Master's Thesis, 2012
88 Pages, Grade: Excellent
Board of Examiners
Acronomys and Abbreviations
List of Tables
List of Figures
1.1 Background of the Study
1.2 Statement of the Problem
1.3 Objectives of the Study
1.3.1 General Objective
1.3.2 Specific Objectives
1.4 Research Questions
1.5 Significance of the Study
1.6 Limitations of the Study
1.7 Organization of the Study
2.1 Theoretical framework on Food Security
2.1.1 Definition of Food Security
2.1.2 Concept of food security
2.1.3 Dimensions of food security
2.1.4 Measurement of household food insecurity
2.2 Conceptual Framework of Household food insecurity HIV/AIDS and ARV adherence
2.3 Perspective on Adherence
2.4 Antiretroviral Therapy Adherence
2.5 Measuring Adherence to ARV
Materials and Methods
3.1 Overview of Methodology
3.2 Description of the Study Area
3.3 Study and Sample Design
3.4 Study Population
3.5 Sampling Methods
3.6 Sample size and sampling procedures
3.7 Inclusion and Exclusion Criteria
3.8 Study Variables
3.8.1 Dependent and Independent Variables
3.9 Data type and Sources
3.10 Data quality control
3.11 Instrument of Data Collection
3.12 Data Management and Analysis
3.13 Ethical Consideration
3.14 Operational Definitions
Results and Discussion
4.1. Quantitative Results
4.1.1 Socio-demographic and economic characteristics of study participants
4.1.2 Dietary Diversity,Meal Frequency and Household food insecurity situation of PLHIV
4.1.3 ART Adherence situation of study participants
4.1.4 Reasons for missing doses ARV regimen
4.2 Qualitative Results
4.2.1 Focus Group Discussions
4.2.2 In -depth Interviews
Conclusions and Recommendations
Annex:1 Consent Sheet
Annex 2 English version Questionnaire
Annex 3 Focus Group Disscusion (FGD) Guide
Annex 4: Guideline for In-depth Interview
Table: 2.1 Comparison of measurement of ARV adherence
Table 4.1 Socio-demographic and economic characteristics of study participants, Hawassa Ethiopia, 2012
Table 4.2 Dietary Diversity, Meal frequency and Household food insecurity situation of PLHIV, Hawassa, Ethiopia, 2012
Table 4.3 The relationship between income status of respondents and household food insecurity situation among PLHIV, Hawassa, Ethiopia, 2012
Table 4.4 Reasons for missing ART doses reported by PLHIV, Hawassa, Ethiopia, 2012
Table 4.5 Associations of variables with ARV adherence status of study participants, in biavariate and multivariate analysis, Hawassa, Ethiopia, 2012
Figure 2.1 Conceptual framework of the relationship between household food insecurity, malnutrition and ARV Adherence
Figure 4.1 The main food groups consumed by PLHIV households during the previous 24 hours
Figure 4.2 Distributions of respondents according to adherence to ART among PLHIV, Hawassa, Ethiopia, 2012
First and foremost, I would like to thank the Almighty God for giving me strength during my study. Then I sincerely thank my advisor, Ato Dejene Hailu for his invaluable professional guidance and advice during the course of study, without his guidance and constructive comments this study could not have been a success. My appreciations also go to coordinators of Tilla, Down of Hope Hawassa branch and Medhine Ethiopia PLHIV association for having permitted me to carry out this study in their respective associations. I am highly indebted to thank study participants for their kind cooperation to participate in the interview. I wish to express my deep sense of gratitude to Dr. Belachew Degife, Addis Ababa University, Medicine Faculty, for his tremendous encouragement and guidance on reviewing the documents and providing timely and instructive comments at every stage of the thesis process. My special thanks also go to Mr. Kidusabe Tseige, who willingly facilitates data collection and compilation for the study. Last but not least, I would like to express a sense of gratitude and love to my brothers and sisters for their moral and spiritual encouragement for my study.
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Background: ARV adherence is a strong predictor of biologic (virologic and immunologic) and clinical outcomes in HIV, including quality of life, HIV progression, hospitalizations, and death. Consistent adherence to antiretroviral therapy (ART) is the cornerstone of effective HIV treatment. This study explores the interrelationship between food insecurity and access and adherence to ARV treatment. Such studies will help inform policy maker in the study area on ways of improving or maintaining adherence to ARV and scale up the treatment level.
Objective: The main objective of the study is to assess the prevalence of ARV adherence and associated factors (with particular focus on household food insecurity) among urban PLHIV.
Method: PLHIV association based cross-sectional study was conducted from January, 2012 to May, 2012 in Hawassa city. Both quantitative and qualitative data were used to triangulate one with another. Adult PLWHA on ARV therapy for at least 3 months were the study participants. A purposive sampling method used to select the study participants. Bivariate and multivariate logistic regressions were computed to assess the factors associated with ARV therapy non- adherence among adult PLHIV in the study area.
Result: Data were collected using structured questionnaire with open and closed type questions where a total of 325 participants were interviewed. Two focus group discussions with 6- 8 members each were conducted. Key informant interviews for PLHIV association’s coordinator and healthcare providers at ART clinic were conducted. Data was presented using frequency tables and graphs. Data was analyzed using SPSS software version 16.0. Results show that that the prevalence of adherence to ART was 82.5 %( that is non –adherence level 17.5%), was sub-optimal(less than 95%).Both dietary diversity and meal frequency score were less than mean ( 48.6% and 60.6%) respectively. Based on household food insecurity access module (63.7%) were food in secured. Household food insecurity was associated with ART adherence. Factors significantly associated with non- adherence to ARV therapy were religious status, protestant and catholic (COR 3.74, 95% CI 1.43-9.78) and (COR 2.11, 95%CI 1.11-4.02) respectively; marital status, divorced (AOR 3.88(1.48-10.20). A significance relationship was also exist between level of education and adherence ARV therapies among study participants (read and write, COR 0.37, 95%CI 0.14-0.41 and Elementary level, AOR 0.43, 95%CI 0.22-0.85). The household food insecurity status of PLHIV on ARV therapy, specifically those moderately food insecure significantly associated with non-adherence to ARV therapy (AOR 2.40, 95%CI 1.04-5.54).From FGDs it was found that household food insecurity is one of the challenges for ART adherence.
Discussion: Study participants religious and marital status were significantly associated with non- adherence to ARV. Education level was significantly associated with adherence to ARV. The proxy indicator of household food insecurity showed that a significant number of PLHIV on ART consumed less than the mean the mean dietary diversity and meal frequency score in the study area. Household food insecurity was a serious problem among PLHIV on ART. Household food insecurity was significantly associated with ART adherence.
Conclusions and recommendations: Based on the findings, lack of food to take with medication is the main reason for those non-adherents. Food support as relief together with a sustainable income generating activities need to be included in ART scale-up program in the study area. To enhance ART adherence the study recommends to the government and other stakeholders to develop strategies to ensure food security in households with people living with HIV and AIDS. There is need for preparing and disseminating IEC material which focus on adherence to ARVs, stigma and disclosure to the community in general and PLHIV in particular. These materials should emphasize that PLHIV on ARVs need support to be fully adherent treatment.
Key words: Antiretroviral therapy (ART); ARV; HIV/AIDS; PLHIV
HIV, the virus that causes AIDS, “Acquired Immunodeficiency Syndrome,” has become one of the world’s most serious health and development challenges, since the first cases were reported in 1981: At the end of 2010, an estimated 34 million people were living with HIV globally, including 3.4 million children less than 15 years. The number of people newly infected in 2010 was 2.7 million. Almost all of those living with HIV (97%) reside in low and middle income countries, particularly in sub-Saharan Africa. Sub-Saharan Africa remained the most affected region in the global AIDS epidemic. This regions accounts more than two third (68%) of people living with HIV. Most children with HIV live in this region. Globally, the annual numbers of people newly infected with HIV continues to decline (Global HIV/AIDS Response progress report, 2011).
The introduction of antiretroviral (ARVs) or Highly Active Antiretroviral Therapy (HAART) drugs in 1996 transformed the treatment of HIV and AIDS by improving the quality of and also greatly prolong the lives of the many infected people in places where the drugs are available (UNAIDS, 2007)
At the beginning of the 21st century, very few people in the developing world had access to HIV treatment. This was in large part because of the very high prices of antiretroviral drugs (ARVs). However, in 2003, the World Health Organization (WHO) and launched the ambitious target of reaching 3 million people in low and middle-income countries with ARVs by 2005. It was not intended as a final objective, but as a stepping stone to universal access.
Though, the target was not attained until 2007, it was seen by some as succeeding in a number of ways. Treatment was vastly expanded overage tripling from 400,000 people in December 2003 to 1.3 million in December 2005 (WHO, 2006). Considering the relative success of the 3 by 5 target, the international community set another target in 2006 that aimed for universal access to HIV treatment, prevention and care by 2010.
However, by the time of WHO’s 2008 universal access report, the heads of UNAIDS, UNICEF and WHO conceded that most countries would not meet the 2010 targets of 80 percent of those in need receiving treatment. In 2011, the international community recommitted to the goal of universal access. This time, countries committed to achieving universal access by 2015.
The goal of universal access is also part of Millennium Development Goal (MDG) 6 which includes the goal of halting and beginning to reverse the spread of HIV/AIDS by 2015(UNAIDS 2011). According to the global HIV/AIDS response progress report 2011, access to antiretroviral therapy in low–and middle income countries increased from 400. 000 in2003 to 6.65 million in 2010(47% )coverage of people eligible to treatment, resulting in substantial declines in the number of people dying from AIDS related causes during the past decade.
The 2010 WHO recommendations on Antiretroviral therapy which reflect the clinical evidence that early initiation of ARV therapy(recommended at CD4 cells counts less than 350 mm3) significantly reduced morbidity and mortality and also has important preventive benefits. Coverage of pregnant women receiving the most effective antiretroviral regimens to prevent mother-to-child transmission of HIV (excluding single-dose nevirapine) is estimated at 48% in 2011. Access to ART among children has also risen significantly, although they have less access than adults. The number of children receiving antiretroviral therapy increased from 71, 500 at the end of 2005 to 456, 000 in 2010. Introducing ARVs therapy have averted 2.5 million death in low- and middle- income countries globally since 1995.Sub –sharan Africa accounts for the vast majority of the averted death: about 1.8 million death (UNAIDS/WHO, 2011).
Despite these successes, more than 60% of those in need of ART still have not received it. Adherence, side effects, viral drug resistance, stigma and cost are challenges to the implementation of safe and effective ART program (UNAIDS 2010).
The 2011 UN high level meeting, at its Political Declaration on HIV/AIDS, set ten targets and commitments which among others includes halving sexual transmission of HIV, ensuring that no children are born with HIV infection, increasing access to antiretroviral therapy to 15 million people and halving tuberculosis deaths in people living with HIV, by 2015(FDRE/MOH,2012)
Ethiopia is one of the hardest hit sub-Saharan African countries by the HIV pandemic. The first case of HIV in Ethiopia was reported in 1984. Since then, HIV/AIDS has become a major public health concern in the country, leading the Government of Ethiopia to declare a public health emergency in 2002. In 2007, the estimated adult HIV/AIDS prevalence was 2.1 percent (ibid).
Ethiopia is among the few sub-Saharan countries showing a decline of more than 25% in new HIV infections. Although the epidemic is currently stable; HIV/AIDS remains a major development challenge for Ethiopia. Poverty, food shortages, and other socio-economic factors amplify the impact of the epidemic (UNAIDS, 2010).
According to ANC surveillance results, HIV prevalence among pregnant women aged 15-24 declined from 5.6%in 2005, to 3.5% in 2007, and then to 2.6% in 2009; showing a declining HIV prevalence trend. DHS 2011 data had shown overall prevalence of 1.5 %( female 1.9% and male 1.0%) among the general population. The estimates show 789,900 people currently living with HIV/AIDS (607,700 adults and 182,200 children aged 0-14 years); and 952,700 AIDS orphans. Adult HIV prevalence in 2010 was estimated to be 2.4 %( urban 7.7% and rural 0.9%). Variations were also observed among administrative regions. According to the Ethiopian Demographic and Health Surveys HIV prevalence ranges from 1% in SNNP and 1.3% in Oromiya region to 6% in Addis Ababa and 7.9% in Gambella region (FDRE/MOH, 2012).
Key intervention have been in place as part of the national HIV prevention response includes HIV counseling and testing (HCT),prevention of mother to child transmission (PMTCT),infection prevention, post- exposure prophylaxis(PEP),sexually transmitted infections prevention and control, condom promotion and distribution and provision of anti-retroviral treatment. As was elsewhere, Ethiopia's initial response to the epidemic had primary focus on prevention, with little attention to treatment (MOH, 2006)
With the introduction of highly active antiretroviral therapy (HAART) in resource-limited settings in early 2000's, Ethiopia was among the first few African countries to introduce ART in 2003 in selected health facilities. A National Guideline on the use of ARV drugs was developed and the Antiretroviral Treatment (ART) programme was launched in 2003. Subsequently, in 2004, a free ART programme was initiated in three government hospitals in Addis Ababa. Since then the geographic distribution and number of centres providing ART services have increased. These efforts have led to marked increase in the number of health facilities and sites providing HIV treatment and care services. While there were 550 facilities providing ART in 2009/10, this reached 743 public and private health facilities in 2010/11fiscal year (FHAPCO, 2010).
By December 2006, a total of 96,897 AIDS patients had ever been enrolled at 192 ART facilities, 58,405 had ever started ART and 46,045 were currently receiving ART at 168 facilities, constituting a drop-out rate of 20.7% for patients who had ever started ART. The actual treatment adherence rate (78.8%) was higher because deaths were included in the default data (MOH, 2005).
According to a comparative cross sectional survey carried out at Yirgalem Hospital between July 10 and August 30, 2006 prevalence of ART adherence was 74.2 %( Enderias et al, 2006). Over the six year reporting period, 473,772 HIV positive client were enrolled for HIV chronic care, and 268,934(56.8%) were initiated on ART treatment. From the number ever initiated on ART, 207,733(72.2%) were currently on ART (FHAPCO, 2010). During the reporting period, a total of 333,434 people had ever started ART. There were 249,174 adults (86%of eligible) and 16,000 children currently on treatment (20% of eligible) by the end of 2011(FDRE/MOH, 2012). Similarly, the percentage of women who received antenatal care (ANC) from a trained health professional at least once for their last birth has increased from 28% in 2005 to 34% in 2010(FMOH/EHNR,2011)
Most people living with HIV or at risk for HIV do not have access to prevention, care, and treatment, and there is still no cure (WHO, 2010). The epidemic not only affects the health of individuals, but also it impacts households, communities, and the development and economic growth of nations. Many of the countries hardest hit by HIV also suffer from other infectious diseases, food insecurity, and other serious problems. Despite these challenges, new global efforts have been mounted to address the epidemic, particularly in the last decade, and there are signs that the epidemic may be changing course. On the other hand over the past five years, the world has been hit by a series of economic, financial and food crises that have slowed down, and at times reversed, global efforts to reduce poverty and hunger.
Now a day, price volatility and weather shocks such as the recent devastating drought in the horn of Africa continue to severely undermine such efforts. In this context, promoting livelihood resilience and food and nutrition security has become central to the policy agendas of governments. According the Food and Agriculture estimates there are 952 million hunger people in the world .The situation becomes even worse among household affected by HIV/AIDS (FAO, 2011).
Food insecurity, defined as “the limited or uncertain availability of nutritionally adequate, safe foods or the inability to acquire personally acceptable foods in socially acceptable ways” (Normen et al, 2005), has recently been identified as a key structural barrier to ARV adherence and as a contributor to ARV treatment interruptions in resource-poor settings (Sanjobo et al, 2008)
The relationship between the HIV epidemic and household food and nutrition insecurity situation is complex. HIV infection can negatively impact food security and nutrition, which in turn affects the disease progression and treatment outcome. Moreover, HIV/AIDS interact with nutrition and food security at a number of different levels such as biological and individual (WHO, 2003)
At a biological level, HIV and AIDS and malnutrition interact in a vicious cycle: HIV-induced immune impairment and heightened risk of infection can worsen nutritional status, lead to nutritional deficiencies through decreased food intake, mal absorption, and increased utilization and excretion of nutrients. These processes in turn hasten the progression of HIV infection to AIDS at individual level, while HIV infection exacerbates malnutrition by attacking the immune system and by negatively impacting nutrient intake, absorption and the body’s use of food (Semba and Tang, 1999). Like HIV /AIDS, malnutrition also compromises the immune function and thus increases susceptibility to severe illnesses and reduces survival. Nutritional status modulates the immunological response to HIV infection, affecting the overall clinical outcomes (WHO, 2003).
Food security is immediate need for individuals, households and communities affected by HIV in developing countries. Lack of food security may enhance the progression to AIDS-related illnesses, undermine adherence and response to antiretroviral therapy, and exacerbate socioeconomic impacts of the virus. Shortage of food is reported to be one of the reasons for non-adherence to ART as the drugs were said to increase appetite (Hardon et al., 2006). HIV infection itself undermines food security by reducing work capacity and productivity, and jeopardizing household livelihoods (Gillespie S, Kadiyala S, 2005).
ARV can interact with food in variety of ways, resulting in negative outcome. Thus, it is critical to understand the specific interactions and implication of drugs taken. This understanding enables effective management of these interactions to maintain food security and improve drug efficacy and adherence. Food affects the efficacy of ARVs by affecting absorption, metabolism and distribution kinetics of the drugs. The side effects of ARV medications can also lead to reduced food intake and nutrient absorption that exacerbates the weight loss and nutritional problems of PLHIV (WHO, 2003). If not properly managed, these interactions result in reduced effectiveness of the therapy.
A person living with HIV/ AIDS therefore needs additional nutrients to help them fight off the virus and related opportunistic infections. It is important to note that individuals infected with HIV have special nutritional needs, such as increased energy requirements (FAO, 2002). Food insecurity is considered as one of the barriers to antiretroviral (ARV) therapy access and adherence in sub-Saharan Africa. But little is known about the mechanisms through which food insecurity leads to ARV non-adherence and treatment interruptions .A combination of energy giving, body building and protective foods are essential (PANOS, 2007).
Amount of food consumed is key to strong immune system. ARV adherence is a strong predictor of biologic (virologic and immunologic) and clinical outcomes in HIV, including quality of life, HIV progression, hospitalizations, and death. Consistent adherence to antiretroviral therapy (ART) is the cornerstone of effective HIV treatment. When used correctly, antiretroviral (ARV) medications decrease viral load and improve immune system functioning (Bangsberg et al., 2000; Paterson et al., 2000).
However, the potential for viral mutations and the chronic nature of HIV infection necessitates near perfect adherence (≥95%) over sustained periods (Conway, 2007; Hogg et al., 2002). Unfortunately, 25–46% of HIV-positive persons on ART are nonadherent (<95% adherence; Gwadz et al., 1999; Paterson et al. 2000). Adherence <95% permits HIV to resume rapid replication producing drug-resistant strains that worsen patient health and complicate treatment (Bangsberg et al., 2000; Bartlett, 2002).
Non-adherence to antiretroviral (ARV) therapy is one of the important predictors of incomplete HIV RNA suppression, immunologic decline, progression to AIDS and death (Paterson et al., 2000). Non-adherence may lead to development of drug- resistant strains of HIV (Hardon, 2006). Failure to suppress viral replication inevitably leads to the selection of drug-resistant strains and limiting the effectiveness of therapy. Though, the World Food Program have recommended integration of food assistance into HIV AIDS programming, there has been little research on the mechanisms through which food insecurity may lead to gaps in treatment and compromise ARV effectiveness.
Thus, understanding such mechanisms is important for designing ARV treatment programs that incorporate food or nutritional supplementation and guiding policy decisions about intervention strategies (WFP, 2003). It is estimated that adherence rates lower than 95% are associated with the development of viral resistance to antiretroviral medications (Nachega et. al., 2007). Failure to effectively manage ARV-food interactions can result in non-adherence (Mills, 2006). In a study among PLHIV living in urban areas in Uganda, 95% of households reported that they sometimes or often had to eat less preferred foods, 62% reported that sometimes or often all household members had to skip meals, and 22% reported that sometimes or often all household members did not eat for an entire day (Bukusuba J. et al, 2007). This study expected to explores the interrelationship between household food insecurity and adherence to ARV treatment. Such studies could help inform policy maker in the study area on ways of improving or maintaining adherence to ARV and scale up the treatment level.
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