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Drugs for life: Factors inhibiting adherence
By Abiose Adelaja

The fear of being seen taking drugs at the office or the challenge of being caught in a public transport at the time for the daily dose of ARV are some factors from several others which are challenges affecting drug adherence by people living with HIV/AIDS (PLWHA). The implication of non adherence poses serious health consequences for people living with HIV.

Swallowing thick, bulky, chalky tablets Drugs for lifeeveryday for a lifetime doesn't sound so bad if it will save your life, does it? But it is one of the major complexities in HIV treatment that one might only understand if one is compelled to follow such a regimen. Inconsistency in observing this somewhat irksome routine empowers the very cunning virus to develop resistance strains to the antiretroviral drugs which are meant to reverse its replication and stop the progression of HIV to AIDS.

Current statistics estimate that there are 6.1 million people living with HIV in Nigeria and 540,000 in need of ARV. The introduction of the ART is a relief for people living with HIV/AIDS because if drugs are strictly adhered to, the concentration of the HIV (viral load) in the blood can become highly suppressed to an undetectable level! Records have it that progression to AIDS has been greatly reduced, diminishing the possibility of early death except where there are treatment complications or failure

However, it doesn't augur well for a positive person who needs ARV treatment to short-change himself or herself by not adhering to their drug demands. Initially, the challenge with ARV therapy came from the lack of access to drugs because of the high cost of treatment. However, there are international charitable missions giving comprehensive treatment for free, such as Doctors Without Borders (MSF). More so, the Federal Government of Nigeria has, since January 2006, declared ARV therapy to be free in all federal treatment clinics. Altogether, in both the Federal and private centers total number of people on treatment is put at 75,000.

"With the quality of our counseling here, treatment and free services, we expected at least 95 per cent adherence rate, but we got 63 per cent adherence level," says, Adetutu Oyedele, an Adherence Counsellor, at the MSF clinic at General Hospital, Lagos.
She observes that the patients adhere strictly during the first six months when they are sick and are eager to get well. "After a while they begin to decline. I think I want to trace it to the natural law of diminishing returns," she says.

For someone who is not used to taking drugs, undergoing antiretroviral treatment means discipline, timeliness and alacrity because drugs must be taken every twelve hours if they are to remain effective. And the dosage must not be missed more than thrice in a month, otherwise, resistance to the therapy will develop, and as a result, the potency of the drugs (called first line drugs) will be reduced. This will require placing the individual on the second line drugs.

Second line drugs are the ARVs with stronger potency than the first line drugs and are usually administered when a person develops resistance to the first line drugs. The implications are varied: The second line drugs are usually much more expensive and less readily available. As well danger looms for such a person, because developing resistance at this point could lead to full-blown AIDS.

"A person who did not adhere to first line drugs cannot adhere to second line drugs. So we always advice them to prevent the possibility of getting on the second line, Oyedele says.

According to Ibrahim Umoru, an HIV counselor "Though everything is made free and easy for patients, but we find that sometimes these people don't even have the money to transport themselves down to the clinic. Stigmatization is another factor that fuels adherence failure."

At a leading research institution in Lagos and one of the pioneering sites for HIV research and treatment, the situation is the same.

"Our patients don't take their dDrugs for liferugs because of stigma," says Dr. Oliver Ezechi, a senior research fellow at the Nigeria Institute of Medical Research (NIMR). "They hide their drugs from an employer, a spouse or friends. And where they hide these drugs sometimes may not be the right atmosphere, because there is a right temperature under which these drugs must be stored," he adds.

In his observation at the clinic, when the patients get their drugs, some of them tear off the cover, so that no one can see or understand what the container carries. Truth is, on this cover is written the prescription's directions. "How can he follow the instructions, when he had already torn the cover?. It boils down to stigma."

Poverty and stigmatization are some other social factors for non-adherence. However multi-drug interaction and certain side effects are some other reasons affecting adherence. Some people, when on treatment for tuberculosis, are often asked to stop taking ARV therapy to avoid drug interaction and side effects.

Elizabeth Ajiboye is a positive woman who the doctor asked to stop taking a particular ARV drug regimen because she was undergoing TB treatment. "By the time I had to resume taking my ARVs, I have lost my memory. So I was always forgetting to take my drugs." For her, memory loss as a side-effect was responsible for her non-adherence. But she said it took the help of her support group of PLWHA who always called her to remind her to take her drugs.

The role of support groups is quite significant in adherence. They do follow up at home. Also incorporating family members into counseling programmes helps. Although it takes just one person who is openly positive to achieve this result, most still prefer secrecy because of stigmatization.

Non-adherence remains a significant public health concern because it causes different strains of the virus to become resistant to drugs. If given an opportunity, the HIV virus works tenaciously to mutate in resistance to the drugs. That is why they must be taken religiously so as not to give the virus a chance to mutate. If an infected person is not scrupulous, they could ultimately pass on this drug-resistant virus to someone else, who will pass it along to others and create a population of HIV positive people who do not respond to ARV treatment.

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