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Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study

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      Abstract

      BackgroundIndividuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.Methods and FindingsDeterminants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and “begging” transport funds, making “impossible choices” to allocate resources in favor of treatment, and “doing without.” Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.ConclusionAdherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.

      Abstract

      Using ethnographic data from Nigeria, Tanzania, and Uganda, Norma Ware and colleagues examine why levels of adherence to HIV/AIDS drugs are so much higher in sub-Saharan Africa than in North America.

      Editors' Summary

      Background.The acquired immunodeficiency syndrome (AIDS) epidemic has killed more than 25 million people since 1981, and about 30 million people (22 million in sub-Saharan Africa alone) are currently infected with the human immunodeficiency virus (HIV), which causes AIDS. HIV destroys immune system cells, leaving infected individuals susceptible to other infections. Early in the AIDS epidemic, most HIV-infected individuals died within ten years but in 1996, combination antiretroviral therapy (ART)—a mixture of powerful drugs—was developed. For HIV-infected people living in affluent, developed countries, HIV/AIDS became a chronic disease, but for the millions of infected people living in low- and middle-income countries, HIV/AIDS remained a death sentence—ART was simply too expensive. In 2003, this situation was declared a global health emergency. Today, through the concerted efforts of governments, international organizations, and funding bodies, nearly one-third of the people in developing and transitional countries who are in immediate need of life-saving ART receive free, reliable supplies of the drugs they need.Why Was This Study Done?For ART to work, it must be taken regularly. If drug doses are missed, the virus can rebound and resistance to ART is more likely to develop. In poor countries, even though free antiretroviral drugs are increasingly available, many obstacles to good adherence to ART remain. These include economic obstacles (for example, the cost of traveling to clinics and the loss of earning associated with clinic attendance), and social, cultural, and behavioral barriers. Some patients fear disclosure, for example. Others receive conflicting messages about the benefits of ART. However, despite worries that the scale-up of ART provision in developing countries would be dogged by inadequate adherence, people living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of their prescribed doses of ART, a better level of adherence than in North America. In this study, the researchers investigate why ART adherence is so high in sub-Saharan Africa by analyzing qualitative data from an ethnographic study done in Nigeria, Tanzania, and Uganda. Qualitative data are often used to address “how” and “why” research questions: ethnography is a comprehensive qualitative approach to describing and explaining human behavior and culture.What Did the Researchers Do and Find?For their study, the researchers interviewed 158 patients, 45 treatment partners (lay-people who help HIV-positive people keep to their treatment), and 49 health care workers. Patients were asked about their experiences of ART and about the help they received from their treatment partners; partners were asked about the type of help they gave and about their feelings about this help; health care workers were asked to describe a typical clinic visit and to indicate how adherence was discussed. From these interviews and observations of clinic sessions, the researchers identified several strategies used by patients and their treatment partners to overcome economic obstacles to ART adherence. These included borrowing and “begging” funds to pay for travel to clinics and making “impossible choices” to prioritize adherence, and “doing without.” The researchers' analysis also indicates that the prioritization of adherence to ART reflects the importance of relationships as a resource for managing economic hardship. So, for example, they found that treatment partners and health care workers expected patients to adhere to ART (which, by improving patients' health, improves their ability to support themselves and their families) and made their expectations known, thereby creating a responsibility among patients to adhere. Patients, in turn, adhered to their treatment to promote good will from their helpers and thus ensure their continuing help.What Do These Findings Mean?The findings offer a possible explanation of adherence success in sub-Saharan Africa. The high level of adherence to ART can be explained as a means of fulfilling social responsibilities. Adherence, the researchers suggest, not only improves personal health (the main driver for ART adherence in resource-rich environments) but also preserves “social capital” in essential relationships. In other words, in sub-Saharan Africa, adherence to treatment may protect the relationships that individuals living in extreme poverty rely on to help them survive.Additional Information.Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000011.This study is further discussed in a PLoS Medicine Perspective by Agnes Binagwaho and Niloo RatnayakeInformation is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDSHIV InSite has comprehensive information on all aspects of HIV/AIDS, including an article about to antiretroviral therapyInformation is available from Avert, an international AIDS charity, on HIV and AIDS in Africa (including detailed information on HIV/AIDS in Nigeria and Uganda) and on providing AIDS drug treatment for millionsThe World Health Organization provides information about universal access to HIV treatment (in several languages)The US Centers for Disease Control and Prevention also provides information on global efforts to deal with the HIV/AIDS pandemic

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      Most cited references 83

      • Record: found
      • Abstract: not found
      • Article: not found

      Competition and the Structure of Industrial Society: Reply to Braithwaite

       James Coleman (1988)
        Bookmark
        • Record: found
        • Abstract: not found
        • Article: not found

        Bowling Aalone: The Collapse and Revival of American Community

          Bookmark
          • Record: found
          • Abstract: found
          • Article: not found

          Social relationships and health.

          Recent scientific work has established both a theoretical basis and strong empirical evidence for a causal impact of social relationships on health. Prospective studies, which control for baseline health status, consistently show increased risk of death among persons with a low quantity, and sometimes low quality, of social relationships. Experimental and quasi-experimental studies of humans and animals also suggest that social isolation is a major risk factor for mortality from widely varying causes. The mechanisms through which social relationships affect health and the factors that promote or inhibit the development and maintenance of social relationships remain to be explored.
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            Author and article information

            Affiliations
            [1 ] Harvard Medical School, Boston, Massachusetts, United States of America
            [2 ] Jos University, Jos, Nigeria
            [3 ] Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
            [4 ] Mbarara University of Science and Technology, Mbarara, Uganda
            [5 ] Muhimbili University/Dar es Salaam City Council/Harvard School of Public Health HIV/AIDS Care and Treatment Program, Dar es Salaam, Tanzania
            [6 ] Harvard School of Public Health, Boston, Massachusetts, United States of America
            [7 ] Massachusetts General Hospital, Boston, Massachusetts, United States of America
            [8 ] Harvard Initiative for Global Health, Cambridge, Massachusetts, United States of America
            Johns Hopkins University, United States of America
            Author notes
            * To whom correspondence should be addressed. E-mail: norma_ware@ 123456hms.harvard.edu
            Contributors
            Role: Academic Editor
            Journal
            PLoS Med
            pmed
            plme
            plosmed
            PLoS Medicine
            Public Library of Science (San Francisco, USA )
            1549-1277
            1549-1676
            January 2009
            27 January 2009
            : 6
            : 1
            2631046
            19175285
            10.1371/journal.pmed.1000011
            08-PLME-RA-1572R2 plme-06-01-18
            (Academic Editor)
            Copyright: © 2009 Ware et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
            Counts
            Pages: 7
            Categories
            Research Article
            Infectious Diseases
            Custom metadata
            Ware NC, Idoko J, Kaaya S, Biraro IA, Wyatt MA, et al. (2009) Explaining adherence success in sub-Saharan Africa: An ethnographic study. PLoS Med 6(1): e1000011. doi: 10.1371/journal.pmed.1000011

            Medicine

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