CHAPTER ONE

INTRODUCTION

1.1 BACKGROUND TO THE STUDY

HIV (Human Immunodeficiency Virus) is a virus that attacks the body's immune system, while

AIDS (Acquired Immunodeficiency Syndrome) is the most advanced stage of HIV infection.

HIV/AIDS is a global health issue, with millions of people living with the disease worldwide.

Antiretroviral Therapy (ART) is a treatment regimen that uses a combination of medications to

suppress the HIV virus and slow disease progression. ART has significantly improved the quality

of life and life expectancy of people living with HIV/AIDS. Adherence to ART is crucial for

achieving and maintaining viral suppression, which reduces the risk of HIV transmission and slows

disease progression. Adherence helps prevent the development of drug-resistant HIV strains,

ensuring the effectiveness of treatment regimens. Adherence is associated with improved health

outcomes, including reduced morbidity and mortality. Non-adherence can lead to treatment failure,

resulting in disease progression and increased risk of transmission. Non-adherence can contribute

to the development of drug-resistant HIV strains, limiting treatment options. Non-adherence is

also associated with increased morbidity and mortality, highlighting the importance of adherence

support and interventions.

1.2 STATEMENT OF THE PROBLEM

Non-adherence to first-line ART is a significant problem worldwide, with varying rates reported

in different settings. Non-adherence can be caused by various factors, including, forgetfulness,

side effects, complexity of regimen, stigma and discrimination, lack of social support, mental

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health issues, Substance abuse etc. Non-adherence can lead to treatment failure, resulting in

disease progression and increased risk of transmission, contribute to the development of drug-

resistant HIV strains, limiting treatment options and increasing the risk of transmission of resistant

strains, associated with increased morbidity and mortality, highlighting the importance of

adherence support and interventions and can result in increased healthcare costs due to the need

for more intensive care, hospitalization, and treatment of opportunistic infections.

Impact on Public Health

Non-adherence can increase the risk of HIV transmission to others, particularly in settings with

high viral loads and contribute to the public health burden of HIV/AIDS, highlighting the need for

effective adherence support and interventions.

Addressing Non-Adherence

Addressing non-adherence requires a multidisciplinary approach, including healthcare providers,

patients, and community-based organizations. Providing adherence support, such as counseling,

education, and reminder systems, can help improve adherence rates. Simplifying treatment

regimens and minimizing side effects can also improve adherence.

1.3 AIM OF THE STUDY

This study aims to:

1. Determine the factors that affect adherence to first-line ART among HIV patients.

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2. Investigate the relationship between patient-related factors (e.g., demographics, socioeconomic

status, psychological factors) and adherence.

3. Examine the impact of treatment-related factors (e.g., regimen complexity, side effects) on

adherence.

4. Evaluate the role of healthcare system-related factors (e.g., access to care, patient-provider

relationships) in adherence.

5. Explore the relationship between adherence and patient outcomes, such as viral suppression and

quality of life.

6. Estimate the prevalence of non-adherence to first-line ART among HIV patients, identify the

predictors of adherence to first-line ART among HIV patients and develop evidence-based

recommendations for improving adherence to first-line ART among HIV patients.

1.4 RESEARCH QUESTIONS/HYPOTHESES

Research Questions

1. What are the factors that affect adherence to first line antiretroviral therapy among HIV patients?

2. Is there a relationship between patient related factors (e.g demographics, socioeconomic status)

and adherence to ART ?

3. Do treatment related factors (e.g regimen complexity, side effects) affect adherence to ART?

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4. Does the healthcare system (e.g access to care, patient-provider relationships) influence

adherence to ART?

Hypotheses

1. Patient related factors (e.g demographics, socioeconomic status) are significantly associated

with adherence to ART?.

2. Treatment related factors (e.g regimen complexity, side effects) significantly affect adherence

to ART.

3. Patients experiencing side effects are less likely to adhere to ART compared to those not

experiencing side effects.

4. Patients with a strong patient-provider relationship are more likely to adhere to ART compared

to those with weak patient-provider relationship.

1.5 SIGNIFICANCE OF THE STUDY

This study will contribute to the understanding of the factors that affect adherence to first line ART

among HIV patients. The study will also identify predictors of adherence, which can inform the

development of targeted interventions, development of strategies to enhance adherence including

viral suppression, reduced morbidity, and mortality. This will inform policy and practice, reduce

healthcare costs and improve quality of life.

1.6 SCOPE OF THE STUDY

The study will assess adherence to first line ART, factors that may affect adherence such as patient-

related factors, treatment related factors and health system related factors.

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 CHAPTER TWO

LITERATURE REVIEW

2.1 LITERATURE REVIEW

HIV, or Human Immunodeficiency Virus, is a virus that attacks the body's immune system by

destroying CD4 cells, which are crucial for fighting off infections. This weakening of the immune

system makes individuals more susceptible to opportunistic infections and certain types of cancer.

According to the World Health Organization (WHO), HIV infection can be managed with

antiretroviral therapy (ART), which suppresses the virus and allows the immune system to recover,

enabling people living with HIV to lead long and healthy lives.

2.2 PREVALENCE OF HIV

Globally, approximately 39.9 million people were living with HIV in 2023, with 38.6 million being

adults and 1.4 million children. The prevalence rate varies significantly across regions and

countries.

2.2.1 GLOBAL HIV STATISTICS

 People living with HIV: 39.9 million (36.1 million-44.6 million)

 New HIV infections: 1.3 million (1 million-1.7 million) in 2023

 AIDS-related deaths: 630,000 (500,000-820,000) in 2023

2.2.2 COUNTRIES WITH THE HIGHEST HIV PREVALENCE RATES:

Eswatini:27.5% (230,000 people living with HIV)

Lesotho: 20.5% (270,000 people living with HIV)

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Botswana: 19.7% (360,000 people living with HIV)

South Africa: 16.6% (7.7 million people living with HIV)

Mozambique: 11.8% (2.4 million people living with HIV)

2.2.3 REGIONAL HIV PREVALENCE

Sub-Saharan Africa: 3.4% of adults aged 15-49 years living with HIV, accounting for more than

two-thirds of people living with HIV worldwide.

-Asia and the Pacific: Lower prevalence rates compared to sub-Saharan Africa, but still a

significant number of people living with HIV.

2.2.4 NIGERIA'S HIV PREVALENCE

National prevalence rate: 1.4% among adults aged 15-49 years

States with the highest HIV prevalence rate:

Akwa Ibom: 5.6%

Benue: 4.9%

Rivers: 3.8%

Taraba: 2.7%

Anambra: 2.4%

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2.3 HIV TRANSMISSION

HIV is spread through bodily fluids, including blood, semen, vaginal fluids, and breast milk, often

during unprotected sex or sharing contaminated needles.

2.4 SYMPTOMS

Early stages may exhibit flu-like symptoms, while advanced stages can lead to severe illnesses

like tuberculosis, cryptococcal meningitis, and certain cancers.

2.5 DIAGNOSIS

HIV can be diagnosed using rapid diagnostic tests that provide same-day results, with confirmatory

testing required for positive diagnoses.

2.6 STAGES OF HIV INFECTION

Acute HIV Infection: Initial stage with flu-like symptoms, high viral load, and increased

infectiousness.

Chronic HIV Infection: Asymptomatic stage where the virus continues to multiply, gradually

weakening the immune system.

AIDS (Acquired Immunodeficiency Syndrome): Advanced stage with severe immune system

damage, opportunistic infections, and increased risk of death.

2.7 CLASSIFICATION OF HIV

HIV classification involves categorizing the virus into different types, groups, and subtypes based

on genetic variations.

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2.7.1 TYPES OF HIV

HIV-1: The most common and virulent type, responsible for the majority of infections worldwide.

HIV-2: Less virulent and less easily transmitted, primarily found in West Africa.

HIV-1 Groups

Group M (Main): The most prevalent group, further divided into subtypes A-K.

Group O (Outlier): Less common, primarily found in Africa.

Group N (Non-M, Non-O): Rare, isolated cases reported in Cameroon.

HIV-1 Subtypes

Subtype : Common in North America and Europe.

-Subtype C: Prevalent in sub-Saharan Africa and Asia.

Other subtypes: A, D, F, G, and others, with varying geographic distributions.

2.7.2 CLASSIFICATION SYSTEMS

WHO Staging System: Based on clinical symptoms and laboratory data, categorizing HIV

infection into four clinical stages.

CDC Classification System: Based on CD4 T-lymphocyte count and percentage, categorizing HIV

infection into three stages.

Clinical Stages (WHO)

Clinical Stage 1: Asymptomatic, persistent generalized lymphadenopathy.

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 Clinical Stage 2: Weight loss, minor mucocutaneous manifestations, recurrent upper respiratory

tract infections.

Clinical Stage 3: Severe weight loss, chronic diarrhea, prolonged fever, oral candidiasis.

Clinical Stage 4: Life-threatening opportunistic infections, such as Pneumocystis pneumonia,

toxoplasmosis, and cryptococcosis.

2.8 TREATMENT OF HIV

The treatment of HIV involves the use of antiretroviral therapy (ART), which suppresses the virus

and allows the immune system to recover.

Goals of HIV Treatment

1. Viral suppression: Reduce the viral load to undetectable levels.

2. Immune system recovery: Restore the immune system and prevent opportunistic infections.

3. Improved quality of life: Enable people living with HIV to lead long and healthy lives.

Antiretroviral Therapy (ART)

1. Combination therapy: ART typically consists of a combination of three or more medications

from different classes.

2. Medication classes: NRTIs, NNRTIs, PIs, INSTIs, and entry inhibitors.

3. Treatment regimens: ART regimens are tailored to individual needs and may change over time.

2.9 FIRST LINE TREATMENT

The first-line treatment of HIV typically involves a combination of antiretroviral medications.

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First-line antiretroviral therapy (ART) refers to the initial treatment regimen used to manage HIV

infection. The goal of first-line ART is to suppress the virus, slow disease progression, and improve

the patient's quality of life.

Characteristics of First-Line ART

1. Combination therapy: First-line ART typically consists of a combination of three or more

antiretroviral medications from different classes.

2. Standardized regimens: First-line ART regimens are often standardized based on national or

international guidelines.

3. Effective and tolerable: First-line ART regimens are chosen for their effectiveness, tolerability,

and simplicity.

Common First-Line ART Regimens

1. Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs): Often used as the backbone of

first-line ART regimens.

2. Non-nucleoside reverse transcriptase inhibitors (NNRTIs): May be used in combination with

NRTIs.

3. Integrase strand transfer inhibitors (INSTIs): May be used in combination with NRTIs.

Examples

1. Tenofovir disoproxil fumarate (TDF) + Emtricitabine (FTC) + Efavirenz (EFV): A common

regimen that combines two NRTIs with an NNRTI.

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2. Tenofovir alafenamide (TAF) + Emtricitabine (FTC) + Bictegravir (BIC): A regimen that

combines two NRTIs with an INSTI.

3. Abacavir (ABC) + Lamivudine (3TC) + Dolutegravir (DTG): A regimen that combines two

NRTIs with an INSTI.

Factors Influencing Regimen Choice

1. Viral load and CD4 count: The choice of regimen may depend on the patient's viral load and

CD4 count.

2. Resistance testing: Resistance testing may be performed to guide the selection of medications.

3. Side effect profile: The side effect profile of each medication may influence the choice of

regimen.

4. Comorbidities and interactions: The presence of comorbidities and potential interactions with

other medications may impact the choice of regimen.

Monitoring and Adjusting First-Line ART

Regular monitoring: Regular monitoring of viral load, CD4 cell count, and side effects.

Regimen adjustments: Adjust the regimen as needed to maintain viral suppression and manage

side effects.

Goals of First-Line Treatment

1. Viral suppression: Achieve and maintain viral suppression to undetectable levels.

2. Immune system recovery: Restore the immune system and prevent opportunistic infections.

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3. Improved quality of life: Enable people living with HIV to lead long and healthy lives.

3.0 IMPORTANCE OF ADHERENCE

1. Viral suppression: Adherence to ART is crucial for achieving and maintaining viral suppression,

which reduces the risk of HIV transmission and slows disease progression.

2. Prevents drug resistance: Adherence helps prevent the development of drug-resistant HIV

strains, ensuring the effectiveness of treatment regimens.

3. Improves health outcomes: Adherence is associated with improved health outcomes, including

reduced morbidity and mortality.

3.1 FACTORS AFFECTING NON ADHERENCE

Patient-related factors: Substance and alcohol abuse are significant predictors of non-adherence.

Other factors include demographics, socioeconomic status, and psychological factors.

Treatment-related factors: Regimen complexity and side effects can impact adherence.

Simplifying treatment regimens and minimizing side effects can improve adherence rates.

Healthcare system-related factors: Access to care, patient-provider relationships, and healthcare

infrastructure can influence adherence.

3.2 CONSEQUENCES OF NON ADHERENCE

1. Treatment failure: Non-adherence can lead to treatment failure, resulting in disease progression

and increased risk of transmission.

2. Drug resistance: Non-adherence can contribute to the development of drug-resistant HIV strains,

limiting treatment options.

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3. Increased morbidity and mortality: Non-adherence is associated with increased morbidity and

mortality, highlighting the importance of adherence support and interventions.

3.3 PROBLEM OF NON ADHERENCE

1. Prevalence: Non-adherence to first-line ART is a significant problem worldwide, with varying

rates reported in different settings.

2. Causes: Non-adherence can be caused by various factors, including:

- Forgetfulness

- Side effects

- Complexity of regimen

- Stigma and discrimination

- Lack of social support

- Mental health issues

- Substance abuse

3.4 IMPACT ON PUBLIC HEALTH

1. Transmission risk: Non-adherence can increase the risk of HIV transmission to others,

particularly in settings with high viral loads.

2. Public health burden: Non-adherence can contribute to the public health burden of HIV/AIDS,

highlighting the need for effective adherence support and interventions.

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3.5 ADDRESSING NON ADHERENCE

1. Multidisciplinary approach: Addressing non-adherence requires a multidisciplinary approach,

including healthcare providers, patients, and community-based organizations.

2. Adherence support: Providing adherence support, such as counseling, education, and reminder

systems, can help improve adherence rates.

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