SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA FACTORS ENHANCING CD4+T-CELL RECOVERY AMONG HIV POSITIVE PATIENTS ON HIGHLY ACTIVE ANTIRETROVIRAL THERAPY FOR ONE YEAR AT THE KORLE-BU TEACHING HOSPITAL, ACCRA. BY ADJOA OBO-AKWA (10507018) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2015 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I, Adjoa Obo-Akwa, declare that except for the other studies which have been duly acknowledged, this work is the result of my own original research, and that this dissertation, either in whole or in part has not been presented elsewhere for another degree. __________________________ _________________________ ADJOA OBO-AKWA DATE STUDENT _________________________ ___________________________ DR. JUDITH K. STEPHENS DATE SUPERVISOR University of Ghana http://ugspace.ug.edu.gh iii DEDICATION I dedicate this dissertation to Almighty God. I also dedicate this dissertation to my lovely mother, Madam Isabella Esi Etruba Enyimayew; indeed I have seen the love of a mother during this project period. Thank you mama. I really appreciate every bit of your love towards me. God bless you richly in Jesus‟ name, Amen. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT I acknowledge my academic supervisor, Dr Judith K. Stephens for her time and input throughout this dissertation period. Thank you for your valuable time and the corrections you made. My appreciation goes to the staff and clients of Fevers‟ Unit, Korle-Bu Teaching Hospital. I appreciate every bit of all the assistance and I say thank you. Thank you to my husband for his support and understanding throughout the study period at the School of Public Health. I also appreciate all my academic friends like Dr Ernest Kenu, Dr Akua Obeng, Charles, Callista, Makafui and Ayomide for your help in the statistics aspect of the dissertation. Class of MPH 2014/2015 is also duly acknowledged for all the teamwork, comments and togetherness. Indeed every student helped me in one way or the other, what a lovely cohort! My family is also acknowledged; the Obo-Akwas, the Enyimayews, the Abbeyquayes and the Affuls. Thank you for all the support. University of Ghana http://ugspace.ug.edu.gh v ABSTRACT The Human immunodeficiency virus (HIV), the etiologic agent of Acquired Immunodeficiency Syndrome (AIDS), since it was discovered in 1981, has become a global pandemic, because it acts by breaking down the immune system exposing the infected persons to other diseases and causing high mortalities. Currently, an estimated 34 million of the world populations are infected with the virus and results in millions of deaths around the world. CD4+T-cells (Cluster of Differentiation T-Lymphocyte cells) are part of the white blood cells which play important role in immune defense during an etiologic infection in a host. CD4+T-cells are attacked by the HIV which reduce their numbers. Antiretroviral Therapy (ART) was introduced to reduce the adverse effects of the virus. The ART reduces the viral load and allows the CD4+T- cells to increase. This study sought to find out the socio-demographic factors of HIV positive patients and the hospital/system factors that enhance CD4+T- cell recovery among clients initiated on the Highly Active Antiretroviral Therapy (HAART) for at least one year. The study was conducted at the Fevers Unit of the Korle- Bu Teaching Hospital, Accra. HIV positive adult patients managed with HAART for one year participated in the study. Selection was done by random sampling from the computer database. A semi-structured questionnaire was administered, after obtaining informed consent to collect data on the socio-demographics, hospital/system factors and CD4+T-cell counts status of the respondents as well. A total of 270 respondents participated in the study. The mean age was 44±8.9 years. Males constituted 27% (n=73) and females 73% (n=197). Few of them had tertiary education (6%). Majority, 93% (250/270) of the respondents had medium adherence. Age, sex, educational level and adherence were all found to contribute to CD4+T-cell University of Ghana http://ugspace.ug.edu.gh vi recovery and the prevalence of co-infections was 25%. Hospital/system factors, especially the belief that most people will be treated with respect by health care workers if they have HIV/AIDS was associated with CD4+T-cell recovery at p=0.020. All the respondents (100%) were very satisfied with the clinic schedule and waiting time at the clinic while 62% (n=168/270) agreed the service received was just about what was expected. HIV/AIDS care is very important and HAART reduces the associated morbidity and mortality. The following factors: age, sex, educational level, income level, adherence, residence, doctors/nurses relationship to patients, HAART availability, confidentiality and cost of care were found to impact on enhancing CD4+T-cell recovery. University of Ghana http://ugspace.ug.edu.gh vii TABLE OF CONTENTS Content Page DECLARATION .................................................................................................................. ii DEDICATION .....................................................................................................................iii ACKNOWLEDGEMENT ................................................................................................... iv ABSTRACT .......................................................................................................................... v TABLE OF CONTENTS .................................................................................................... vii LIST OF TABLES ................................................................................................................ x LIST OF FIGURES ............................................................................................................. xi LIST OF ABBREVIATIONS ............................................................................................. xii CHAPTER ONE ................................................................................................................... 1 INTRODUCTION ................................................................................................................ 1 1.1 Background ................................................................................................................. 1 1.2 Statement of the Problem ............................................................................................ 2 1.3 Conceptual Framework ............................................................................................... 4 1.4 Justification of the Study ............................................................................................. 6 1.5 Objectives .................................................................................................................... 6 1.5.1 General Objective ................................................................................................. 6 1.5.2 Specific Objectives ............................................................................................... 6 CHAPTER TWO .................................................................................................................. 8 LITERATURE REVIEW...................................................................................................... 8 2.1 Global Prevalence of HIV ........................................................................................... 8 2.2 Factors contributing to enhanced CD4+T-cell recovery among those initiated on HAART ........................................................................................................................... 11 2.2.1 Socio-demographic/patient factors ..................................................................... 11 2.2.2 Hospital/System factors ...................................................................................... 13 University of Ghana http://ugspace.ug.edu.gh viii CHAPTER THREE ............................................................................................................. 15 METHODOLOGY .............................................................................................................. 15 3.1 Study Design ............................................................................................................. 15 3.2 The Study Location ................................................................................................... 15 3.3 The Study Population ................................................................................................ 15 3.3.1 Inclusion Criteria ................................................................................................ 16 3.3.2 Exclusion Criteria ............................................................................................... 16 3.4: Study Variables ........................................................................................................ 16 3.4.1 Dependent variable ............................................................................................. 16 3.4.2 Independent variables were ................................................................................ 16 3.5 Sample Size Calculation ............................................................................................ 16 3.6 Sampling Methods. .................................................................................................... 17 3.7 Data Collection Tools and Techniques...................................................................... 17 3.8. Training of Research Assistants ............................................................................... 18 3.9 Pre-Testing ................................................................................................................ 18 3.10 Data Handling and Processing................................................................................. 19 3.11 Data Analysis .......................................................................................................... 19 3.12. Ethical Consideration ............................................................................................. 19 3.13 Limitations to the study ........................................................................................... 20 CHAPTER FOUR ............................................................................................................... 21 RESULTS ........................................................................................................................... 21 4.1. Socio-Demographic Characteristics of Respondents: .............................................. 21 4.2: Respondents Clinical Characteristics: ...................................................................... 22 4.3. Mean CD4+T-Cell Counts ....................................................................................... 24 4.4: Hospital/System factors ............................................................................................ 25 4.4.1. Doctors/Nurses relationship to patients ............................................................. 25 University of Ghana http://ugspace.ug.edu.gh ix 4.4.2. Cost of Care: ...................................................................................................... 25 4.4.3. Confidentiality: .................................................................................................. 25 4.4.4. Availability of laboratory reagents and equipment: .......................................... 25 4.4.5. Availability of drugs (HAART):........................................................................ 25 4.4.6. Long waiting time at the clinic .......................................................................... 25 4.5: Factors associated with CD4+T-cell Recovery ........................................................ 27 CHAPTER FIVE ................................................................................................................. 34 DISCUSSION ..................................................................................................................... 34 5.1 Mean CD4+T-cell counts .......................................................................................... 34 5.2 Socio- demographic/Patient factors ........................................................................... 34 5.3 Hospital/System factors ............................................................................................. 37 5.4 Hospital factors associated with CD4+T-cell Recovery is Respect .......................... 39 CHAPTER SIX ................................................................................................................... 41 CONCLUSION AND RECOMMENDATIONS ................................................................ 41 6.1 Recommendations ..................................................................................................... 41 REFERENCES .................................................................................................................... 43 APPENDICES .................................................................................................................... 50 Appendix 1: Consent Form ............................................................................................. 50 Appendix 2: Questionnaire .............................................................................................. 52 University of Ghana http://ugspace.ug.edu.gh x LIST OF TABLES Table 1: Socio-demographic Characteristics of 270 Respondents on HAART at Korle- Bu Teaching Hospital, Accra ..................................................................................... 21 Table 2: Clinical and Health Service Characteristics of Respondents‟ on HAART at Korle- Bu Teaching Hospital, Accra ............................................................................... 23 Table 3: Difference in means of CD4+T-cells at baseline (CD41+T-cell counts) and at 1 year of initiation of HAART (CD42+T-cell counts) ............................................ 24 Table 4: Respondents‟ Assessment of Hospital /System Characteristics at the Korle-Bu Teaching Hospital, Accra ..................................................................................... 25 Table 5: Socio-demographic Factors Associated with CD4+T-cell Recovery among Respondents‟ on HAART at the Korle Bu Teaching Hospital, Accra, 2015. ...... 28 Table 6: Clinical and Health Service Factors Associated with CD4+T-cell Recovery among Respondents on HAART at Korle- Bu Teaching Hospital, Accra ........... 29 Table 7: Socio-demographic Factors Associated with CD4+T-cell Recovery among Respondents on HAART at KBTH, Accra, using Logistic Regression. .............. 30 Table 8: Health System Factors associated with CD4+T-cell Recovery among Respondents on HAART at the Korle- Bu Teaching Hospital, Accra. ................ 31 Table 9: Health System Factors Associated with CD4+T-cell Recovery using logistic regression at the Korle- Bu Teaching Hospital, Accra ........................................ 32 Table 10: Co-infections and the distribution of CD4+T-cell recovery among Respondents on HAART at Korle- Bu Teaching Hospital, Accra ............................................ 33 University of Ghana http://ugspace.ug.edu.gh xi LIST OF FIGURES Figure 1: Conceptual Framework showing the effect of demographic patient factors and hospital/system factors on CD4+T-cell recovery ........................................................... 5 University of Ghana http://ugspace.ug.edu.gh xii LIST OF ABBREVIATIONS AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy ARV Antiretroviral cART Combination Antiretroviral Therapy CD4+T-Cells Cluster of Differentiation T-Lymphocyte cells GAC Ghana AIDS Commission HAART Highly Active Antiretroviral Therapy HIV Human Immunodeficiency Virus KBTH Korle-Bu Teaching Hospital NACP National AIDS/STI Control Program NGO Non-Governmental Organization NHIS National Health Insurance Scheme PLHIV People Living with HIV STI Sexually Transmitted Infections TB Tuberculosis WHO World Health Organization University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background The Human Immunodeficiency Virus (HIV) is the etiologic agent of Acquired Immunodeficiency Syndrome (AIDS). The virus infects the vital organs of the human immune system, alters it and make the infected more vulnerable to infections and diseases and when not checked progresses to AIDS (MNT, 2015). The first AIDS case was reported in Los Angeles, United State of America in June, 1981 (CDC, MMWR, 2001). Around 35 million people are living with HIV/AIDS worldwide in 2013 and 1.5 million people died of AIDS- related deaths in the same year, (WHO,2015). About 23.5 million people are infected in sub-Saharan Africa with the virus. The first case of AIDS was reported in Ghana in 1986, since then there has been a rise in the number of people, both adults and children infected by HIV ((WHO, 2005, NACP, 2010). The 2013 sentinel survey from the Ghana AIDS Commission (GAC) puts the national prevalence at 1.3% (GAC, 2014). The HIV and AIDS epidemic remains a threat to the economies of many nations particularly in sub-Saharan Africa, including Ghana. Antiretroviral Therapy (ART) was started in Ghana in 2003 and has proved to be a major lifeline for People Living with HIV (PLHIV) and an important HIV preventive intervention that ensures minimal new infections in the general population (NACP, 2012). The introduction of Highly Active Antiretroviral Therapy (HAART) has resulted in significant decreases in HIV-related morbidity and mortality in both the developed and developing countries (Lartey et al., 2014). The World Health Organizations (WHO) guidelines for antiretroviral therapy University of Ghana http://ugspace.ug.edu.gh 2 initiation were reviewed by the NACP (National AIDS/STI Control Programme) in 2010. The guidelines recommend that HAART should be started when Cluster of Differentiations T-Lymphocyte cell (CD4+T-cell) counts is below 350cells/µl. The CD4+T-cell counts measures the degree of immunosuppression in HIV-positive patients, used as an indicator for the commencement of antiretroviral therapy, in staging the disease and for the determination of treatment failure (Akinbami et al., 2012). CD4+T-cell counts have been used to monitor the progress of patients initiated on HAART. The monitoring of CD4+T-cell counts and its understanding are a basis for assessing the effectiveness of most HIV treatments and how patients respond to treatment with time. Even though CD4+ T-cell recovery is observed in patients initiated on ART, quite a number of factors have been shown to affect how the recovery takes place (Crum- Cianflone et al., 2010). The level of CD4+T-cell increase was found to be inversely associated with age (Akinbami et al., 2012, Luguterah and Mustapha, 2013 and Semeere et al., 2014). 1.2 Statement of the Problem The spread of HIV/AIDS can be checked by the initiation of ART among HIV positive patients. Ghana started implementing the WHO guidelines on HAART initiation in 2003 through the Ghana Health Service, Ghana AIDS Commission (GAC) and National AIDS/STI Control Programme. HIV positive patients with low CD4+T-cell counts (< 350c/µl) received a combination antiretroviral therapy (cART) or HAART comprising of University of Ghana http://ugspace.ug.edu.gh 3 three ART medications from at least two classes of antiretrovirals, currently the recommended treatment for HIV infection for adults and children (Siegfried, 2013) . A lot of research has been carried out on the outcome of HAART between patients in lower and higher income countries which shows that while on HAART, mortality was higher in low-income countries than those in higher income countries (Dabis et al., 2006). HAART has also been found to suppress the viral load and enhance immunological recovery by increase in CD4+T-cells (Mulu et al., 2014). In Ghana, studies on factors that affect the treatment of patients on HAART, have also been carried out in the Northern Region by (Luguterah & Adams, 2013) involving the pattern of CD4+T-cell dynamics among patients who have been initiated on HAART and found out that the effectiveness of treatment decreased with time. While marital status and gender did not have any significant effect on the CD4+T-cell counts, religious and educational level of the patients had an effect. Although the Korle-Bu Teaching Hospital is one of the hospitals which provides medical care and HAART to HIV positive patients, not much research has been done with respect to the factors that enhance CD4+T- cell recovery. Anecdotally the HAART is expected to increase the CD4+T-cell counts of these patients. However, empirical evidence to substantiate this notion is limited. Patients initiated on HAART, experience more energy, gain weight, better sleep and are motivated to do more physical activity (Collen et al., 1999) as an indication of better immunological recovery due to rise in their CD4+T-cell counts. Even though this is what is normally expected, some patients don‟t feel any improvement. Quite a number of University of Ghana http://ugspace.ug.edu.gh 4 factors affect how the CD4+T-cell count increase in patients on HAART. The level of rise or recovery of CD4+T-cell count among those initiated on HAART for at least one year has not yet been determined at the Korle-Bu Teaching Hospital. This study seeks to find evidence and document the CD4+T-cell recovery, determine the factors that have contributed to the enhancement of immune recovery in patients who are initiated on HAART. 1.3 Conceptual Framework Generally, when a patient is initiated on HAART, a recovery of the immunological system is expected, depicted by an increase in the CD4+T- cell counts of between 50-150cells/µl, but some patients do not achieve this increase (Gaardbo, et al., 2012). There are so many factors which affect the CD4+T-cell increase. These include, but not limited to the socio- demographic factors which include age, sex, educational level, income level, occupation, place of residence, adherence to the drug, disease condition and baseline CD4+T-cell counts at initiation of HAART, and the viral load. There are also hospital/system factors which influence the immune response of the patients initiated on HAART. These include the availability of the HAART, long waiting time at the clinic, confidentiality issues, availability of laboratory reagents and equipment, doctors/nurses relationship to patients, and cost of care. University of Ghana http://ugspace.ug.edu.gh 5 Figure 1: Conceptual Framework showing the effect of socio- demographic patient factors and hospital/system factors on CD4+T-cell recovery University of Ghana http://ugspace.ug.edu.gh 6 1.4 Justification of the Study A lot of research has been carried out concerning factors enhancing CD4+T-cells recovery in other hospital facilities. The NACP introduced the HAART combination since 2003 and this research seeks to find out what has been happening to the patients who have been initiated on these HAART according to the WHO guidelines. Generally HAART is supposed to improve the lives of the patients, prolong disease progression to AIDS and wasting syndrome, restore and preserve the immune system of the patients infected by HIV and reduce HIV associated morbidity and mortality among those infected (WHO, 2008). According to the WHO guidelines (WHO, 2008), an adequate response to ART is defined as an increase in CD4+T-cell count in the range of 50-150cells/µl, during the first year of ART. This study seeks to determine rise of CD4+T-cell counts and to identify either the barriers or facilitators which enhance CD4+T-cell recovery among the patients who have been initiated on HAART for one year. This serves as an indicator for monitoring and evaluation of the success of the implementation of HAART in Ghana. 1.5 Objectives 1.5.1 General Objective The general objective of the study was to assess the factors that enhance CD4+T-cell recovery among HIV positive patients on HAART for one year at the Korle-Bu Teaching Hospital, Accra. 1.5.2 Specific Objectives The specific objectives are to: To determine the socio-demographic factors of patients on HAART for one year. University of Ghana http://ugspace.ug.edu.gh 7 To assess adherence to treatment by patients on HAART. To identify co-infections among patients on HAART for one year. To determine the difference in CD4+T-cell counts from being initiated on treatment to one year of being on HAART among patients at the Korle-Bu Teaching Hospital. To determine hospital/system factors that affect the CD4+T-cell recovery among those initiated on HAART for at one year. University of Ghana http://ugspace.ug.edu.gh 8 CHAPTER TWO LITERATURE REVIEW 2.1 Global Prevalence of HIV The HIV, Human Immunodeficiency Virus is a virus from the Retroviridae family of Lenti viruses. When the virus progresses in the individual it causes AIDS and sometimes death. Since its appearance in 1981, the virus has become a global concern because the virus breaks down the immune system of persons infected by it and causes high mortalities. Globally, it was estimated that 35.2 million people were living with the virus by 2012 (GLOBAL REPORT, 2013). Estimated new infections were 2.3 million. The number of AIDS related death also declined to 1.6 million in 2012 from 2.3 million in 2005 (GLOBAL REPORT, 2013). The World Health Organization is working with its developing partners and countries to reduce new infections and to also tackle the HIV/AIDS pandemic as found in the 2011 UN Political Declaration Millennium Development Goal 6 (GLOBAL REPORT, 2013). Antiretroviral therapy (ART) is now available and according to the UNAIDS Global Report, (GLOBAL REPORT,2013) the world is almost on the verge of providing antiretroviral therapy to about 15 million people by 2015. In 2012, 9.7 million people in the Low- and Middle- Income Countries received ART representing 61% of those eligible for it in 2010. In 2013, only 34% of the 28.6 million people who were infected with the virus were able to receive ART in the middle- and low- income countries including Ghana (GLOBAL University of Ghana http://ugspace.ug.edu.gh 9 REPORT, 2013). From 1996-2012, ART has averted 6.6 million mortalities worldwide including 5.5 million in the middle- and low- income countries. The course of HIV infection has fundamentally changed since the discovery of antiretroviral therapy and fortunately has turned this very serious disease into a chronic condition (Kittner et al., 2013). WHO has been working with many countries and providing guidelines concerning the administration of the antiretroviral therapy. The 2008 guidelines, updated in May 2014 enumerated that two surrogate markers should be used to monitor the ART to show the virologic and immunological efficacy of the ART. The laboratory markers are CD4+T-cell counts and plasma HIVRNA (WHO, 2008). The HIV/AIDS pandemic in Africa has assumed a dimension that is raising serious concern and calculated efforts among national governments and civil service groups. In Ghana, the HIV/AIDS pandemic is well documented and has gone past not only a health problem but also encompassing all socio-economic aspects of life. The government is working tirelessly with all its developing partners, Non-Governmental Organizations (NGO), donors, civil societies and Ministries to reduce the HIV/AIDS prevalence (Fobil & Soyiri, 2006). In line with combating HIV/AIDS, the Government of Ghana has set up the Ghana AIDS Commission and the NACP (National AIDS/STI Control Programme) which provide technical support, leadership, training and implementation of the strategies to prevent and mitigate the socioeconomic impact on individuals and communities and also to reduce new infections among the 15-49 year group. University of Ghana http://ugspace.ug.edu.gh 10 The first case of AIDS (Acquired Immunodeficiency Syndrome) was reported in Ghana in 1986, since then there has been a rise in the number of people both adults and children infected by HIV (WHO, 2005; NACP, 2010). Antiretroviral Therapy was started in Ghana in 2003 and has proved to be a major lifeline for PLHIV and an important HIV preventive intervention that ensures minimal new infections in the general populace (NACP, 2012). HIV positive patients are initiated on HAART when the CD4+T-cell counts are less than 350cells/µl. The HAART is made up of three antiviral drugs (2 Nucleoside Reverse Transcriptase Inhibitors and 1 Non-Nucleoside Reverse Transcriptase Inhibitor; 2 Nucleoside Reverse Transcriptase Inhibitors and 1 Protease Inhibitor and 2 Nucleoside Reverse Transcriptase Inhibitors and 2 Protease Inhibitors). The triple drug regimen is to prevent the development of resistance to the medication and also to produce maximum effect against the virus. Although treatment of HIV infected patients with HAART usually results in diminishing viral replication and increasing CD4+T-cell counts, a reversal of most immunological disturbances and reduction in risk of morbidity and mortality, there is still about 20% who do not attain the optimal immune reconstitution (Gaardbo et al., 2012). Cluster of Differentiation T-Lymphocyte cells are a type of lymphocytes produced in the bone marrow, but mature in the thymus. They play important roles in immune protection during an etiologic infection in a host. During an infection by HIV, the CD4+T-cells help B lymphocyte cells to produce antibodies, induce macrophages, and develop microbicidal activity which in turn recruit neutrophils, eosinophils and basophils. These cells initiate inflammatory reaction and through the production of cytokines and chemokines initiate full response against the virus (Zhu and Paul, 2008). During HIV infection in a host, more University of Ghana http://ugspace.ug.edu.gh 11 of these CD4+T- cells are destroyed because they are found at the inflammatory sites. However in the course of HAART, the combination effect of Non-nucleoside Reverse- Transcriptase, Nucleoside Reverse Transcriptase and Protease Inhibitors disrupts the replication cycles of the viruses and so the CD4+T-cells become free, hence their numbers increase which translate into immunological response for the patients. Quite a number of studies have shown that there are some factors that allow the CD4+T-cells to increase when patients are initiated on HAART. The WHO guidelines define CD4+T-cell counts in the range of 50 – 150 cells/µl during the first year of ART as adequate response to ART (WHO, 2008). 2.2 Factors contributing to enhanced CD4+T-cell recovery among those initiated on HAART 2.2.1 Socio-demographic/patient factors Age affects CD4+T-cell recovery, as younger and middle aged patients responded to treatment better than older patients (Annison et al.,2013; Semeere et al., 2014,) People > 50 years had 7.55% increase of CD4+T- cells while those of 31-50 years had 36.5% increase (Akinbami et al., 2012). A study by Luguterah & Adams (2013) showed that the level of education had an impact on the CD4+T-cell counts as those with tertiary education showed increase in CD4+T-cell counts compared with those of lower level of education. Based on these factors enumerated above which seem to have an effect on CD4+T-cell recovery when patients are initiated on HAART, this research seeks to find out the factors that have influenced increased CD4+T-cell counts among HIV positive patients attending clinic at the Korle-Bu Teaching Hospital who have been on HAART for one year. University of Ghana http://ugspace.ug.edu.gh 12 2.2.1.1 Age: Age affects CD4+T-cell recovery, as younger and middle aged patients responded to treatment better than older patients (Annison & et al., 2013; Semeere et al., 2014,) and increase in CD4+T-cell counts was reached faster in younger age group (Viard et al.,2001). People > 50 years had 7.55% increase of CD4+T- cells while those of 31-50 years had 36.5% increase (Akinbami et al., 2012). 2.2.1.2 Sex: The female sex tends to have enhanced immunological response than men according to a study in rural South Africa by Malaza et al., (2013). The study found women to have higher CD4+T-cell counts than men. 2.2.1.3. Educational level: A study carried out by Luguterah and Adams (2013); found out that patients with tertiary education had better CD4+T-cell counts than those of lower level of education. 2.2.1.4. Income level: It is expected that patients with higher level of income will take care of themselves better than people with lower income level. HAART improves the immune system and will help the infected patients remain in employment (Howley et al., 2010). 2.2.1.5. Adherence to the HAART: This plays a very vital and significant role in the immune recovery process for the patients. It ensures viral suppression, decrease risk of disease progression and reduces drug resistance (Rougemont et al., 2009). The HAART are pills and need to be swallowed at a particular time by the patients. It is expected that University of Ghana http://ugspace.ug.edu.gh 13 the patients adhere to the HAART. Adherence also measures retention to care for those who are newly diagnosed. 2.2.1.6. Co-infection and CD4 +T-cell counts: The co-infection a patient has also affects the rate of immunological response upon initiation on to HAART. Some patients have disease like Hepatitis B Virus or Cytomegalovirus or Tuberculosis. Jung and Paauw (1998) documented that based on the CD+T-cell counts, there were some diseases associated with the patients like Cytomegalovirus, Kaposi Sarcoma, Cerebral toxoplasmosis, Mycobacterium Avium Complex and Pneumonia. This is because some of the patients present late to the hospital and may have reached advanced stages of the HIV infection. CD4+T-cell counts are not affected by Hepatitis B Virus co-infection (Hoffmann et al., 2008). Those with low CD4+T-cell counts of less than 200c/µl had mortality reduced by 34%, when started on ART and Anti-tuberculosis agents, (Luetkermeyer, 2010). 2.2.2 Hospital/System factors The hospital/ system factors that enhance CD4+T-cell recovery include: the availability of HAART, doctors and nurses relationship with patients, long waiting time at the clinic, presence of laboratory equipment and reagents, confidentiality and cost of care (Scanlon and Vreeman 2013). All these factors relate in one way or the other to how patients fare when initiated on HAART. Doctors and nurses always have to be available at the clinic to take care of the patients and address their specific issues and needs concerning their health. University of Ghana http://ugspace.ug.edu.gh 14 The equipment and reagents for conducting laboratory investigations also have to be available. Nakanjako et al., (2009) suggested that it is good to optimize care through investing in laboratory tests and equipment as this supports clinical monitoring of patients initiated on HAART. These boost patients‟ confidence and make them always want to come to the hospital. Laboratory investigations are also important for monitoring the progress or lack thereof. Dissatisfaction of clinical services can be due to long waiting time at the clinic (Dahab et al, 2008). This implies that factors that will encourage long waiting time in the clinics such as overcrowded and overburdened health facilities should be addressed. The cost of care includes other medical expenses such as laboratory tests, antibiotics for other opportunistic infections, Moon et al., (2008) and these may pose financial difficulty to patients and may stop them from assessing healthcare services, even though the HAART may be given free by the government. Confidentiality on the part of healthcare providers is also important. When they are not confidential to the patients, the patients will feel stigmatized and will refuse to come to the hospital again. When these factors are checked adequately and made accessible to the patients, they will enhance CD4+T-cell recovery. University of Ghana http://ugspace.ug.edu.gh 15 CHAPTER THREE METHODOLOGY 3.1 Study Design A cross-sectional study was conducted at the Fevers‟ unit of Korle-Bu Teaching Hospital. 270 respondents participated in the study. 3.2 The Study Location The study was undertaken in the Fevers Unit of the Korle-Bu Teaching Hospital in Accra. It is the premier teaching hospital and a referral center. The unit takes care of diagnosis and treatment for HIV/AIDS and all infectious diseases. The unit is made up of the Out Patient Department and the in-patient on the wards. The staff is made up of specialist doctors, nurses, counselors/health educators and laboratory personnel who provide care and support to the patients. The unit has about 19000 registered patients on referrals from other health facilities. As part of the routine care, baseline CD4+T-cell counts test is done together with Full Blood Count. Other laboratory investigations like Liver Function Tests, Kidney Function Tests, Chest X-rays and Sputum Acid fast bacilli (AFB) are requested, but these are done outside the Unit. The Unit has a very good information management system which captures all the patients‟ demographic information and updates on the clinical care from their clinical records into a computer system. The clinic runs by the appointment system. 3.3 The Study Population The study population was made up of adult HIV positive patients attending clinic at the Fevers Unit, Korle-Bu Teaching Hospital (KBTH). University of Ghana http://ugspace.ug.edu.gh 16 3.3.1 Inclusion Criteria Adult males and females aged 18years and above who have been initiated on HAART for at least one year were eligible. 3.3.2 Exclusion Criteria This was made up of those who were not yet 18 years, not yet initiated on HAART or were not yet up to one year on HAART. 3.4: Study Variables 3.4.1 Dependent variable The dependent variable was CD4+T-cell counts 3.4.2 Independent variables were 1. Socio-demographic/patient factors: age, sex, educational level, income level, occupation, place of residence, adherence to HAART and co-infections 2. Hospital/System factors: Cost of care, Confidentiality, Availability of laboratory equipment and reagents, Doctors/nurses relationship to patients, Availability of HAART, and Long waiting time at the hospital. 3.5 Sample Size Calculation The sample size was calculated based on 20% Immunological Non Respondence (Gaardbo et al., 2012). n = (z 2 pq)/d 2 = z2 xpxq/d2 University of Ghana http://ugspace.ug.edu.gh 17 Where n=sample size z=confidence interval (1.96)2 p=probability of Immunological Respondence 80% or 0.80 q=probability of Non-Immunological Respondence 20% or 0.20 d= distance on either side of mean in confidence interval (0.05)2 n= (1.96)2 x0.80x0.20/ (0.05)2 n=0.615/0.0025=246 10% of 246 that will be added 10/100x246=25 Total sample size will be 246+ 25=271 3.6 Sampling Methods. The respondents were selected and labeled from a list generated by the computer using the patient‟s unique identification number. The first case was selected by simple random sampling after which the remaining 269 numbers were by systematic selection of every second patient. The respondents were invited for enrollment into the study. Non- responding patients were replaced by the next person on the list. 3.7 Data Collection Tools and Techniques A well-structured questionnaire was administered to the respondents after obtaining informed consent. The completed questionnaire were entered into a database by Excel Spreadsheet. The identification numbers were decoded to protect the respondents‟ identification. Access to the data was by password only. The completed questionnaire were kept under lock and key in a locked cabinet. The questionnaire was adapted using several tools as shown in Appendix 1 and 2. University of Ghana http://ugspace.ug.edu.gh 18 Adherence was adapted from Morisky‟s Medication Adherence Scale (MMAS-8) Cuevas and Periate (2015), which had a maximum score of 8, with 8 scoring high adherence, medium adherence was a score of 6-7 and low adherence being less than 5. The hospital/system factors were adapted from 2 tool kits: I. USAID TB Care II: Reducing Delays in Diagnosis, Data Collection Tools to Evaluate the Cause and Frequency of TB Delay (Holschneider, et al., 2011). II. USAID TB II, Tool Kit to Address Timely TB Case Detection and Treatment (Holschneider, et al., 2013). The questions were asked using the modified Likert Scales with 5 options of 1-5 in the strengths of strongly agree to strongly disagree with neither as 3 (Sclove, 2001). 3.8. Training of Research Assistants Research assistants were trained on how to administer the questionnaire. This helped them to give uniformed interpretation to the questions, administer and collect data using the questionnaire. 3.9 Pre-Testing Questionnaire was pretested at the Ridge Regional Hospital OPD, Accra. This was because Ridge is also an ART center. This was done to check for the acceptability, willingness, time needed, and sequencing of the questions, clarity and accuracy in interpretation of the questions. University of Ghana http://ugspace.ug.edu.gh 19 3.10 Data Handling and Processing Physical examination of the final data of the Excel spreadsheet was done and checked for properly entered data, missing or omissions and outliers. Responses were picked at random and cross-checked with the Excel spreadsheet. 3.11 Data Analysis STATA version 12.0 was used to analyze the data. Frequency tables of socio-demographic dependent and independent variables were generated. Univariate analysis was used to investigate the distribution of all the variables. Logistic regression was used to find the strength of association between the dependent and independent variables. The outcome was generated by finding the difference in the CD4+T-cell counts at 1 year of initiation on HAART and the CD4+T-cell counts at baseline at the time of initiation. An increase of 50 cells/µl was measured as 0 outcomes while greater than 50cells/µl was measured as 1 outcome. The outcome was used to test for association between the CD4+T- cell counts and the independent variables (WHO, 2008). 3.12. Ethical Consideration Ethical approval was sought from the Ghana Health Service Ethics Review Committee and permission obtained from Korle-Bu Teaching Hospital. The respondents were assured of strict confidentiality and the research topic was explained to them in English, Twi, Ga and Ewe (where necessary). Informed consent was obtained from the respondents prior to administration of the questionnaire. The signed informed consent forms are being kept in safe place, under lock and key. University of Ghana http://ugspace.ug.edu.gh 20 3.13 Limitations to the study Ethical clearance and approval from the Ghana Health Service Ethical Review Committee delayed a bit, so this did not allow the study to start in good time. Permission from the Korle-Bu Teaching Hospital allowing the conduct of the study at the Fever‟s unit delayed, this reduced the data collection time. The use of phone numbers to recruit the respondents was hectic as some of the phone numbers were not working or were wrong contacts. University of Ghana http://ugspace.ug.edu.gh 21 CHAPTER FOUR RESULTS 4.1. Socio-Demographic Characteristics of Respondents: A total of 270 respondents participated in the study made up of 27 %( n =73/270) males and 73% (n=197/270) females. The mean age was 44±8.9 years and ranged from 24 to 75 years. Table 1: Socio-demographic Characteristics of 270 Respondents on HAART at Korle- Bu Teaching Hospital, Accra Characteristics Frequency Percentages (%) Sex Male 73 27.0 Female 197 73.0 Age range(years)* <30 10 3.70 30-39 80 29.6 40-49 112 41.4 >50 68 25.2 Marital status Single 52 19.3 Married 121 44.8 Widowed 46 17 Divorced/Seperated 51 18.9 Educational Level Nil 52 19.3 Primary/JSS ˟ 113 41.8 SSS/MLSC/Voc/Tech˟ 91 33.7 Tertiary 14 5.19 Employment Status Unemployed 37 13.7 Employed 233 86.3 Income Level (monthly) Less than Ghc400 225 83.3 Between GHc400-1000 39 14.4 More than GHc1000 6 6.2 Place of Residence Rural 16 5.9 Urban 254 94.1 Total 270 100 JSS = Junior Secondary School SSS = Senior Secondary School MLSC= Middle School Leaving Certificate Voc/Tech = Vocational and Technical Education *Age range reference: Akinbami et al., (2012) University of Ghana http://ugspace.ug.edu.gh 22 From the data collected, most of the respondents, 41% (n=112/270) were within the 40-49 age group. Nineteen percent (n=52/270) of the respondents were single, 45% (n=121/270) were married, while 17% (n=46/270) were widowed. On assessing educational level, 42% (n=113/270) of the respondents had basic education at the Primary and Junior Secondary School level. Majority, 86% (n=233/270) of the respondents were employed and majority, 83% (n=225/270) earned less than GHc 400 monthly, while majority of them 94% (n= 254/270) lived in urban areas (Table 1). 4.2: Respondents Clinical Characteristics: Majority, 67% (n=182/270) of the respondents had registered for the National Health Insurance Scheme (NHIS) in order to assess healthcare. Majority of the respondents were at WHO clinical stages III and IV of HIV/AIDS. Forty–four percent (n=118/270) of the respondents were in WHO stage III whereas 14% (n=34/270) were in WHO stage IV. The main therapy being used by respondents were Combivir/Efavirenz 47 % (n=128/270). The rest were on Combivir/Nevirapine 38% (n=102/270) and Tenofovir/Lamivudine/Efavirenz 11% (n=30/270). The proportion of respondents with other diseases was 25% (n=68/270). The adherence level was very high 93% (250/270) shown in Table 2. Majority, 94% (n=255/270) of the respondents commuted to the hospital by public transportation while the rest came by private cars. Those respondents who had registered with the NHIS never spent money on medications 36% (n=98/270). Majority, 77% (n=208/270) of them sometimes had money to come to the hospital whereas 20% (n=53/270) always had money to come to the hospital. Table 2 shows the clinical and health characteristics of the respondents. University of Ghana http://ugspace.ug.edu.gh 23 Table 2: Clinical and Health Service Characteristics of Respondents’ on HAART at Korle- Bu Teaching Hospital, Accra Variables frequency Percentages (%) NHIS No 88 32.6 Yes 182 67.4 HIV Stage I 45 16.7 II 73 27.0 III 118 43.7 IV 34 12.6 Drug Combination Comb/EFV 128 47.4 Comb/NVP 102 37.8 TDF/EFV/3TC 30 11.1 TDF/NVP/3TC 1 0.4 Others 9 3.3 Other disease No 202 74.8 Yes 68 25.2 Adherence Level Low Adherence 20 7.4 Medium Adherence 250 92.6 Transportation (means) Walking 10 3.7 Taxi/Trotro 255 94.4 Private car 5 1.9 Transport Expenses (per each clinic visit) < 5GHc 184 68.2 Between 5-10GHc 65 24.1 > 10GHc 21 7.8 Laboratory Expenses (every 6 month) Zero 119 44.1 < 5GHc 3 1.1 Between 5-50GHc 45 16.7 > 50GHc 103 38.2 Drug Expenses (per month) Never 98 36.3 < 10GHc 50 18.5 >10GHc 122 45.2 Finance ( drugs and investigations) Never 9 3.3 Sometimes 208 77.0 Always 53 19.6 Total 270 100 University of Ghana http://ugspace.ug.edu.gh 24 4.3. Mean CD4+T-Cell Counts Eighty-seven percent (n=235/270) of the respondents achieved the increase of greater than 50 cells/µl at one year of being initiated on HAART. The mean CD4+T-cell counts at baseline of initiation was 155cells/µl with a standard deviation (SD) of 108 and at 95% Confidence interval (CI: 142 to 169 cells/µl) while the mean CD4+T-cell counts at one year of being initiated on HAART was 355cells/µl with a SD of 198 and 95%( CI: 331 - 379 cells/µl) as shown in Table 3. Table 3: Difference in means of CD4+T-cells at baseline (CD41+T-cell counts) and at 1 year of initiation of HAART (CD42+T-cell counts) CD4+T-cell counts Observations Mean (cells/ µl) Standard Error Standard Deviation 95% Confidence interval CD42 +T-cell count (cells/ µl) After 1 year on HAART 270 355 12 198 331-379 CD41+T-cell counts (cells/ µl) Baseline 270 155 7 108 142-169 Difference 270 200 10 167 220 P-value <0.0001 H0=No difference in the means of CD42+T-cell counts and CD41+T-cell counts H1=There is difference in the means between CD42+T-cell counts and CD41+T-cell counts Conclusion: There is difference between CD4+T-cell counts at baseline and CD4+T-cell counts after one year of HAART (p-value<0.0001) Where CD41+T-cell counts = CD4+T-cell counts at baseline CD42+T-cell counts = CD4+T-cell counts at 1 year of being initiated on HAART University of Ghana http://ugspace.ug.edu.gh 25 4.4: Hospital/System factors 4.4.1. Doctors/Nurses relationship to patients Majority of the respondents agreed/strongly agreed that the healthcare workers were supportive, 99.6% and respectful, 99.3% to people who had HIV/AIDS. They also agreed/strongly agreed that most people believe the healthcare workers will be respectful to people who had HIV/AIDS, 44% (n=119/270); 19 %( n= 50/270) respondents disagreed and 37% (101/270) were not sure, Table 4. 4.4.2. Cost of Care: Majority, 68%, (184/270) of the respondents spent less than GHc 5 for transportation and 44% (119/270) did not spend any money for laboratory expenses, however 38%(n=103/270) spent more than GHc 50. About 45% (n=122) of the respondents spent more than GHc10 on medication while the rest either don‟t pay at all or spent less than GHc10 shown in Table 2. 4.4.3. Confidentiality: Majority, of the respondents 94 % (n= 253/270) strongly agreed that they were being given the opportunity to ask questions while only 3% (7/270) were not sure of what happened as shown in Table 4. All the respondents 100 %( n=270) agreed/agreed strongly to the clinic schedule. 4.4.4. Availability of laboratory reagents and equipment: Majority, 68% (183/270) of the respondents said yes (reagents were not available) while 32% (n=87/270) said no (reagents were available) as shown in Table 4. 4.4.5. Availability of drugs (HAART): Most, 61% (n=165) of the respondents, said no (there were drugs available) while 39% (n=105) said there were shortage of drugs as shown in Table 4. 4.4.6. Long waiting time at the clinic: At least 95% (n=256/270) agreed/strongly agreed they were satisfied and happy with the waiting time while 62 %( n=168/270) said the service was just about as expected as shown in Table 4. University of Ghana http://ugspace.ug.edu.gh 26 Table 4: Respondents’ Assessment of Hospital /System Characteristics at the Korle- Bu Teaching Hospital, Accra Variables Frequency Percentages (%) Supportive Agree/Strongly agree 269 99.6 Disagree/Strongly disagree 1 0.37 Respectful Agree/Strongly agree 268 99.3 Disagree/Strongly disagree 2 0.7 Before Supportive Agree/Strongly agree 257 95.2 Disagree/Strongly disagree 5 1.9 Neither 8 3.0 Before Respectful Agree/Strongly agree 255 94.4 Disagree/Strongly disagree 6 2. Neither 9 3.3 Believe Agree/Strongly agree 119 44.1 Disagree/Strongly disagree 50 18.5 Neither 101 37.4 Satisfied Agree/Strongly agree 256 95.2 Disagree/Strongly disagree 12 4.5 Neither 1 0.4 Happy Agree/Strongly agree 265 98.2 Disagree/Strongly disagree 4 1.5 Neither 1 0.4 Service Better than expected 94 34.8 About what is expected 168 62.2 Not good as expected 8 3.0 Ask Questions Agree/Strongly agree 253 93.7 Disagree/Strongly disagree 10 3.7 Neither 7 2.6 Clinic Schedule Agree 270 100 Drugs Available Agree/Strongly agree 265 98.2 Disagree/Strongly disagree 5 1.9 Drug Shortage No 165 61.1 Yes 105 38.9 Reagent Shortage No 87 32.2 Yes 183 67.8 Total 270 100 University of Ghana http://ugspace.ug.edu.gh 27 4.5: Factors associated with CD4+T-cell Recovery Table 5 shows the socio-demographic factors and CD4+T-cell recovery using the Pearson‟s Chi2. Sex, age (age range), marital status, educational level, income level, occupation and place of residence were all not found to be significant with the CD4+T- cell recovery at a p –value of <0.05. At bivariate level, the dependent variable, CD4+T- cell was not significantly associated with sex (p=0.827), age (0.636), educational level (p=0.662) as shown in Table 5. Doctors/nurses relationship to patients, availability of HAART, equipment and reagents, cost of care, confidentiality and long waiting time at the clinic, it was only belief (most people believe they will be treated respectfully by health care providers if they have HIV/AIDS) that is doctors/nurses relationship to patients that yielded a significant value of 0.020 (p<0.05) as shown in Tables 6, 7, 8 and 9. University of Ghana http://ugspace.ug.edu.gh 28 Table 5: Socio-demographic Factors Associated with CD4+T-cell Recovery among Respondents’ on HAART at the Korle Bu Teaching Hospital, Accra, 2015. Variables Cd4+T- cell counts <50c/µl N (%) Cd4+T-cell counts>50c/µl N (%) Frequency & Percentages (%) Pearson’s Chi- square p-value Sex Male 10(13.7) 63(86.3) 73(27.0) Female 25(12.7) 172(87.3) 197(73) 0.05 0.827* Age range(years) <30 0 10(100) 10(3.7) 30-39 10(12.5) 70(87.5) 80(29.6) 1.71 0.636* 40-49 15(13.4) 97(86.6) 112(41.5) >50 years 10(14.7) 58(85.3) 68(25) Marital status Single 6(11.5) 46(88.5) 52(19.4) Married 14(11.6) 107(88.4) 121(44.8) 1.13 0.770* Widowed 8(17.4) 38(82.6) 46(17.0) Divorced/Seperated 7(13.7) 44(86.2) 51(18.9.0 Educational Level Nil 4(7.7) 48(92.3) 52(19.26) Primary/JSS 16(14.2) 97(85.8) 113(41.9) 1.59 0.662* SSS/MLSC/Voc/Tech 13(14.3) 78(85.7) 91(33.7) Tertiary 2(14.3) 12(85.7) 14(5.19) 0ccupation Unemployment 5(13.5) 32(82.5) 37(13.7) 0.01 0.915* Employment 30(12.9) 203(87.1) 233(86.3) Income Level (monthly) GHc1000 2(33.3) 4(66.7) 6(2.2) Place of Residence Rural 3(18.8) 13(81.3) 16(5.9) 0.50 0.477* Urban 32(12.6) 222(87.4) 254(94.1) Total 270 *= not significant at p-value <0.05 University of Ghana http://ugspace.ug.edu.gh 29 Table 6: Clinical and Health Service Factors Associated with CD4+T-cell Recovery among Respondents on HAART at Korle- Bu Teaching Hospital, Accra Variables Cd4 <50c/µl N (%) Cd4>50c/µ l N (%) Frequency & Percentage s (%) CHI2 p-value Adherence Level Low Adherence 2(10) 18(90) 20(7.4) Medium Adherence 33(13.2) 217(86.8) 250(92.6) 0.17 0.682* Other Disease No 24(11.9) 178(88.1) 202(74.8) 0.83 0.362* Yes 11(16.2) 57(83.8) 68(25.2) Transport Expenses(per each clinic) GHc10 1(4.8) 20(95.2) 21(7.8) Laboratory Expenses(every 6 month) Zero 14(11.8) 105(88.2) 119(44.1) GHc5-50 5(10.4) 43(89.6) 48(17.8) 1.03 0.597* >GHc50 16(15.5) 87(84.5) 103(38.2) Drug Expenses(per month) Never 12(12.2) 86(87.8) 98(36.3) <10GHc 10(20) 40(800 50(18.5) 2.81 0.245* >10GHc 13(12.2) 109(89.3) 122(45.2) Finance (drugs and laboratory) Never 0 9(100) 9(3.3) Sometimes 30(14.4) 178(85.6) 208(77.0) 2.32 0.314* Always 5(9.4) 48(9.6) 53(19.6) Drug Combination Comb/EVE 15(11.7) 113(88.3) 128(47.4) Comb/NVP 17(16.7) 85(83.3) 102(37.8) 2.65 0.619* TDF/EFV/3TC 2(6.7) 28(93.3) 30(11.1) TDF/NVP/3TC 0 1(100) 1(0.4) Others 1(11.1) 8(88.9) 9(3.3) Total 270 : *=not significant at p-value <0.05 Table 6 shows the Clinical and Health Service factors associated with CD4+T-cell recovery. There was no significant association between CD4+T-cell recovery and adherence level (p=0.682), other disease, (p=0.362), transport expenses, (p=0.127) laboratory expenses, (p=0.597) drug expenses (p=0.245), finance (p=0.314) and drug combination, (p=0.619). University of Ghana http://ugspace.ug.edu.gh 30 Table 7: Socio-demographic Factors Associated with CD4+T-cell Recovery among Respondents on HAART at KBTH, Accra, using Logistic Regression. Variable Frequency and Percentages (%) Odds Ratio P- value 95% Confidence interval Sex Male 73(27.0) Ref˟* Female 197(73) 1.09 0.83 0.5-2.4 Marital Status Single 10(3.7) Ref Married 80(29.6) 1.00 0.77 0.6-2.8 Widowed 112(41.5) 0.62 0.68 0.2-2.0 Divorced/Seperated 68(25) 0.82 0.11 0.3-2.6 Education Nil 52(19.26) Ref Primary/JSS 113(41.9) 0.51 0.24 0.2-1.6 SSS/MLSC/Voc/Tech 91(33.7) 0.50 0.24 0.2-1.6 Tertiary 14(5.19) 0.50 0.45 0.1-3.1 Occupation Unemployed 37(13.7) Ref Employed 233(86.3) 1.16 0.91 0.4-2.9 Income (monthly) Low( (GHc1000) 6(2.2) 0.31 0.16 0.1-1.8 Adherence Low 20(7.4) Ref Medium 250(92.6) 0.7 0.68 0.2-3.3 Transport expenses(per each clinic) GHc10 21(7.8) 3.7 0.18 0.5-29.4 Drug Shortage No 165(61.1) Ref Yes 105(38.9) 1.5 0.33 0.6-3.11 Ref *˟ means Reference, having an Odds Ratio of 1. At multivariate levels, females were 1.0 more likely to have CD4+T-cell recovery than males (95% C.I=0.5-2.4, p=0.83).Also, respondents with medium adherence were 0.7 times less likely to have CD4+T-cell recovery than those having low adherence (95% C.I. =0.2-3.3, p=0.68). University of Ghana http://ugspace.ug.edu.gh 31 Table 8: Health System Factors associated with CD4+T-cell Recovery among Respondents on HAART at the Korle- Bu Teaching Hospital, Accra. VARIABLES CD4+T-cell counts<50c/µl N (%) CD4+T-cell counts>50c /µl N (%) X2 P-value Support Agree/Strongly agree 35(13) 234(87) 0.15 0.699* Neither 0 1(100) Respectful Agree/Strongly agree 35(13.1) 233(86.9) Disagree/Strongly disagree 0 2(100) 0.30 0.58* Before Respectful Agree /Strongly Agree 32(12.60) 222(87.4) Disagree/Strongly disagree 2(33.3) 4(66.7) 2.31 0.314* Neither 1(10.0) 9(90.0) Before Respectful Agree/Strongly agree 32(12.5) 224(87.5) Disagree/Strongly disagree 2(33.3) 4(66.7) 2.26 0.324* Neither 1(12.5) 7(87.5) Believe Agree/Strongly agree 15(12.8) 102(87.2) Disagree/Strongly disagree 12(24) 38(76) 7.87 0.020** Neither 8(7.8) 95(92.2) Satisfied Agree/Strongly agree 31(12.1) 226(87.9) Disagree/Strongly disagree 3(25) 9(75) 1.74 0.19* Happy Agree/Strongly agree 35(13.2) 251(86.8) Disagree/Strongly disagree 0 4(100) 0.60 0.437* Service Better than expected 11(12.1) 80(87.9) About what is expected 24(14.0) 147(86) 1.43 0.490* Not as good as expected 0 8(100) Ask Questions Agree/Strongly agree 32(12.7) 220(87.3) Disagree/Strongly disagree 3(27.3) 8(72.7) 3.05 0.217* Neither 0 7(100) Clinic Schedule Agree/Strongly agree 35 235 - - Drugs Available Agree/Strongly agree 35(13.2) 230(86.8) 0.94 0.332* Disagree/Strongly disagree 0 5(100) TOTAL 270 **= Significant at p-value<0.05 *= not significant at p-value<0.05 There was however, significant association between CD4+ T-cell Recovery and belief (Doctors/nurses relationship with HIV/AIDS patients) [Chi-square=7.87, p=0.02]. University of Ghana http://ugspace.ug.edu.gh 32 Table 9: Health System Factors Associated with CD4+T-cell Recovery using logistic regression at the Korle- Bu Teaching Hospital, Accra Variable Frequency and percentage (%) Odds Ratio P-value At 95% Confidence interval Supportive Agree/Strongly agree 269(99.6) ˟Ref Disagree/Strongly disagree 1(0.4) - 0.505 - Respectful Agree/Strongly agree 268(99.3) Ref Disagree/Strongly disagree 290.7) - 0.58 - Before Supportive Agree/Strongly agree 257(95.2) Ref Disagree/Strongly disagree 5(1.9) 0.44 0.55 0.03-7.21 Neither 8(3.0) Before Respectful Agree/Strongly agree 255(94.4) Ref Disagree/Strongly disagree 6(2) 0.13 Neither 9(3.3) 0.76 0.14 0.16-3.27 Believe Agree/Strongly agree 119(44.1) Ref Disagree/Strongly disagree 50(18.5) 0.84 0.66 0.39-1.83 Neither 101(37.4) 1.26 0.46 0.68-3.25 Happy Agree/Strongly agree 265(98.2) Ref - Disagree/Strongly disagree 4(1.5) - 0.18 - Neither 1(0.4) - 0.50 Satisfied Agree/Strongly agree 256(95.2) Ref Disagree/Strongly disagree 12(4.5) 4.6 0.11 0.58-37.79 Neither 1(0.4) Service Better than Expected 94(34.8) Ref About what is expected 168(62.2) 1.3 0.43 0.71-2.27 Not as good as expected 8(3.0) 0.8 0.83 0.19-3.84 Ask Question Agree/Strongly agree 253(93.7) Ref Disagree/Strongly disagree 10(3.7) 0.3 0.13 0.07-1.49 Neither 7(3.0) 1 0.94 0.20-5.63 Clinic Schedule Agree/Strongly Agree 270(100) - - - Drugs Available Agree/Strongly agree 265(98.2) Ref Disagree/Strongly disagree 5(1.9) 1.8 0.59 0.20-16.58 Total Ref= reference, having an odds of 1. Table 9 shows health system factors associated with CD4+T-cell recovery. Belief, though there is an association, it‟s not significant: (OR=0.84; 95%CI 0.39-1.83, p-value=0.66). University of Ghana http://ugspace.ug.edu.gh 33 Table 10: Co-infections and the distribution of CD4+T-cell recovery among Respondents on HAART at Korle- Bu Teaching Hospital, Accra Co-infections CD4+T-cell counts<50c/µl (%) CD4+T-cell counts>50c/µl (%) Total number of co- infections/Percentages (%) Pulmonary Tuberculosis 4 (25) 12 (75) 16(24.2) Pneumonia 0 6 (100) 6(9.1) Candidiasis (Oral, Esophageal, Vaginal) 0 8 (100) 8(12.1) Diabetes and Hypertension 0 4 (100) 4(6.1) Gastroenteritis 1 (20) 4 (80) 5(7.6) Others* 5 (18.5) 22 (81.5) 27(40.9) Total 10 56 66 Others* =Anaemia, Jaundice, Cerebral Toxoplasmosis, Pharyngitis, Herpes Zoster Pruritic Papular Dermatitis and Hepatitis B Table 10 shows co-infection and the distribution of CD4+T-cell recovery among the respondents. Pulmonary tuberculosis was high with 24.2% as co-infection with HIV/AIDS and had 75% CD4+T-cell recovery. Diabetes and Hypertension were 4 (6%) with 100% CD4+T-cell recovery. University of Ghana http://ugspace.ug.edu.gh 34 CHAPTER FIVE DISCUSSION 5.1 Mean CD4+T-cell counts The mean increase in the CD4+T-cell counts of 200cells/µl at the end of one year of being initiated on HAART was similar to Gaardbo et al., (2012) study which reported that 20% patients will not achieve immunological response. This is because the immunological non-respondents have severely altered immunological functions, including malfunction and diminished production of cells within the T-lymphocytes. Although Mulu et al., (2014) had a high immunological recovery (82%) among adults study in Ethiopia, this study revealed about 87% (n=235) achieved higher immunological response by the baseline CD4+T-cell counts increasing by a minimum of 50cells/µl at one year of HAART initiation. Although the 13% who experienced immunological failure is similar to Collini et al., (2009) study in Ghana which followed patients on ART for 3 years. This study is however similar to Kwofie et al., (2015) and Annison et al.,(2013) at Komfo Anokye Teaching Hospital and Kumasi South Hospital which reported that the administration of ART resulted in immunological recovery by increase in CD4+T-cell counts with adherence to HAART. 5.2 Socio- demographic/Patient factors In this study, 10 patients who were found to be less than 30 years were found to have a higher CD4+T-cell recovery of 100%, whilst 70 patients of 30 - 39 years had CD4+T-cell recovery of 87.5%, patients of >50 years were found to have a recovery 85.3% (Table 5). Findings from this study are similar to Carter (2011) which reported that patients of older age (>50years) had fewer naïve CD4 cells compared to younger age in Paris. This is as a University of Ghana http://ugspace.ug.edu.gh 35 result of a patient‟s body‟s immunological activities which takes place when one is initiated on HAART. Although the females had a slightly higher CD4+T-cell (87.3%) recovery than the males (86.3%), it has been reported by Sempa et al., (2013) in a 7 year study in Uganda that immune recovery is slower in men than women because the women were found to have CD4>400cells/µl increase earlier than in the men. This may probably be a reflection of women‟s better health seeking behavior than men, women are more likely to adhere to treatment and eat nutritiously (Annison et al., 2013, Folasire et al., 2012). In this study, those without any level of education had a CD4+T-cell recovery of 92.3%, while those with tertiary had 85.7%. This is contrary to Luguterah and Adams, (2013) study previously carried out in Northern Ghana which reported that those with higher level of education had a high CD4+T-cell recovery. Furthermore, patient adherence to taking the ART in CD+T-cell recovery is very important, this study found the respondents had medium adherence of 7 for 250(92.6%) patients, however 217 of the patients had a recovery of 86.8% of cell increase although the differences was found to be non-significant (p-value 0.68 at 95% CI: 0.2-3.3) (Table 6 &7). In Ethiopia an adherence of 87% have been reported by Mitiku et al., (2013), this is similar to this study (86.8%). HAART gives effective check against the activities of the virus and reduces the viral loads in infected individuals (Rougemont et al., 2009). It is obvious that the patients took their HAART, which is the basis for fighting the virus. .Scanlon and Vreeman (2013) pointed out in a review that improving assess to adherence must have interventions that addresses its barriers. University of Ghana http://ugspace.ug.edu.gh 36 Having co-infection and being initiated on the HAART is reported to protect the patients against the risk of death (Yang et al., 2014). Some of the respondents as at the time of being initiated on the HAART, had co-infection of various diseases. Some of the co- infections were: Pulmonary Tuberculosis, Pneumonia, Gastroenteritis, Candidiasis (Esophageal, Oral and Vaginal), Hypertension, Hepatitis B, Cerebral Toxoplasmosis, Herpes Zoster, Diabetes Mellitus, Respiratory Tract Infection and Pruritic Papular Dermatitis, among others. Out of the 270 respondents, only 66 (25%) had co-infections. Those with pulmonary tuberculosis co-infection was 24.2%, this is similar to WHO finding that the risk of developing Tuberculosis is between 26 and 31 times greater in those infected with HIV (WHO, 2015). HIV/AIDS pandemic has caused an emergence of Tuberculosis and increased morbidity and mortality worldwide (Sharma et al., 2005). Coinfections are common in HIV patients because HIV predisposes the infected individuals to these infections (MNT 2015). In a South African study, Herpes Zoster was reported be 2.3% in HIV patients (Shearer et al., 2014). In Ghana the double burden of HIV, tuberculosis, malaria (communicable diseases) and non-communicable diseases like stroke, hypertension and diabetes has been documented (Aikins, 2007). Cryptococcal meningitis, tuberculosis and cerebral meningitis also constitute infections of the Central Nervous System and Primary CNS Lymphoma have been reported in HIV patients (Leligdowicz et al., 2006). A study by Sagoe et al., (2011) in Ghana found out that 13% of the HIV patients had Hepatitis B coinfection. This study therefore shows that coinfection among HIV patients increases morbidity and mortality (Sharma et al., 2005), so continuous planning and interventions to treat these infections have to be considered. University of Ghana http://ugspace.ug.edu.gh 37 5.3 Hospital/System factors The hospital/system factors explored the availability of HAART, waiting time at the clinic, availability of laboratory equipment and reagents, doctors and nurses relationship to patients, cost of care and confidentiality (Table 4). This study revealed that the availability of HAART was found to be 98.2%. When there are drugs available, patients easily go to the hospital for refills, adherence is improved, drug resistance is reduced, and patients look healthier and are able to go about their normal businesses (Howley et al., 2010; Collen et al., (1999). The introduction of HAART in the first place was to reduce the viral load in the infected individuals and enhance immunological recovery by increasing the CD4+T- cells (Mulu et al., 2014). As a result, the demand for HAART will continue to grow in the coming years (Schouten et al., 2011). In this study, the respondents were very satisfied with the waiting time at the clinic because they did not waste too much time when they came to the clinic. This is similar to a study in Ghana where generally, the patients (who were insured on National Health Insurance Scheme) were very satisfied with the waiting time at the clinic (Fenny et al., 2014). This findings is contrary to a study in Kenya where the patients were dissatisfied with longer waiting time at the clinic (Wambua et al., 2015). It was observed that the picking of patients‟ clinical records, checking of weights and blood pressure, queuing to the consulting room, picking up HAART and getting an appointment schedule were efficiently organized to give patients the needed satisfaction. This was similar to a study in Tanzania by Miller et al., (2014) which found out that patients were very satisfied as the doctors and nurses took care of less than 10 patients a day. University of Ghana http://ugspace.ug.edu.gh 38 Furthermore, the doctors and nurses at the clinic were found to be respectful and supportive to those with HIV/AIDS. This is very important as it boosts the patient‟s confidence to continue attending the clinic, thus get all the medical attention and this enhances life quality generally and is likely to recommend that clinic to others, (Woodward, 2000), However dissatisfaction with clinical services stop patients from going to the hospital to assess care and medications (Daban et al., 2008). This study is similar to Iloh et al., (2013) a study in Nigeria which reported satisfaction from the medical staff as good. Similarly, Nwabueze et al., (2011) also had an overall high patient satisfaction score for healthcare workers in a study carried out in an ART clinic of a Nigerian tertiary hospital. Another study in Sunyani Regional Hospital of Ghana also reported that patients were very satisfied with the service delivery at the hospital (Peprah, 2014), whilst a study conducted in China have revealed that health professionals had negative biases against patients with HIV/AIDS (Li et al., 2007). Cost of care involving transportation expenses, laboratory expenses and drug expenses were found to vary in this study. Over 95% had money to come to the clinic at their appointment schedule. This is very important because if one cannot commute to the hospital, he/she cannot get the refills of the HAART and will not be adherence complaint. Moon et al., 2008 argued that some of these expenses can constitute financial barriers to some of the patients, which will stop them from assessing medication and care. Findings in this study is slightly higher than a study in South Africa which reported that 90% of the patients paid for transport to attend clinic (Rosen et al., 2007). HIV/AIDS households spent more money on medical care and transportation cost than households without HIV/AIDS (Falleiro, 2014). This means that transportation expenses are very important when dealing with HIV/AIDS care since some patients will prefer to go to health facilities University of Ghana http://ugspace.ug.edu.gh 39 that are further away from their communities to avoid stigmatization because some of the patients are still being stigmatized and discriminated against by healthcare workers (Famoroti et al., 2013). Confidentiality is a fundamental principle which is grounded in patient‟s right to autonomy, and the main source of concern is disclosure of the HIV status to others (Williams M., 2011). Stigma is a very big issue with HIV and many studies have reported that stigma may discourage patients from accessing care and taking their medications (Chambers et al., 2015; Rao et al, 2012; Dlamini et al., 2009 Sabin et al., 2008, Kinsler et al., 2007). When patients are stigmatized by their healthcare providers, they will not feel free to ask questions bothering their health and this will not enable them to relate well and feel relaxed with them. This study showed otherwise, patients were very satisfied with the level of service and were free to ask questions about their health. Famoroti et al., (2013) study in Kwazulu-Natal, South Africa reported there was continuous gossiping among health care workers about patients‟ HIV status which compromised patients‟ confidentiality. With confidentiality, patients are able to trust their healthcare providers like doctors, nurses and allied health professionals, this will make them happy, have positive attitude towards life, enhance patients‟ continuity to clinic and hence enhance CD4+T-cell recovery. 5.4 Hospital factors associated with CD4+T-cell Recovery is Respect The belief that patients will be treated respectfully when they come to the hospital with HIV/AIDS infection (doctors/nurses relationship to patients) was found to be significant with p-value of 0.020 (p<0.05) (Table 8). Healthcare system is very important and when patients are satisfied, they will keep coming to the clinic which is linked to care and University of Ghana http://ugspace.ug.edu.gh 40 retention in care (Peprah, 2014, Woodward, 2000). A study carried out in South Africa showed that while patients observed that although some patients were not being respected by some healthcare workers, they themselves were respected by their healthcare workers (Chimbindi et al., 2014). If patients are respected at their various clinics, they will spread the good news about positive hospital factors to other infected people in the community and this will help them to make decisions concerning visiting the hospital for early treatment. The people in the community will like to visit the hospital when they have HIV/AIDS because of the results of some of the patients who have already gone to receive care there. The government of Ghana through its technical bodies like the NACP and GAC are working hard to reduce HIV/AIDS prevalence and also to reduce morbidity and mortalities due to the virus (Fobil and Soyiri 2006). It‟s quite expected that when people in the communities have HIV/AIDS that they go to the hospital for prompt care and timely intervention and also initiation into ART as soon as possible. When patients don‟t believe they will be treated with respect at the hospital, they will not go, which will jeopardize the Governments‟ activities and efforts (Fobil and Soyiri 2006). It‟s therefore imperative that the hospital system and health care workers should respect and treat all patients with dignity and respect. University of Ghana http://ugspace.ug.edu.gh 41 CHAPTER SIX CONCLUSION AND RECOMMENDATIONS This study has shown that the introduction of HAART actually causes immunological recovery by the mean increase in CD4+T-cell counts. The socio-demographic/patient factors that enhance CD4+T-cell recovery are listed as age, sex, educational level and adherence. The healthcare workers are trying to take care of the patients while at the same time reducing disease progression to AIDS and death. The belief that patients will be treated with respect when they come to the hospital with HIV/AIDS infection was found to be associated with CD4+T-cell recovery. The hospital/ system factors enhance CD4+T-cell recovery in this study. 6.1 Recommendations Based on this study, a number of recommendations can be made: The doctors, nurses and allied health professionals at the Fevers‟ Unit should continue to maintain better health service delivery to those with HIV/AIDS in terms of respect, support and confidentiality. NACP and all her developing partners should continue to ensure that there are HAART available for all the people living with the HIV. Non-Governmental Organizations can continue to carryout programs that will help the PLHIV, so that they can engage in meaningful socio-economic activities which will enable them to financially make it to the hospitals at their respective appointment times. Further research is needed to find the cause of widowhood among 17% of the respondents. University of Ghana http://ugspace.ug.edu.gh 42 As more people with HIV/AIDS are approaching ≥50 years, it‟s a source of worry due to the fact that they do not achieve immunological recovery earlier enough, this can be subject for further investigation. University of Ghana http://ugspace.ug.edu.gh 43 REFERENCES Aikins, A. de-Graft. (2007). Ghana‟s neglected chronic disease epidemic: a developmental challenge. Ghana Medical Journal, 41, (4):154-159 Akinbami, A., Dosunmu, A., Adediran, A., Ajibola, S., Oshinaike, O., Wright, K., & Arogundade, O. (2012). CD4 Count Pattern and Demographic Distribution of Treatment-Naïve HIV Patients in Lagos, Nigeria. AIDS Research and Treatment, 2012, 352753. doi:10.1155/2012/352753 Annison, L.,Dompreh, A. & Sarkodie, A.Y. (2013). The immunological response of HIV- positive patients initiating haart at the Komfo Anokye Teaching Hospital. Ghana Medical Journal, 47,(4) 164-170 Carter, M.(2011). 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University of Ghana http://ugspace.ug.edu.gh 50 APPENDICES Appendix 1: Consent Form RESPONDENTS INFORMED CONSENT FORM My name is ADJOA OBO-AKWA, a female student of the School of Public Health, University of Ghana. I am conducting a research titled: FACTORS ENHANCING CD4+T-CELL RECOVERY AMONG HIV POSITIVE PATIENTS ON HIGHLY ACTIVE ANTIRETROVIRAL THERAPY FOR ONE YEAR AT THE KORLE-BU TEACHING HOSPITAL, ACCRA. Your response will be used to find out how CD4+T- cells recover. I will be pleased if you could give me the permission to ask a few questions in relation to the study. I want to assure you that any information you provide will strictly be confidential, for the purpose of academics. This study is being carried out to find the effect of Highly Active Antiretroviral Therapy on CD4 counts; you will just answer questions using a questionnaire. You may also voluntarily opt out of the study anytime if you so wish, this will not affect the care you receive at this hospital in any way. The results of the research will add to scientific knowledge in HIV/AIDS research. If you have further questions, you may contact the Ethical Review Committee (ERC) Administrator of the Ghana Health Services, Madam Hannah Frimpong on 0243235225 or 0507041223. Thank you. University of Ghana http://ugspace.ug.edu.gh 51 „I have read the information or it has been read to me and has had opportunity to ask questions. I consent and voluntarily agree to participate and understand that I can withdraw at any time without it affecting my medical care‟. ----------------------------------------------- --------------------------------- Participant‟s signature or thumbprint Date ------------------------------------------------- ---------------------------------- - Signature or thumbprint of witness Date ------------------------------------------------- ------------------------------------- Name & Signature of Person Obtaining Consent Date University of Ghana http://ugspace.ug.edu.gh 52 Appendix 2: Questionnaire QUESTIONNAIRE FOR THE RESEARCH TOPIC: Factors Enhancing CD4+T-cell Recovery among HIV Positive Patients on Highly Active Antiretroviral Therapy for One Year at the Korle-Bu Teaching Hospital, Accra. Kindly answer these questions concerning how you feel about the hospital. It will take few minutes. Section A: Demographics 1. Patient Code______________ KF No_____________- 2. Sex: Male (1) Female (2) 3. Age (as at last birthday) ___________________ 4. Marital Status Single (1) Married (2) Widowed (3) Divorced (4) Separated /Cohabiting (5) 5. Educational Level Nil (1) Primary/JHS (2) SSS/MSLC/Sec/Tech/Voc (3) Tertiary (4) 6. Occupation Civil/ Public Servant (1) Professional (2) Businessman/woman (3) Artisan (4) Hairdresser/Seamstress (5) Trader (6) Hawker (7) Unemployed (8) Others specify (9) ____________________ University of Ghana http://ugspace.ug.edu.gh 53 7. Income level Less than GHC 200 (1) 200-399GHc (2) 400-599GHc (3) 600-799GHc (4) 800-1000 (5) Greater than 1000GHc (6) 8. Place of Residence: Rural (1) Peri-Urban (2) Urban (3) 9. Do you have an NHIS card? Yes/ No. 10. If yes do you use the card when you come to the clinic? (1) Yes (2) No (3) Sometimes SECTION TWO 11. Date of HIV Diagnosis (extracted from the folder) _________________________ Risk factors 12. How will you describe yourself? Heterosexual (1) MSM (2) Mode of transmission Heterosexual (1) MSM (2) Blood transfusion (3) Mother to Child (4) Any Other (Specify) (5) __________________________ 13. WHO Clinical Stage (at the time of diagnosis, extracted from the folder) 1.I 2. II 3. III 4. IV 14. Date start HAART (extracted from the folder) _________________ 15. HAART Combination COMB/EFV (1) COMB/NVP (2) TDF/EFV/3TC (3) TDF/NVP/3TC (4) Others specify (5) __________________________________ 16. CD4 Count at entry/baseline HAART (extracted from folder) _______c/ul date of lab ______ 17. CD4 Count at I year of HAART (extracted from older) __________c/ul date of lab _____ University of Ghana http://ugspace.ug.edu.gh 54 18. Any disease condition at initiation of HAART (extracted from the folder) Yes/No If yes, specify _______________________ 19. ADHERENCE TO HAART- QUESTIONS Yes No Do you sometimes forget to take your medicines? 1 0 In the past two weeks have u forgotten to take your medicines? 1 0 Have you ever stopped taking your medicines without telling your doctor because you felt worse when you took it? 1 0 When you travel or leave your house do you sometimes forget to go along with your medicine? 1 0 Did you take all your medicine yesterday? 1 0 When you feel like you are not sick, do you sometimes stop taking your medicine? 1 0 Do you ever feel bothered about sticking to your treatment plan? 1 0 Do you have difficulty in remembering to take your medicine? Never/Rarely..........................0 Once in a while.......................1 Sometimes..............................2 Usually...................................3 All the time.............................4 1 0 TOTAL SCORE Hospital/System factors. Please select the most suitable response 1=strongly agree 2=Agree 3=Not sure 4=Disagree 5=strongly disagree 20. The health care providers are supportive of people who have HIV/AIDS 1 2 3 4 5 University of Ghana http://ugspace.ug.edu.gh 55 21. If not, in your opinion, why not? ___________________________________________ 22. The healthcare workers are respectful to people who have HIV/AIDS. 1 2 3 23. If not, in your opinion, why not? ___________________________________________ 24. Before coming for treatment, you expected the providers would be supportive of people who have HIV/AIDS 1 2 3 4 5 25. Before coming for treatment, did you expect that the providers would be respectful to people who have HIV/AIDS? 1 2 3 4 5 26. Most people believe they will be treated respectfully by health care providers if they have HIV/AIDS. 1 2 3 4 5 27. You are satisfied with the waiting time at the clinic. 1 2 3 4 5 28. You are happy with the service you are receiving from this facility. 1 2 3 4 5 29. The level of service you are getting from this facility is____________________________ 1. Better than you expected 2. About what you expected 3. Not as good as you expected 30. You have been given the opportunity to ask questions about HIV/AIDS. 1 2 3 4 5 31. You are satisfied with the clinic schedule (clinic days). 1 2 3 4 5 32. Drugs (HAART) are available at the health center. 1 2 3 4 5 33. Has the hospital experienced any shortages of HAART (drugs) in the past year? 1. Yes 2. No 3. Don‟t know if No, skip to Q37 University of Ghana http://ugspace.ug.edu.gh 56 34. If yes for how long? 1. One month 2. Between 1-3 months 3. Between 3-6 months 4. More than 6 months 35. Did it result in patient interruption of treatment? 1. Yes 2. No 3. Don‟t know 36. What were the reasons for the shortage? 1. Procurement not made in time 2. Late delivery 3. No requisition forms to order for the drugs 4.Dont know 5. Others (Specify) __________________________________________________________________ 37. Have there been shortage of laboratory reagents like CD4 counts in the last one year? 1. Yes 2. No 3. Don‟t know if No, skip to Q39 38. What were the reasons for the shortage of the reagents? 1. Procurement not made in time 2. Late delivery 3. No requisition forms to order for the reagents. 4. Don‟t know 5. Others (Specify) __________________________________________________________________ 39. How far is your home from this health facility? (Distance or time) 1. Less than 30 minutes 2. Less than 1 hour 3. Between 1-2 hours 4. More than 2 hours 40. How do you commute to the hospital? 1. Private car 2.Taxi 3.Bus (trotro) 4.Walking 5. Others (specify) __________________________________________ 41. How much do you spend to get to the hospital in answer to question 40? ___________ 42. Is there other health facility closer to your home? 1. Yes 2. No 43. Do you have to pay to see a health provider? 1. Yes 2. No →SKIP TO Q 45 44. How much ___________________________________ 45. Do you have to pay to have the lab test done? 1. Yes 2. No → SKIP TO Q 47 46. How Much? ___________________________ University of Ghana http://ugspace.ug.edu.gh 57 47. Do you have to pay for the drugs and other treatment? 1. Yes 2. No→ SKIP TO Q 49 48. How Much? ___________________________ 49. Do you have the money to buy the drugs and do the labs? 1. Always 2. Sometimes 3. Never 50. Cost of consultation/care is satisfactory 1 (strongly agree) 2 (agree) 3 (disagree) 4(Strongly disagree) University of Ghana http://ugspace.ug.edu.gh