
(HIV) since it was first described over two decades ago. Africa alone accounts
for 70% of the infection with two-third of these living in sub-Saharan Africa
(UNAIDS/WHO, 2005). The first reported case in Nigerian was in 1986 and ever
since there has been a steady increase in the incidence of HIV infection in
Nigeria. With the 5% National HIV sero-prevalence rate, Nigeria is in a state
of generalized epidemic involving all geographical areas of the country (FMOH,
Nigeria, 1997).
Until
recently the hope of survival for HIV infected persons has been very bleak
especially in developing countries where there has been limited access to
antiretroviral treatment. The best offered care in most developing countries
before now has been treatment of opportunistic infections and in some instances
palliative care. With the current global initiative which brought to focus the
inequity in access to care between developing and developed countries, there
has been increasing resources to enable developing countries to have access to
anti-retroviral treatment (ART) especially with the 3 by 5 programme of the
World Health Organization (WHO, 2003). Anti-retroviral treatment has been shown
to improve the quality of life and has led to the reduction in morbidity and
mortality comparable to observations made in developed countries (Daquin 2003).
A
critical issue however to the success of ART is adherence to treatment regime.
.Adherence is a complex dynamic behaviour influenced by several factors.
Non-adherence to ART will lead to the development of drug resistance virus and
ultimately drug failure (Romano et al 2002). Adherence therefore remains
a public health concern, which needs to be addressed so that the maximum
benefit from ART can be obtained. Thus this study was embarked upon to assess
the pattern and reasons for default from ART treatment in Sagamu.
MATERIALS
AND METHODS
A cohort of 100 HIV
positive patients attending the Centre for Special Studies (CSS) specialist
clinic located at Olabisi Onabanjo Teaching Hospital Sagamu, Ogun State
Nigeria. All HIV positive receiving ART at the centre were enrolled into the
study and followed up for one year.
Study
Area and ART Control Programme
The
study was carried out in Sagamu Local Government area, Ogun State, Nigeria. The
town is a semi-urban area with an estimated population of 200,000 people. It is
located midway about 50km northward from Lagos and southward from Ibadan.
One
hundred and one patients were recruited into the drug program between June 2000
and September 2003.One patient was a rape case who had one month post-exposure
prophylaxis (PEP) treatment. The remaining hundred patients were selected
depending on the world health organisation (WHO) guidelines for initiating
treatment. The antiretroviral medication was supplied by the Starfish project,
Centre for Special Studies New York City (NYC). All combination antiretroviral
drugs were selected by the CSS Sagamu clinicians after consultations with the
clinicians at the CSS-NYC before commencement of therapy. Each patient was
followed up as outpatients on a monthly appointment. If for any reason a
patient is admitted in the hospital, a community health extension worker (CHEW)
from the CSS-Nigeria team administers the ART drugs to the patients in the
wards. The CHEW followed up patients who miss their monthly appointment to know
the reasons why they missed appointment.
Patients who default from treatment were defined as those who had failed to
collect medication for more than 6 consecutive months after the date of the
last attendance during the course of treatment. Information was collected with
the aid of a proformas designed for the study. Data was analyzed using
standard statistical procedures including the use of Epi 6 statistical soft
ware.
RESULTS
A
total of 100 HIV positive patients attending the CSS clinic were enrolled into
the study. There were 43 men and 57 women with male: female ratio of 1:1.3. The
patients were aged between 16-58 years. The mean age of patients in this study
was 35.7±11.4.The mean age of men was significantly higher than for women
(39.2±11.1 vs 33.1±11.1; p =0.007). Heterosexual route was identified as
the major route of acquisition of HIV 96%, while 4% was plausibly through
blood transfusion .There was no history of men who have sex with men or
intravenous drug use. Majority of the respondents were currently married 60%,
Christians 80%, from Yoruba ethic group 84% and secondary school education 45%.
(Table I).
Table 1: Socio-Demographic
Characteristics of Patients on ART In Sagamu.
CHARACTERISTIC |
PERCENT (%) |
AGE
15-24
25-34
35-44
45-54
>55
SEX
Male
Female
MARITAL STATUS
Single
Married
Separated
Divorced
Widowed
EDUCATIONAL STATUS
No
formal education
Primary
education
Secondary
education
Post-secondary
education
Classification of HIV patients
HIV
1
HIV
2
HIV1&2
|
12
36
29
17
6
43
57
18
60
4
9
9
10
33
45
11
92
2
6
|
Thirty-six
respondents had defaulted treatment during the follow up period, 18 had died
while 46 were still alive and well after one year of follow up (Table II).
Among
the 36 individuals who had defaulted ART treatment, the main reasons for
default were: opted for spiritual/faith/alternative healing (8%), lost of
interest in the programme (7%), moved to home town of origin (6%), changed
address (5%), untraceable home address or name (5%), side effects of ART (2%),
widowhood rites (1%). Two individuals were not met at home after repeated
visits by the Community health extension workers.
Table 2 Treatment Outcomes of
patients receiving antiretroviral therapy
Outcomes |
Percentages |
Defaulted |
36 |
Dead |
18 |
Still on/Alive and well |
46 |
Total |
100 |
DISCUSSION
The
study reveals that about a third of the study population had defaulted
treatment during the 24 months of follow up. The rate of default is high
considering the grave consequences of treatment failure and the development of
drug resistant strain that will require second line treatment which are
difficult and expensive to manage. The study highlights that both biomedical
and social factors are important in issues of adherence to treatment in
developing countries.
Stigma
and rejection are daily issues facing people infected with HIV/AIDS especially
in developing countries. The issue of stigma has been a barrier to people
living with AIDS disclosing their status and getting access to available
support and care services. This may be responsible for patients giving wrong
address or changing their address and relocating to a new location where they
are not known. Furthermore family members relocated some of the patients to
avoid suspicion from neighbours and friends about the status of their kin. The
effort aimed at challenging stigma and discrimination can lead to improvement
in how PLWHA take care of their health and access available care.
Personality
trait, depression and emotional adjustment to the HIV infections have been
observed as other possible reasons why patients are non-adherent to
anti-retroviral drug use, thus it is not surprising to observe patients loosing
interest in the treatment programme which could be due to several factors which
may be intrinsic or extrinsic. Therefore, intensifying counselling of patients
before initiating and during treatment is of utmost importance so that PLWA can
adjust both psychologically and emotionally to the disease.
Other
factors identified such as abandoning treatment to seek spiritual/faith healing
especially when they feel better on the drugs is also worrisome. The
unverifiable claim especially on the media by spiritualist and traditional
medicine practitioners of an instant cure for HIV infection contributed a great
deal to patients abandoning treatment. The government has a role in regulating
the misinformation and misconception about HIV that is being propagated in the
media. Also traditional and spiritual leaders need to be involved in the fight
against HIVAIDS by proper training as they can be used as change agents for
positive action against HIV/AIDS in our community.
In
the African setting particularly when a member of the family is ill, major
decisions that affect the patients are taken by the immediate and extended
family. It was observed that family members took some patients to their town of
origin, to forestall the huge expenses that will be incurred if patients should
die far away from their home town. It was observed that most of the family
members were not aware of the HIV status of their wards nor were they aware of
the type of medications being taken. PLWA must be encouraged to disclose their
status to family members who can provide treatment and psychological support.
Another
factor responsible for default was staying away to perform widowhood rites
which were practised by indigents in this community. Some of the women had lost
their husbands to HIV/AIDS and were required by the local custom to mourn the
dead for a period of 3 months or more. After this period some of the women are
married out to close family members many of whom are not aware of the HIV
status of these women. This has considerable implication for continued transmission
of drug- resistant strain of HIV infection in the community.
It
must however be noted that many of the patients enrolled into the program were
not residing in the town. The cost of transportation and other service charge
including paying for medications for the management of opportunistic infections
may have contributed to default from treatment. The decentralisation or ART
programme using existing primary health care structure may need to be
considered in bringing ART services closer to the people. Other services such
as treatment of opportunistic infections should be provided free to PLWA.
In
conclusion, the introduction of anti-retroviral treatment into drug naïve
communities needs to take the social and cultural factors into consideration to
prevent the emergence and transmission of drug-resistant HIV strain in the
community. Effectively addressing the issues of stigma and discrimination,
intensifying counselling, decentralisation of ART services and providing free
treatment for opportunistic infections will go a long way in ensuring adherence
of patients to ART.
REFERENCES
- Daquin TT (2003) Primary HIV-1 ARV resistance observatory in Cote dIvoir (ANRS Stydy)
13th ICASA, Nairobi, Abstract 665186, 2003
- Federal Ministry of Health Nigeria. (1997). National AIDS/STD control programme. Report of
1995/1996 HIV Sentinel Sero-Surveillance Rate In Nigeria
- Romano L, Venturi G, Vivarelli A, Galli L, Zazzi M,
(2002) Detection of a drug-resistant
human Immunodeficiency virus variant in a newly infected heterosexual couple.
Clinical Infectious Diseases 1 volume :34 pg 116-117
- UNAIDS/WHO (2005): AIDS Epidemic Update: December 2005
- WHO (2003) Treating three million by 2005: Making it happen, WHO strategy. Geneva: World
Health Organization.
Copyright 2008 - Ibadan Biomedical Communications Group
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