CHAPTER ONE: INTRODUCTION

1.1 Background of the Study

The Human Immunodeficiency Virus (HIV) remains one of the most pressing global public
health concerns. Since its emergence in the early 1980s, HIV/AIDS has affected millions of
people worldwide and continues to place a heavy burden on health systems, especially in sub-
Saharan Africa. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS,
2023), an estimated 38.4 million people were living with HIV globally, with sub-Saharan
Africa accounting for approximately 67% of the total cases. Although great progress has been
made in expanding access to treatment, adherence to antiretroviral therapy (ART) continues
to be a major challenge that undermines efforts to achieve viral suppression and halt the
spread of the epidemic.

Kenya, like many countries in sub-Saharan Africa, has made substantial progress in scaling
up HIV testing, care, and treatment services. According to the Kenya Demographic and
Health Survey (KDHS, 2022), approximately 1.4 million people are living with HIV in the
country, with a national prevalence rate of about 4.3%. Through initiatives by the Ministry of
Health, the National AIDS and STI Control Programme (NASCOP), and global partners such
as PEPFAR and the Global Fund, ART services are now widely available in both public and
private health facilities. Despite this, adherence remains suboptimal, particularly in rural and
low-income communities such as those found along the coastal region of Kenya.

Antiretroviral therapy (ART) refers to the combination of several antiretroviral drugs used to
suppress the replication of the HIV virus and stop the progression of the disease. Consistent
adherence to ART—taking medications exactly as prescribed, without missing doses—is
vital to achieve viral suppression, prevent drug resistance, and reduce HIV-related morbidity
and mortality. Research indicates that maintaining an adherence rate of at least 95% is
necessary to ensure optimal treatment outcomes. However, in Kenya, studies have shown that
adherence rates in some counties remain below this threshold due to various socio-economic,
psychological, and health system challenges (NASCOP, 2021).

In Kilifi County, located along the Kenyan coast, HIV prevalence is estimated at around
3.8%, slightly below the national average. Despite relatively widespread availability of ART
in local health centers, many patients experience difficulties adhering to their treatment
regimens. Rabai Sub-County, one of the administrative units within Kilifi County, faces
unique challenges such as poverty, long travel distances to health facilities, cultural beliefs,
stigma, and inadequate health literacy—all of which contribute to treatment interruptions.
Furthermore, some patients discontinue treatment due to the side effects of medication or due
to misconceptions that ART can be stopped once physical health improves.

Non-adherence to ART is a multifaceted issue influenced by individual, social, economic,

and health system factors. On the individual level, forgetfulness, depression, and lack of
understanding about the importance of adherence may contribute. Socially, stigma and
discrimination associated with HIV remain pervasive and discourage patients from taking
medication openly or attending clinic appointments. Economically, poverty limits access to
transportation, nutritious food, and other essentials that support treatment adherence. Health
system-related issues such as drug stock-outs, long waiting times, and negative attitudes from
healthcare providers also discourage patients from maintaining consistent adherence.

Given these complex challenges, there is a pressing need to investigate and document the
specific factors contributing to ART non-adherence among adults in Rabai Sub-County, Kilifi
County. Understanding these factors is essential for designing locally relevant interventions
that will improve adherence levels, enhance health outcomes, and contribute to the national
goal of achieving universal viral suppression.

1.2 Statement of the Problem

Despite the Kenyan government’s sustained efforts to scale up HIV treatment programs, non-
adherence to ART remains a persistent challenge, particularly in rural areas. Reports from the
Kilifi County Health Department (2023) indicate that a significant number of adults enrolled
in ART programs miss doses or default from treatment altogether. These cases often result in
increased viral load levels, drug resistance, and higher rates of morbidity and mortality
among affected populations.

In Rabai Sub-County, anecdotal evidence from healthcare workers suggests that many clients
begin ART with high motivation but later struggle to remain consistent. Factors such as fear
of disclosure, stigma from family and community, long distances to clinics, economic
hardships, and drug side effects have been commonly cited. These barriers not only
compromise the health of individuals but also undermine public health goals aimed at
controlling the spread of HIV.

Non-adherence poses a direct threat to Kenya’s commitment to the UNAIDS 95–95–95

targets: ensuring that 95% of people living with HIV know their status, 95% of those
diagnosed are on ART, and 95% of those on ART achieve viral suppression. Without
sustained adherence, viral suppression rates decline, and new infections increase. Therefore,
understanding the root causes of non-adherence in specific contexts such as Rabai Sub-
County is essential for effective program design and policy formulation.

1.3 Objectives of the Study

General Objective:

To assess the factors contributing to non-adherence to antiretroviral therapy among adults

aged 30–50 years at Rabai Sub-County, Kilifi County, Kenya.

Specific Objectives:

To determine the socio-economic factors influencing adherence to ART among adults aged
30–50 years in Rabai Sub-County.

To examine the role of stigma and discrimination in ART non-adherence.

To establish the influence of ART side effects on adherence among patients.

To identify health system-related barriers affecting ART adherence.

1.4 Research Questions

What socio-economic factors contribute to ART non-adherence among adults aged 30–50
years in Rabai Sub-County?

How does stigma and discrimination affect ART adherence among clients?

What are the common side effects experienced by patients, and how do they influence
adherence?

What health system challenges contribute to ART non-adherence in Rabai Sub-County?

1.5 Justification and Significance of the Study

Adherence to ART is critical in achieving viral suppression and improving the quality of life
for people living with HIV. However, despite free ART services in Kenya, adherence remains
a key obstacle to achieving positive treatment outcomes. This study is justified by the need to
provide evidence-based insights into the underlying causes of ART non-adherence in Rabai
Sub-County.
The findings will be significant to multiple stakeholders. For the Ministry of Health and Kilifi
County Health Department, the results will inform targeted interventions, policy reviews, and
the allocation of resources to improve treatment adherence. Healthcare providers will benefit
from a deeper understanding of patient challenges and can use the findings to enhance
counseling and follow-up practices. Community Health Volunteers (CHVs) will gain
guidance for developing outreach programs that address stigma and support treatment
continuity.

For the academic and research community, this study contributes to the growing body of
literature on ART adherence and provides a reference point for future research. At the
community level, the study will help raise awareness about the importance of ART adherence
and empower patients to take greater responsibility for their health. Ultimately, improved
adherence will reduce viral load levels, decrease HIV transmission rates, and enhance the
overall health status of Rabai Sub-County residents.

1.6 Scope of the Study

The study focuses on adults aged 30–50 years who are currently enrolled in ART programs at
selected health facilities within Rabai Sub-County, Kilifi County. This age group was chosen
because it represents a socially and economically active segment of the population that often
experiences competing responsibilities—work, family care, and social commitments—that
may interfere with consistent treatment adherence.

Geographically, the study will be limited to Rabai Sub-County, which comprises several
administrative wards. The research will collect data from ART clinics and community-based
support programs. The scope is restricted to factors influencing adherence and does not
include clinical aspects such as drug resistance testing.

1.7 Limitations of the Study

The study acknowledges several potential limitations. First, some respondents may provide
socially desirable answers due to the sensitivity of the topic, leading to response bias. Second,
limited financial resources and time constraints may restrict the size and diversity of the
sample. Third, some participants might be hesitant to disclose personal experiences due to
stigma or confidentiality concerns.
To mitigate these limitations, the researcher will ensure anonymity, obtain informed consent,
and build trust with participants. Despite these constraints, the findings are expected to
provide valuable insights into ART adherence challenges in Rabai Sub-County.

1.8 Assumptions of the Study

The study assumes that respondents will provide honest and accurate responses regarding
their ART adherence behaviors. It also assumes that healthcare workers and CHVs in Rabai
Sub-County have sufficient knowledge of ART programs and can provide reliable
information. Lastly, the study assumes that the selected health facilities adequately represent
the ART adherence situation in the sub-county.

1.9 Definition of Key Terms

Antiretroviral Therapy (ART): The use of a combination of drugs that suppress HIV
replication and improve immune function.

Adherence: The extent to which a person’s behavior in taking medication corresponds with
agreed recommendations from a healthcare provider.

Non-Adherence: The failure to take ART medication as prescribed, including missed doses or
complete discontinuation.

Stigma: The negative attitudes, discrimination, or social rejection experienced by individuals

because of their HIV-positive status.

Viral Load: The amount of HIV virus present in a person’s blood. A low or undetectable viral
load indicates successful treatment.

Viral Suppression: Achieving undetectable levels of the HIV virus in the blood through
consistent ART adherence.

Health System Barriers: Challenges within healthcare delivery such as drug shortages, long
waiting times, and negative staff attitudes that hinder patient adherence