Transportation, worries about personal safety, weakness in health infrastructure and food insecurity are barriers to adherence to antiretroviral treatment in the conflict zone in northern Uganda, an international team of investigators report in the September 12th edition of AIDS.
The study involved HIV-positive individuals living in displaced persons’ camps and healthcare workers. A study published earlier in 2008 found that good HIV treatment outcomes were possible in the northern Ugandan conflict zone. The investigators believe that their findings provide “a nuanced explanation of reasons for nonadherence” and that understanding patient-important barriers to adherence is "critical to effectively scaling up…therapy access.”
Access to antiretroviral therapy is expanding in resource-limited settings. Some of the countries hardest hit by HIV are politically insecure, nevertheless, providing antiretroviral therapy to individuals in these settings is important from both a public health and a human rights perspective.
Earlier studies have looked at the factors affecting adherence to antiretroviral therapy in resource-limited settings, but adherence to HIV treatment in conflict zones has not previously been examined.
One of Africa’s longest lasting conflicts is in northern Uganda where there has been a humanitarian emergency for over 20 years. The area is politically insecure and as well as experiencing violence has been affected by famine and floods. Over 400,000 displaced persons are living in over 60 camps and there has been a limited humanitarian response.
In early 2008 investigators conducted focus group discussions involving 40 HIV-positive individuals who had been living in the camps for at least five years and were taking antiretroviral therapy. The research also involved a separate focus group which involved healthcare workers. The aim was discover the barriers to HIV treatment adherence.
The ages of the HIV-positive individuals ranged from 30 to 67 years, and half were women. The healthcare workers had a wide variety of backgrounds including laboratory technician, dispensary worker, senior nursing officers, a clinical officer and an information worker.
Four major themes emerged in the focus group discussions as barriers to adherence: transport, human security, health infrastructure and food insecurity.
Transport
Transport was frequently cited as a barrier to good adherence. The cost of transport, and ill health prohibiting travel were mentioned by focus group members.
One individual mentioned that they were asked to attend a healthcare facility at fortnightly intervals. The researchers were told “to come back every two weeks…means many trips…which is too expensive”.
A healthcare worker told the investigators: “those who are quite ill at [treatment] initiation are likely to miss their doses, as they will require a treatment supporter who may not be available all the time.”
Personal safety issues
Insecurity and fear were also mentioned as barriers to adherence, with one individual noting “insecurity results in loss of drugs or forgetting to pick them up on time from your house. If you hear the alarm, you just take off.”
Health infrastructure
Lack of healthcare resources, particularly personnel were also cited as barriers to adherence. One patient said “healthcare workers are very few or not available, and yet you cannot get a drug refill before being seen by a healthcare worker.
Long waits were also mentioned by paitents: “the line is very long and you sometimes wait the whole day before you are seen, even if you arrived at the clinic as early as 5.00 am.”
A lack of second-line treatment options within the camps’ healthcare facilities was also raised, with patients requiring such medication having to make long journeys.
Food insecurity
Flooding had meant that some communities could only have one meal a day, and this was impacting on adherence. Patient dependence on care-givers for food security was also raised as a reason for non-adherence: “those people who are disabled miss their doses when they fail to get someone to give them food. We cannot share our little food with them all the time even if we know that they need our support.”
In conclusion, the investigators write, “the logistical and security concerns highlighted by participants in this study merit attention from public health officials and clinicians to aid HIV-positive populations in northern Uganda. Efforts to ensure uninterrupted care in these populations remain a core challenge.”
Olupot-Olupot P et al. Adherence to antiretroviral therapy among a conflict-affected population in Northeastern Uganda: a qualitative study. AIDS 22: 1882 – 84, 2008.