HIV treatment knowledge still patchy among people with HIV in Soweto

Patients with HIV from Soweto, South Africa have a relatively good understanding of HIV/AIDS according to a report in the February 1^st issue of the Journal of Acquired Immune Deficiency Syndromes.

The study, based upon a survey of 105 people attending an HIV outpatient clinic in Soweto, suggests that the patients are not fearful of going onto antiretroviral treatment (ART). However, their overall impression of antiretroviral therapy might be overly optimistic. It is unclear whether that positive attitude toward treatment will translate into good adherence — particularly in light of the fact that many have not yet disclosed their HIV status to their to sexual partners.

HIV in South Africa

According to some projections, 6 million (out of a population of around 44 million) South Africans will be infected with HIV by the year 2005. Without treatment, the mortality rate of HIV/AIDS could reach 800,000 deaths per year by 2010.

Despite much foot-dragging, the government of South Africa has initiated a comprehensive plan for the care of its citizens with HIV, which includes the use of antiretroviral drugs. At present, ART is reaching only about 20,000 patients though targets are much higher.

The effective delivery of ART will require patients to be well informed about the nature of their disease, with adequate support and preparation to adhere to treatment.

Researchers of the JAIDS study sought to gauge the general knowledge, attitudes, beliefs, and practices of HIV-infected South Africans concerning HIV/AIDS and ART and to examine potential barriers to adherence by questioning outpatients attending the Chris Hani Baragwanath Hospital HIV Outpatient Clinic.

This government facility is one of the largest hospitals in the world. It serves Soweto, an urban township neighbouring Johannesburg. Soweto’s 3 million residents are predominantly black Africans with a low to moderate education level and socio-economic status (SES). Patients attending this clinic receive counselling about HIV, ART, and the importance of adherence at their initial visit and every 3 months on return visits to the clinic.

The questionnaire

The study involved 105 randomly selected HIV-positive adults who were asked questions (in one of three local languages) about how HIV is transmitted, how the disease progresses, the effects of ART and the importance of adherence. They were also asked whether they had disclosed their HIV status to anyone (including their current partner) and about whether they were using condoms or taking ART. Demographic information including age, sex, race, marital status, employment status, and education were also recorded.

The questionnaires were scored and each patient’s performance was analysed in light of demographic characteristics, socioeconomic status, and education.

Demographics, sexual practices and disclosure

The majority of participants were black African (99%), unmarried (81%), and female (72%).

Only 35% were employed and an average of 1 out of 5.2 adult household members were employed at the time of the survey. Many subjects had only the pension payments of someone else in their home to live on. 70% of the participants had less than a high school education, though 95% of those interviewed reported they could read.

Thirty-one (29%) of the patients were taking ART at the time of the study.

At the time of the study, 19% participants reported that they were married; 50% had a steady partner, and 30% stated did not have a sexual partner. During the previous year, 14% had no sexual partners, 62% had one, 14% had two, and 9% had three or more. 69% had previously been treated for an STD, 44% within the past year.

84% of those interviewed reporting using condoms at least some of the time. Condom use decreased with increasing age (adjusted odds ratio [AOR] = 0.93, 95% CI: 0.88, 0.99; P

Participants had known about their HIV status for an average of 3.5 years and 90% had disclosed their HIV status to at least 1 person — usually a sibling. However, 38% of those with a spouse or partner had not disclosed their status to their sexual partner.

Knowledge about HIV/AIDS

In general, most patients had a good understanding of HIV and how it is transmitted — although 59% of patients mistakenly though that HIV could also be transmitted by mosquitoes.

Most (84%) patients knew that people with HIV did not always show symptoms. 87% realized that progression to AIDS could develop later however.

Knowledge about ART and adherence

98% of the subjects believe that ART can prevent disease progression and vertical transmission of the virus.

However, some patients may have unrealistic expectations of treatment. — 49% believe that ART can cure HIV (49%) and 36% think the medicine does not have side effects. The belief that ART is a cure for HIV was associated with lower education levels (P

Although a majority of patients know that adherence is important, a substantial proportion do not understand that missing doses can lead to disease progression (35%) or increased transmission rates (44%).

The researchers also investigated whether worries about side effects, the effectiveness of treatment and the possibility that people might discover they were on treatment would negatively affect treatment adherence. But 59% of patients said were not worried about potential side effects, and few (only 24%) had worries that the medication might not be effective. The majority of subjects said that they would not be worried if family (83%) or friends (74%) found out if they were going to take ART — however, the fact that a number of subjects (38%) had not yet disclosed their HIV status to their sexual partners suggests that patients may be more worried about stigma that they report.

Caveats and implications

Since all of these patients come from the same clinic, this questionnaire may only demonstrate how good the Chris Hani Baragwanath hospital’s educational programme is — and may tell us little about the HIV/AIDS knowledge/attitudes of HIV positive patients elsewhere in South Africa.

Also, there is always a danger that patients will tell the investigator the answers they think they want to hear – and that worries about treatment outcome and fears of disclosure may be understated.

However, the study does point to some areas where interventions can clearly be improved. The authors note that the fact that so many patients had not disclosed their HIV status to sexual partners reveals a need for “urgent and culturally adapted, multidimensional interventions to decrease HIV/AIDS-related stigmatization and discrimination.”

Finally, unrealistic expectations about treatment could backfire and decrease adherence once side effects are encountered. There is also a danger that patients could under-report side effects or wait until toxicity becomes serious before presenting unless they are adequately prepared for side effects that could occur on treatment.