Uptake, adherence and discontinuation of antiretroviral treatment in the Kibera slum, Nairobi, Kenya

Background: As antiretroviral treatment (ART) is being scaled-up, long-term success depends on high adherence to ART and retention in care. Rapid urbanization and growing slum populations present specific challenges for sustaining HIV-infected patients on ART.

Aim: To study determinants for low adherence to ART in an urban slum in sub-Saharan Africa and to explore factors related to drop-out from ART.

Methods: All studies were conducted at the Médecins Sans Frontières s (MSF) or at the African Medical Research Foundation s (AMREF) HIV clinics in the Kibera slum, Nairobi, Kenya. Study I: 26 patients eligible for ART at the MSF clinic who choose to not initiate ART were interviewed to understand underlying reasons. Study II: Patient records were reviewed to study access to ART during the violence in Kibera following the general elections in Kenya 2007/08. Study III: Adherence to ART and drop-out from the programme was analyzed retrospectively through review of 830 patient records. Study IV: 20 patients known to have dropped-out of ART to seek alternative care/cure, were interviewed about their reasons. Study V: A prospective cohort study of 800 patients to analyze dose-adherence to ART by creating an adherence index based on dosing, timing and special instructions and performing Cox-regression survival analysis to study time to drop-out.

Findings: Study I: The main reason for not accepting ART was fear of taking medication on an empty stomach due to lack of food. Study II: During post-election turbulence in January 2008, 42% of 447 scheduled appointments were missed compared to 14% in January 2007. Study III: 27% of ART patients had a mean adherence below 95%. No factor remained independently associated with low adherence. 29% dropped out more than 90 days after the last prescribed dose. Residence in Kibera was associated with drop-out. The probability of remaining on treatment was 0.83 at 6 months, 0.74 at 12 months and 0.65 at 24 months. Study IV: The most important reasons for dropping-out from ART related to religious beliefs and traditional medicine were: patients firm belief that traditional medicine was more effective/had fewer side effects compared to biomedical medicine; faith, praying and religious practices to seek cure from HIV; negative attitudes from religious leaders; and; important personal trigger events. Study V: Among 800 patients, 11% were non-adherent at 6 months follow-up (dose-adherence<95%). Undisclosed HIV-status and living below the poverty limit were significant predictors of adherence <95%. Using the adherence index, also taking adherence to timing and special food instructions into account, 38% of patients were defined as non-adherent. Lack of treatment buddy and low education were significant risk factors. Almost 1 in 4 dropped-out from the ART programme for more than 90 days after the last prescribed dose. Cox regression analyses showed a significantly higher hazard ratio for people who lacked a treatment buddy for support.

Conclusion: Sustaining HIV patients on ART in high-risk and highly mobile settings such as urban slums is a major future challenge. The high proportion of patients dropping out from ART and being non-adherent must be addressed using context-specific solutions. It is important to invest more in poverty reduction strategies in general, but also to encourage an open, non-judgmental discussion between patients and providers around possible foreseen challenges to treatment maintenance e.g. food shortages, religion and traditional medicine, in order to strengthen uptake and adherence to ART and to reduce drop-out from ART, especially important in resource-poor settings where stigma, and poverty is prevalent.

List of scientific papers

I. Unge C, Johansson A, Zachariah R, Some D, Van Engelgem I, Ekstrom AM. (2008). "Reasons for unsatisfactory acceptance of antiretroviral treatment in the urban Kibera slum, Kenya" AIDS Care 20: 146-149.
https://doi.org/10.1080/09540120701513677

II. Unge C, Södergård B, Thorson A, Ragnarsson A, Carter J, Ilako F, Waweru M, Ekström AM (2008). "HIV treatment in times of civil strife: serious threats to antiretroviral drug access in the Kibera slum following the Kenyan elections" AIDS 22: 1693-1694. 18670238
https://doi.org/10.1097/QAD.0b013e32830a751a

III. Unge C, Södergård B, Ekström AM, Carter J, Waweru M, Ilako F, Ragnarsson A, Thorson A. (2009). "Challenges for scaling up ART in a resource-limited setting: a retrospective study in Kibera, Kenya" J Acquir Immune Defic Syndr 50: 397-402.
https://doi.org/10.1097/QAI.0b013e318194618e

IV. Unge C, Ragnarsson A, Ekstrom AM, Indalo D, Belita A, Carter J, Ilako I, Sodergard B. (2010). "The impact of traditional medicine and religion on discontinuation of ART in an urban informal settlement in Nairobi, Kenya." [Submitted]

V. Unge C, Sodergard B, Marrone, G, Thorson A, Lukhwaro A, Carter J, I lako J, Ekstrom AM. (2010). "Long-term adherence to antiretroviral treatment and program drop-out in a high-risk urban setting in sub-Saharan Africa. A prospective cohort study." PLoS ONE. [Accepted]
https://doi.org/10.1371/journal.pone.0013613