Antiretroviral Treatment in Sub-Saharan Africa


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The introduction of antiretroviral therapy (ART) in middle and low income countries is arguably one of the most meaningful outcomes recorded in the fight against HIV and AIDS. A record number of some 6.2 million people living with HIV and AIDS are reported to be benefiting from the treatment, which is reported to have risen by 19 per cent between 2010 and 2011 and as a result of this, the region has also enjoyed a significant decline in AIDS mortality. This volume is the outcome of the �call for abstracts� put out by OSSREA in 2011 for senior researchers, social scientists and practitioners to write scientific articles on issues surrounding ARVs. The volume contains eight chapters organized into four sections: ART and quality of life; Adherence to ART; Traditional medicine and ART; and Sexual behaviour of ART attendants. The chapters are contributed by Academics and researchers from three different African countries: four from Ethiopia, two from Uganda and two from Zimbabwe.



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Published 13 May 2013
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Edited by
Getnet Tizazu and Rahel Mesfn
Organisation for Social Science Research in

Organisation for Social Science Research in
Eastern and Southern Africa (OSSREA)

© 2013 Organisation for Social Science Research in Eastern and Southern Africa
OSSREA acknowledges the support of Swedish International Development
Cooperation Agency (Sida), Norwegian Agency for Development Co-operation
(NORAD), The Netherlands Ministry of European Affairs and International
Cooperation, International Development Research Centre (IDRC), and Danish
Development Agency (DANIDA).

Printed in Ethiopia
All rights reserved.
ISBN: 978-99944-55-70-6

Edited by: Getnet Tizazu and Rahel Mesfin
Copy-edited at OSSREA
Text layout: Alemtsehay Zewde

Organisation for Social Science Research in Eastern and Southern Africa
P.O. Box 31971, Addis Ababa, Ethiopia
Fax: 251-11-1223921
Tel: 251-11-1239484

Table of Contents
vi Acronyms
Chapter One Introduction 1
Getnet Tizazu Fetene
Chapter Two Adherence to Antiretroviral Therapy in sub-Saharan 15
Africa: Challenges and Prospects
Sibhatu Biadgilign and Ayalu Aklilu
Chapter Three Quality of Life among Patients Living with HIV AIDS 39
in Sub-Saharan Africa
Francis Bajunirwe
Chapter Four Religion, Stigma and ART Adherence in Ethiopia: The 67
Experience of Ethiopian Religious Associations of
People Living with HIV and AIDS
Bereket Tarekegn
Chapter Five Determinants of Adherence to Antiretroviral Therapy 87
Drugs in the Phase of Rapid Scale-up of Antiretroviral
Treatment in sub-Saharan Africa: The Case of Ethiopia
Woinishet Asnake Sisay and Abiy Ayalew Alemayehu
Chapter Six Determinants of Access to Treatments by AIDS Patients 113
in Uganda
Joseph Wasswa-Matovu
Chapter Seven Traditional Medicine and HIV and AIDS Treatment: 139
Challenges, Prospects and Lessons for Zimbabwe
Enock Mandizadza and Gordon Chavunduka
Chapter Eight The Ambivalent Patient: A Study of Patients’ Attitudes 165
and Perceptions Towards ARVs and Traditional
Medicines or Faith Healing for Managing HIV and
AIDS Illness in Rural Harare, Zimbabwe
Shastry Njeru
Chapter Nine Sexual Behaviour of People Attending Anti-retroviral 193
Therapy in Addis Ababa
Nathan Negussie
Chapter Ten Concluding Remarks 211
Getnet Tizazu Fetene and Rahel Mesfin vi Antiretroviral Treatment in sub-Saharan Africa

AIDS Acquired Immune Deficiency Syndrome
AMR Adaptive Multi-Rate
ART Antiretroviral therapy
ART Antiretroviral Treatment
ARV Antiretroviral
BCC Behavioural Change Communication
BHPs Biomedical Health Practitioners
BMPs BiomediPractitioners
CBOs Community-based Organizations
CET Cardio-respiratoryExercise Training
CORPs Community-owned Resource Persons
CSA Central Statistical Agency
CSOs Civil Society Organizations
DCA Danish Church Aid
EECMY Ethiopian Evangelical Church Mekane Yesus
EIASC Ethiopian Islamic Affairs Supreme Council
EIFDDA Ethiopian Inter-faith Forum for Development, Dialogue and Action
EOC Ethiopian Orthodox Church
ETNEREL Ethiopian Network ofReligious Leaders Living with or Personally
A+ Affected by HIV and AIDS
EWB Existential Well-being
FBOs Faith-based Organizations
FHAPCO Federal HIV/AIDS Prevention and Control Office
FMOH Federal Ministry of Health
HAART Highly Active Antiretroviral Therapy
HAPCO HIV/AIDS Prevention & Control Office
HAPCSO HIV/AIDS Prevention, Care and Support Organization
HBV Hepatitis B
HC Health Centre
HCV Hepatitis C
HCT HIV Counselling and Testing
HIV Human Immuno-deficiency Virus
HRQL Health-related quality of life Acronyms
HSS HIV Symptom Scale
IAS International AIDS Society
IEC Information Education and Communication
IGA Income generation activity
IPA Interpretative Phenomenological Analysis
KAP Knowledge, attitude and practice
KS Kaposis sarcoma
MEMS Medication Event Monitoring Systems
MHS Mental Health Summary
MOH Ministry of Health
MOS Medical Outcomes Study
MOS-HIV Medical Outcomes Study HIV Health Survey
MVQOLI Missoula Vitas Quality of Life Index
NAC National AIDS Council
NCDs Non-communicable diseases
NCS Nutrition care and support
NGOs Non-governmental organizations
OIs Opportunistic infections
OLS Ordinary Least Square
OVC Orphan and Vulnerable Children
PHS Physical Health Summary
PLHIV People Living with HIV and AIDS
PLWHA People Living with HIV/AIDS
PMTCT Prevention of Mother-to-Child Transmission
PSD Psychosocial distress
QOL Quality of life
RWB Religious well-being
SDD Stigma, denial and discrimination
SNNPR Southern Nations, Nationalities and Peoples Region
SSDDIM Stigma, shame, discrimination, denial, inaction and mis-action
STIs Sexually transmitted infections
TASO The AIDS Support Organisation
TAWG Tanga AIDS Working Group
TB Tuberculosis viii Antiretroviral Treatment in sub-Saharan Africa
TBA Traditional birth attendants
THPs Traditional health practitioners
TMPC TraditionMedical Practitioners Council
TMPs Traditional medical practitioners
ToT Training of trainers
UAC Uganda AIDS Commission
UNAIDS United Nations Joint Programme on HIV/AIDS
UNESCO United Nations Educational, Scientific and Cultural Organization
UNICEF United Nations International Children’s and Educational Fund
VCT Voluntary Counselling and Testing
WHO World Health Organization
ZINATHA Zimbabwe National Traditional Healers Association

Getnet Tizazu Fetene

The introduction of antiretroviral therapy (ART) in middle- and
lowincome countries is arguably one of the most meaningful outcomes
recorded in the fight against HIV and AIDS. Thanks to the expansion of the
therapy in these countries, fewer and fewer people are dying as a result of
HIV and AIDS related causes. In other words, despite apparent expansion
of ART that enabled eight million people worldwide to receive the
treatment, it is reported that it is in the Sub-Saharan Africa, the region hit
hardest, that the most dramatic progress has been observed (UNAIDS
2012). A record number of some 6.2 million people living with HIV and
AIDS are reported to be benefiting from the treatment, which is reported to
have risen by 19 per cent between 2010 and 2011 (Ibid. 19). As a result of
this, the region has also enjoyed a significant decline in AIDS mortality.
The number of AIDS-related deaths, which was frighteningly 1.8 million in
the year 2005, has dropped to 1.2 million in 2011 (UNAIDS 2012). So has
morbidity. All this is good news, and the success stories are largely
attributable to the rapid expansion of ART.
Irrespective of these encouraging trends, a number of challenges/problems
have been encountered following the introduction of ART and in relation to
its expansion. The need to maintain/achieve equitable access, failure to
reach those who haven’t known their sero-status, and difficulty of
convincing people living with HIV and AIDS (PLWHA), who are reluctant
to receive the therapy until they see AIDS-related illness, are some of the
challenges observed along the expansion of ART. Poor adherence (often
leading to drug resistance), complete discontinuation of the treatment, some
long-term and short-term side-effects resulting from ART management, are
other key problems occurring following ARV (antiretroviral) therapy. The
issue of maintaining the pace at which HIV treatment is currently
expanding is also another related challenge (Ivers, Kendrick, and Doucett
2005; UNAIDS 2012).
Mostly inspired by the need to find ways of tackling these challenges,
researchers and scholars in the developed and the developing world have
been conducting various studies on ART-related issues. Even though there
appears to be a consensus among them regarding the obvious benefits of
ARV therapy, they disagree on a number of other issues, for example on
measuring level of adherence among patients, on reasons for poor
adherence, on the role of traditional medicine in HIV treatment, and on
relevant methods of conducting related studies (Ivers, Kendrick, and
Doucett 2005). The debates on these issues are ongoing and they are likely
to continue.

2 Antiretroviral Treatment in sub-Saharan Africa
At this juncture, it is perhaps worth citing some specific areas of ARV
treatment that attracted scholars’ and researchers’ attention. Mostly because
of the negative repercussions poor adherence can bring about at societal
and individual levels, it could be argued that the issue of adherence is
perhaps one of the areas that have been widely researched and debated.
Many researchers such as (see Coetzee, Kagee, and Vermeulen 2011;
Kalichman, Catz, and Ramachandran 1999; Tam et al. 2011 and Watta et
al. 2010) have, for example, conducted studies examining the possible
barriers (personal, structural or institutional) responsible for poor
adherence. The different studies have come up with different findings and
at times with conflicting results. Regarding the methods of assessing levels
of adherence, some use indirect methods (e.g. Blacher et al. 2010); some
others use direct methods (e.g. Liechty and Bangsberg 2003) and still
others employ a combination of both direct and indirect methods. Thus,
there doesn’t seem to be a consensus on the perfect method for measuring
adherence. While researchers who favour the direct method say the method
is reliable, some question its applicability in resource-constrained settings,
like the sub-Saharan Africa. Similarly, those who object to indirect
methods argue that data gathered through these methods are questionable
because of social desirability bias (Blacher et al. 2010). The studies
included in this volume could be considered a continuation of and
contributions to this ongoing debate on a number of ART- related issues.
This volume, titled “Antiretroviral Treatment in sub-Saharan Africa:
Challenges and Prospects”, is the outcome of the ‘call for abstracts’ put out
by OSSREA in 2011 for senior researchers, social scientists and
practitioners to write scientific articles on issues surrounding ARVs.
Recognising the intricacies of numerous but often linked concerns
surrounding ARVs, OSSREA invited interested authors to write book
chapters, focusing on the following issues:
Quality of life of patients under ARV treatment; social support
systems to PLWHA in ARV treatment; role of gender, age, class, and
ethnicity in determining patients’ access to ARVs of life; and
effectiveness of policies and programmes which attempt to ensure
equitable and non-discriminatory access to ARVs;
The link between the formal and informal HIV and AIDS treatment
services, particularly on the role of informal health providers,
including traditional and faith-based healers, in influencing patients’
decision to receive and adhere to or refrain from ARVs treatment;
The supportive role of community-based organizations (CBOs),
nongovernmental organisations (NGOs), and the private sector,
especially in enhancing confidential, equitable and
nondiscriminatory provision of ARV treatment;
Scaling up ARV and government budgetary allocations, support
programmes for increasing access to patients, and roles of
Getnet Tizazu Fetene. Introduction 3
international, continental and regional organizations in sub-Saharan
Africa in ensuring sustained provision and use of ARV treatments.
This volume contains eight chapters organized into four sections. The
chapters are contributed by Academics and researchers from three different
African countries: four from Ethiopia, two from Uganda and two from
Zimbabwe. The chapters put into the four sections have four themes: 1)
ART and quality of life, 2) Adherence to ART, 3) Traditional medicine and
ART, and 4) Sexual behaviour of ART attendants. While Sections I and III
consist of two chapters each, Section II contains three chapters. Included in
Section IV is just a chapter. Whereas two of the chapters incorporated in
the first section are review works, the other six chapters presented under the
three sections are results of original empirical studies. Four of the six
empirical studies included in the volume employed qualitative methods
while the other two are more of quantitative studies. Chapter Six, a study
by Wasswa-Matovu is purely quantitative and it employs sophisticated
statistics like logistic regression. The fifth chapter by Woinishet and Abiy
is the only chapter that employed mixed methods (i.e. quantitative and
qualitative). It could thus be said that the book contains chapters that are
the result of studies that employed quite a variety of methods, and is
apparently balanced in terms of methodology.
The two review articles, “Adherence to Antiretroviral Therapy in
subSaharan Africa: Challenges and Prospects” and “Quality of Life among
Patients Living with HIV and AIDS in sub-Saharan Africa” are
intentionally included in the first section of the volume for two reasons. In
the first place, in their comprehensive review of empirical works and
theoretical issues, the two articles have attempted to offer the major debates
raised on the subject in the region in particular and in the world as a whole.
Secondly, the articles are complementary and foreshadow the kind of
empirical works that need to be carried out.
Driven by the paucity of comprehensive review studies on ART in
subSaharan African region, in the second chapter titled “Adherence to
Antiretroviral Therapy in sub-Saharan Africa: Challenges and prospects”,
Sibhatu Biadgilign and Ayalu Aklilu critically assess works that evidence
challenges in and prospects of ART adherence in the region. To that effect,
the authors make a thorough search of the literature from six online
bibliographic sources and big databases of conference abstracts using some
nine different relevant search items. The search has resulted in over 100
articles and abstracts written in English, which in turn led to analyses of
works reviewed under three thematic headings: 1) adherence estimates, 2)
adherence barriers, and 3) suggested solutions for mitigating the problem.
With respect to an overall adherence estimates, contrary to expectations,
Sibhatu and Ayalu report a high degree of adherence ranging from 75 per
cent to 77 per cent, a much higher level of adherence than the one reported
in North American studies (55 per cent). The finding is in agreement with
Ivers, Kendrick and Doucett’s (2005) meta-analyses. On a negative note, 4 Antiretroviral Treatment in sub-Saharan Africa
the chapter reveals that, albeit the overall encouraging ART
coverage/adherence among the adult PLWHA, the adherence among
children and young adolescents is not that encouraging. The review has
shown a number of challenges and problems resulting from poor
adherence; and they are categorized under: patient and family-related
challenges, socio-economic and environmental challenges,
medicationrelated challenges, health care- and systems-related challenges, and patient-
and family-related challenges. More specifically, regarding paediatric
patients, the review has indicated that age, treatment refusal, knowledge
about HIV status and treatment process, and depressive symptoms affect
ART adherence. Denial and fear of HIV status, misinformation and
misconceptions about HIV, low availability of ART, accessibility and
acceptance of therapy are identified as some of the problems preventing
HIV-infected adolescents from benefiting from ART. The administration of
complex regimens also compounded the problems.
Lack of the will to disclose one’s own sero-status to friends and family
members is also reported as a predictor to poor adherence among adults. In
relation to socio-economic and environmental challenges, poverty-related
factors, for example, financial troubles, and distance or lack of
transportation to the ART clinic are identified as some of the reasons for
poor adherence.
With respect to solutions to mitigating adherence problems, the third
major theme, the authors generally underlie the need to maintain
regulated access to ART and avoid individual’s treatment failure. Failure
to do so, the author’s caution, would lead to “rapid emergence of
drugresistant viral strain” and “the transmission of drug-resistant strains of
HIV” that would seriously hamper future treatment efforts. The authors
further call for rigorous evaluative and operational research on ART
service provision. The chapter winds up by offering a conceptual
framework that sums up factors that determine adherence to ART, with
implications for possible intervention.
The overall objective of the third chapter by Bajunirwe is to provide
aggregate evidence and research on quality of life (QOL) among
HIVinfected patients in sub Saharan Africa. In this chapter, the author argues
for the need to provide such a comprehensive review since the literature on
QOL is dominated by empirical studies from the West, where ART has
been available for a much longer period of time. In Africa, where free ART
is a recent phenomenon—a little more than five years old— works that
offer a review of studies on factors that affect the quality of life of PLWHA
is, according to the author, scanty. Unlike related reviews such as Beard,
Feeley, and Rosen (2009) which were dominatly on the impact of ART on
quality of life (QOL), Bajunirwe’s review is more comprehensive. It first
chronicles factors that influence QOL of PLWHA prior to the initiation of
ART. It then examines factors (variables) that positively or negatively
affect the quality of life of people who are on ART.