Adherence and sustained access to antiretroviral treatment in the Free State public health sector: a gender perspective

[摘要] English: Sustained access to ART and adherence to ARV medications remain crucial for reducing AIDS-related mortality and morbidity, minimising the development of drug resistance, and for appropriate treatment decision-making by health care providers. Thus, the factors associated with non-adherence to ARV medication and poor sustained access need to be identified and addressed. Although there is a preponderance of treatment adherence research, in which social aspects that affect the way patients manage HIV/AIDS and related treatment have been identified, far less attention has been paid to the relevant gender dimensions of treatment, care and support. The aim of this study was to examine how gender influences adherence to ARV medications and sustained access to treatment among patients on ART in the Free State public health sector. To achieve this aim, several methods were deemed necessary. First, current literature was reviewed to identify factors that predict nonadherence to ARV medications and impede sustained access to ART. Second, a framework was adapted to focus on inequalities in treatment from a gender perspective, and to take cognisance of both biological sex and socially constructed gender influences on the health of patients on ARV treatment, with specific reference to access and adherence to treatment. Masculinity and femininity is discussed in respect of the varied resources that an individual has access to and control over, an individual's decision-making power, the gender norms held by society, and gender roles that men and women are expected to adhere to. Third, an empirical investigation of data from a prospective cohort study was conducted to identify similarities and differences in factors associated with nonadherence to ARV medications and to poor sustained access among men and women on ART in the Free State's public health sector. A total of 1609 patients were interviewed in face-to-face interviews using semi-structured questionnaires. Patients were interviewed six times during the course of this study with an average six-month interval between interviews. The outcome variables assessed included self-reported seven-day adherence to ARV medication regimens and self-reported adherence to scheduled appointments over a six-month period as a measure of sustained assess to treatment. Sex was used as the dependent variable in all analyses. Demographic, psychosocial/behavioural, clinical, and service delivery variables were all tested for a statistically significant association with non-adherence to medications and appointments in separate sex-disaggregated multivariate regression analyses (P�?.05). Logistic regression models showed that the strongest predictors of medication nonadherence among men included financial difficulties in visiting hospital facilities and poor treatment knowledge. Among women, tobacco use and perceived stigma were identified as the strongest predictors of medication non-adherence. Self-reported depression or anxiety and experiencing difficulties in visiting clinic and hospital facilities were similarly associated with non-adherence to appointments for men and women. Service satisfaction at clinics and having few self-reported service needs were also independently associated with appointment non-adherence among women, but not among men. Findings for men do however need to be interpreted with caution, as both outcomes, despite being valid measures for the combined sample and among women, were not valid for men. Marked differences and similarities in the factors influencing medication adherence and sustained access to treatment between men and women were identified, reflecting the different lived experiences of men and women on ART in the Free State. Gender-sensitive interventions - as opposed to standardised ones - are thus required to improve adherence and sustained access in this population. Further research and possible interventions are required in respect of gender-sensitive outcome measures for adherence, improving treatment knowledge among men, coping responses to gender role stressors among women, less stigmatising means for taking medications, improving mental health and improving the quality of services rendered at health care facilities.

[发布机构] University of the Free State