Adherence and sustained access to antiretroviral treatment in the Free State public health sector: a gender perspective - De Reuck, Chantell Jacqualine (University of the Free State, 2008)
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≤0.05). 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.

Volgehoue toegang tot teenretrovirale behandeling en die nakoming van voorskrifte vir die gebruik van teenretrovirale medikasie bly deurslaggewend vir die vermindering van Vigsverwante mortaliteit en morbiditeit, die minimalisering van die ontwikkeling van middelweerstandigheid en vir toepaslike besluitneming aangaande behandeling deur gesondheidsorgvoorsieners. Dus moet die faktore wat verband hou met nienakoming van teenretrovirale medikasievoorskrifte en swak volgehoue toeganklikheid geïdentifiseer en hanteer word. Alhoewel heelwat navorsing gedoen is ten opsigte van behandelingsnakoming - waarin die sosiale aspekte van die wyse waarop pasiënte MIV/Vigs en verbandhoudende behandeling hanteer geïdentifiseer is - is veel minder aandag egter geskenk aan die relevante genderdimensies van behandeling, sorg en ondersteuning. Die doel van hierdie studie was om die invloed van gender op die nakoming van teenretrovirale medikasievoorskrifte en ook op die volgehoue toeganklikheid tot behandeling onder pasiënte in die openbare gesondheidsektor in die Vrystaat te ondersoek. Verskeie metodes is nodig geag om hierdie doel te bereik. Eerstens is die huidige literatuur hersien met die oog op identifikasie van die faktore wat nienakoming van teenretrovirale medikasievoorskrifte voorspel en volgehoue toeganklikheid tot teenretrovirale behandeling belemmer. Tweedens is ‘n raamwerk aangepas om vanuit ‘n genderperspektief op ongelykhede ten opsigte van behandeling te fokus, asook om kennis te neem van die wyse waarop sowel biologiese geslag as sosiaal-gekonstrueerde gender die gesondheid van pasiënte op teenretrovirale behandeling beïnvloed, met spesifieke verwysing na toeganklikheid en nakoming van behandeling. Manlikheid en vroulikheid word bespreek in terme van die uiteenlopende hulpbronne waartoe ‘n individu toegang toe en beheer oor het, ‘n individu se besluitnemingsmag, die gendernorme wat die samelewing huldig, asook die genderrolle waaraan mans en vroue verwag word om te voldoen. Derdens is ‘n empiriese ondersoek uitgevoer op die data van ‘n voortgesette kohortstudie ten einde ooreenkomste en verskille te identifiseer met betrekking tot die faktore wat verband hou met nie-nakoming van die voorskrifte van teenretrovirale medikasie en met swak volgehoue toeganklikheid vir mans en vroue op teenretrovirale behandeling in die Vrystaat se openbare gesondheidsektor. Aan die hand van semigestruktureerde vraelyste is persoonlike onderhoude met 1609 pasiënte gevoer. Ses onderhoude is tydens die verloop van die studie met pasiënte gevoer, met gemiddelde tussenposes van ses maande tussen onderhoude. Die uitkomsveranderlikes wat geassesseer is, het ingesluit: selfgerapporteerde sewedaagse nakoming van teenretrovirale medikasievoorskrifte en selfgerapporteerde nakoming van geskeduleerde afsprake oor ‘n periode van ses maande as ‘n maatstaf van volgehoue toegang tot behandeling. In alle ontledings is geslag as die afhanklike veranderlike gebruik. Demografiese, psigo-sosiale/gedrags-, kliniese, en diensleweringsveranderlikes is almal getoets vir ‘n statisties-beduidende verband met nie-nakoming van medisynevoorskrifte, asook afsprake in afsonderlike geslagsgedisaggregeerde meervoudige regressie-analises (P≤0.05). Logistiese regressiemodelle het aangetoon dat die sterkste voorspellers van medikasie nie-nakoming by mans finansiële probleme in verband met besoeke aan hospitaalfasiliteite en swak behandelingskennis was. By vroue is tabakgebruik en waargenome stigma geïdentifiseer as die sterkste voorspellers van medikasie nienakoming. Selfgerapporteerde depressie of angs, probleme ten opsigte van besoeke aan kliniek- en hospitaalfasiliteite het vir mans en vroue op dieselfde wyse verband gehou met nie-nakoming van afsprake. Dienstevredenheid by klinieke en enkele selfgerapporteerde diensbehoeftes het ook onafhanklik verband gehou met afspraak nie-nakoming. Daar dien op gelet te word dat die bevindinge ten opsigte van mans met omsigtigheid geïnterpreteeer moet word, aangesien albei uitkomsmaatstawwe in die geval van mans nie geldig was nie, ten spyte daarvan dat hulle wel geldig was vir die gekombineerde steekproef en vir vroue. Beduidende verskille en ooreenkomste is geïdentifiseer in die faktore wat medikasienakoming en volgehoue toegang tot behandeling by mans en vroue beïnvloed. Dit reflekteer die uiteenlopende geleefde ervaringe van mans en vroue op teenretrovirale behandeling in die Vrystaat. Derhalwe is gender-sensitiewe en niegestandaardiseerde intervensies nodig om nakoming en volgehoue toegang in hierdie populasie te verbeter. Verdere navorsing en moontlike intervensies word benodig ten opsigte van gender-sensitiewe uitkomsmaatstawwe vir nakoming, ten opsigte van die bevordering van mans se kennis omtrent behandeling, ten opsigte van vroue se vermoëns om geslagsrolstressors te hanteer, ten opsigte van minder stigmatiserende wyses waarop medikasie geneem kan word, ten opsigte van die verbetering van geestesgesondheid en ten opsigte van die verbetering van die gehalte van dienste by gesondheidsorgfasiliteite gelewer.
Thesis (Ph.D. (Sociology))--University of the Free State, 2008
Keywords: Patient compliance -- South Africa -- Free State; Antiretroviral agents -- Therapeutic use -- South Africa -- Free State; HIV infections -- Treatment; AIDS (Disease) -- Treatment; Femininity; Masculinity; Social construction; Sex; Gender; Sustained access; Adherence; Antiretroviral treatment; Human immunodeficiency virus; Acquired immunodeficiency syndrome