CHAPTER ONE

INTRODUCTION

1 .1 Background to the Study

Antiretroviral therapy (ART) has led to substantial increase in life expectancy and quality of life for HIV-infected persons, (UNAIDs) 2012 and reduces transmission of the virus. Cohen MS, Chen YQ Mc Cauley M et al. As a result, treatment guidelines now recommend ART for all HIV-infected individuals.Thompson M.A et al 2012. While ART has become more convenient, HIV infection still requires lifelong treatment. As HIV-infected individuals experience life expectancies that approach those without HIV, co-morbid conditions, including those associated with aging, become increasingly prevalent. Wohl D, Gallant JE, Western CW, Hasse B, et al 2011.Consequently, clients with HIV are likely to be prescribed a number of different medications both for HIV-related and -unrelated indications. Such polypharmacy risks drug interactions and overlapping toxicities, can be costly, and as medication complexity increases, may affect treatment adherence and virologic suppression, Onen N.F, Nachega JB et al.

Estimates of medication burden among persons living with HIV infection vary. Studies conducted between 1988 and 2010 examining cohorts in Switzerland and Canada, countries with centralized healthcare systems, found a relatively high medication burden among HIV-infected persons, compared to those without HIV, especially among older clients Hasse B, Krentz HB et al, 2011.However, less is known about the medication burden and daily pill count for HIV-infected persons, where there is a greater diversity in client populations and less uniform access to HIV care and medication.

HIV is a chronic lifelong illness with no known cure, and therefore people living with HIV and AIDS (PLWHA) have to befollowedup medicallyfortherest of their lives SG Deeks et al. (2013). The core component of the treatment and care of PLWHA is the provision of antiretroviral therapy (ART). In 2003, HIV was declared a global health emergency, and so governments, international agencies and funding bodies began to implement plans to increase ART uptake and coverage in developing countries WHO(2021). About 4 million of the 9.5 million people in need of ART in low and middle income countries were receiving treatment by the end of 2008 WHO and UNICEF (2009). Starting treatment in patients with very low CD4 count imposes unnecessary morbidity and mortality while starting ART early, when opportunistic infections are still absent, gives a good prognosis Ying et al. (2016).HIV/AIDS infection has become a pandemic, with severe consequences for humanity, affecting the lives of 36.9 million people Pena et al. (2021). Initially, the epidemic affected mainly men, yet current data shows that 57% of all those with HIV are women T.Girum et al. (2018). An alarmingly high proportion of HIV-infected individuals present late for care in developing countries like Sub-Saharan Africa, South-East Asia, and South America due to limited health care access and health WHO (2021) Despite the use of ART, numerous reports worldwide indicate failure of therapy due to lack of potency of combinations, insufficient drug adherence and transmission of drug resistant virus Chen et al. (2017).Drug resistance is a significant cause of therapy failure and may be a consequence of the other factors such as poor adherence WHO (2021).Adherence (ADH) to antiretroviral therapy (ART) acquires immense importance due to its impact on the immune system, since a sub-optimal adherence leads to therapeutic failure and an increase in morbidity and mortality in those with HIV Pena et al. (2021).There are, therefore, numerous studies which raise the need to explore and consider the social contexts of those undergoing ART in order to identify any required adaptations and favor effective adherence. In this sense, interventions must be designed and planned such that they might be adapted to the needs of specific subgroups, taking into account sociocultural aspects and available support and applying solutions to specific gender-based vulnerabilities in terms of the transmission and development of the disease Igulot et al (2022).

Adolescence is the period between 14 and 25 years of age with about one-fifth of the world’s population belonging to this age group. Adolescence is a period of dynamicchangerepresentingthe transition from childhood to adulthood Backes et al. (2019).During this stage, rapid changes in physical, emotional, cognitive and social characteristics take place. In many resource-poor settings, adolescent’s arenow the emerging group of HIV-infected population as survival of children with parentally acquired HIV infection into adolescence is increasingly being documented. In addition to the prenatally acquired infection, adolescents and young adults are vulnerable to acquiring HIV through sexual route. 82% of the estimated 2.1 million adolescents aged 10-24years living with HIV by the end of 2012 were in sub-Saharan Africa Firdu et al. (2017).Emphasis should be placed on family as one of the most important supportive elements as well as on eliminating conflicts generated by discriminatory processes such as social exclusion and the marginalization of people living with HIV/AIDS in the workplace, school and social environments or the increase in violence towards women, all of which highlights the need for research to approach this phenomenon in a holistic and exhaustive manner.

Globally default rates vary from 32.7% in America, 1 2.1 % in Europe to 39.4 to 79.4% in Africa Chirambo et al. (2019). Non-adherence to treatment reduces the immunological benefits of ARVs which predisposes clients to opportunistic infections, increases both the risk of drug resistance and HIV transmission. Patient level factors that contribute to defaulting from ART include forgetfulness fatigue, hopelessness, and absence of symptoms and severity of the illness. Furthermore, lack of support from a partner negative perceptions towards ART medication, pre-occupation and absence from home due to employment compromises adherence to ARVs. Stigma and discrimination coupled with familypressure, regular changes of residence and religious beliefs influence defaulting from ART. Therefore, the main objective proposed by the present study is to determine the factors influencing adherence to ARVs amongst adolescents in Bamenda Nkwen District Hospital.

1 .2 Problem Statement

The adherence to ARVs amongst adolescents such as knowledge happens to be one of the major reasons for adherence problems which bring about a misconception of the myths and facts surrounding HIV/AIDs. There also exist factors such as low self-esteem, difficulty for most adolescents to accept their status, peer pressure from friends, lack of support from family and society, pill burden, attitude towards status awareness, stigma and discrimination, including religious beliefs. These factors have contributed to cause most adolescents to find it difficult to take their ARV medication which as statistics indicates, have led to school dropout due to poor health and death due to high viral load and AIDs associated with Opportunistic infections.

In the course of interaction with some adolescents at the Nkwen District Hospital Bamenda during internship, the researcher realized adherence to ARVs is linked to the factors mention above and stigmatization being a situation which is almost causing them to give up in life. This therefore prompted this study. The facts and experiences mentioned by the researcher at the adolescent treatment center of the Nkwen District Hospital Bamenda (UPEC Unit) are the reasons for this study.

Despite the sensitization, free screening/services and free medications (antiretroviral therapy) for treatment, why is there still adherence problems?

1.3 RESEARCH QUESTIONS

1. What are the factors influencing adherence to ARV treatment amongst adolescents at the Nkwen District Hospital?
2. How will status awareness influence adherence to ARV treatment amongst adolescents at Nkwen District Hospital?
3. How does pill burden and attitude towards ARV treatment influence adherence amongst adolescents at Nkwen District Hospital

1 .4. OBJECTIVES OF THE STUDY

1 .4.1 Main Objective

To determine the factors influencing adherence to ARVs amongst adolescents at the Nkwen District Hospital.

1.4.2. Specific Objectives

In carrying out this research, the researcher bears in mind the following specific objectives;

1. To assess the level of awareness of Antiretroviral therapy (ARVs)
2. To assess the effect of pill burden on the adherence to ARVs
3. To assess the influence of status awareness on adherence to ARVs amongst adolescents at the Nkwen District hospital