University of Ghana http://ugspace.ug.edu.gh UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH DEPARTMENT OF POPULATION, FERTILITY AND REPRODUCTIVE HEALTH FACTORS AFFECTING ADHERENCE TO ANTI-RETROVIRAL THERAPY AMONG WOMEN IN SELECTED HEALTH FACILITIES IN THE GREATER ACCRA REGION BY ADWOA PRIMS ESSEL (10289552) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE. JULY, 2018 University of Ghana http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to the Almighty God for the good health and strength to conduct this research. I also dedicated to Mr. Philip Yamoah Essel (Husband) for all the support and assistance he gave me throughout this study. To my children for behaving themselves well at home for all the weekends that I had to be in school. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS I am most grateful to the Almighty God for the guidance and good health throughout my studies. I extend my appreciation to Dr. Richmond Aryeetey my Academic Supervisor for his time, guidance and contribution to this work. Finally, I sincerely thank all my classmates (MPH weekend class of 2017/2018) who motivated and helped me in one way or the other to reach this far, I say thank you and God bless you. “TO GOD BE ALL THE GLORY”. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: HIV/AIDS was discovered as far back as 1981; however, a cure for it is yet to be found. The only remedy currently is to manage using Antiretroviral Therapy (ART). Standard ART consists of the combination antiretroviral (ARV) drugs to suppress the HIV virus and stop the progression of HIV disease. ART can limit transmission of HIV. Non-adherence to ART is a growing concern to clinicians, healthcare systems, and other stakeholders. Objective: To determine the factors associated with ART adherence among women seeking treatment from selected health facilities in the Greater Accra region. Method: The study was conducted on a sample size of 109 women using a cross sectional study design, selected conveniently from selected health facilities providing ART services. Quantitative data collection with structured questionnaire was used. Data was collected over a one-month period. Respondent seeking treatment services from five facilities (Ghana Atomic Energy Commission Hospital, Pantang Psychiatric Hospital, Pentecost Mission Hospital, Abokobi Health Center, and International Health Care Center) were recruited. Descriptive statistics such as means, standard deviation, frequency and percentage were used to describe demographic characteristics of the population under study. Chi-square statistic was used to for association between each independent variable (socio-cultural, socio-economic factors, HIV status disclosure factors and disclosure audience) and dependent variable (compliance to ART).Binary logistic regression was then used to determine the association between dependent variable and independent variables. Level of significance was set at 5%. . Results: More than half of the women (67.6%) have disclosed their HIV status. Adherence to ART treatment among the women was poor, 73.3% did not adhere to medications as compared with good adherence rate of 26.73%. Socio-cultural factors (using herbal treatment instead of medical treatment; blame for family mishap; indifferent treatment from friends and family, loss iv University of Ghana http://ugspace.ug.edu.gh of respect) had no significant association with adherence to ART (p>0.05). However, there was a significant association between adherence to ART and being perceived as promiscuous (χ2=6.2740; p=0.020). Women who did not disclose their status due to its association with promiscuous behavior were more likely to adhere to their ART‟s. ARV treatment factors (tablets swallowed daily, medication other than ARV, ease of swallowing tablet, loss of appetite because of ART intake) did not have any significant association with adherence to ART with a p>0.05. Nonetheless, effect of ART intake on daily activities predicted adherence to ART (p=0.026). Most of the women 58.6% indicated their preferred disclosure audience will be their parents. Participants who disclosed to their parents (40.70%) had poor adherence to ART (p>0.05). Conclusion: Adherence to ART was low. All the independent variables were not significantly linked with adherence to ART, except for disclosure (not disclosing status due to perceived promiscuous attachment to the disease) and drug related factors (drug side effects interrupting with daily activities) that had a significant association with adherence. Majority preferred to disclose to their parents and all of them did not adhere. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ............................................................................................................................. i DEDICATION ................................................................................................................................ ii ACKNOWLEDGEMENTS ........................................................................................................... iii ABSTRACT ................................................................................................................................... iv TABLE OF CONTENTS ............................................................................................................... vi LIST OF TABLES ......................................................................................................................... ix LIST OF FIGURES ........................................................................................................................ x LISTS OF ABBREVIATIONS...................................................................................................... xi CHAPTER ONE ............................................................................................................................. 1 INTRODUCTION .......................................................................................................................... 1 1.1Background of study .............................................................................................................. 1 1.2 Statement of the Problem ...................................................................................................... 7 1.3 Main Objective ...................................................................................................................... 9 1.4 Specific Objectives ................................................................................................................ 9 1.6 Justification for the study .................................................................................................... 10 1.7 Conceptual Framework ....................................................................................................... 10 CHAPTER TWO .......................................................................................................................... 14 REVIEW OF LITERATURE ....................................................................................................... 14 2.2 Epidemiology of HIV .......................................................................................................... 14 2.4 HIV among Women in Reproductive Age in Ghana ` ........................................................ 16 2.4 HIV Testing and Counselling (HTC) .................................................................................. 17 2.5 Disclosure of HIV Status..................................................................................................... 18 2.6 HIV Treatment .................................................................................................................... 19 2.7 Treatment Compliance/Adherence ...................................................................................... 19 CHAPTER THREE ...................................................................................................................... 21 METHODOLOGY ....................................................................................................................... 21 3.2 Research Design .................................................................................................................. 21 3.2 Study area ............................................................................................................................ 22 3.3 Variables.............................................................................................................................. 22 3.3.1 Dependent variable ....................................................................................................... 22 vi University of Ghana http://ugspace.ug.edu.gh 3.3.2 Independent variables ................................................................................................... 23 3.4 Study population ................................................................................................................. 25 3.5 Inclusion criteria .................................................................................................................. 25 3.6 Exclusion criteria................................................................................................................. 25 3.7 Sampling.............................................................................................................................. 26 3.8 Sample size .......................................................................................................................... 27 3.9 Data Collection Process ...................................................................................................... 27 3.10 Training of Field Staff (Research Assistant) ..................................................................... 28 3.11 Data collection Tools ........................................................................................................ 29 3.12 Quality control................................................................................................................... 29 3.13 Data analysis ..................................................................................................................... 30 3.14 Ethical considerations/Issues............................................................................................. 30 3.15 Ethical clearance ............................................................................................................... 30 3.16 Approval from study area .................................................................................................. 30 3.17 Description of subjects involved in the study ................................................................... 31 3.18 Potential risks/benefits ...................................................................................................... 31 3.19 Privacy/Confidentiality ..................................................................................................... 31 3.20 Data storage and usage ...................................................................................................... 31 3.21 Description of the consenting process ............................................................................... 32 3.21.1 Voluntary withdrawal ................................................................................................. 32 3.21.2 Compensation ............................................................................................................. 32 3.22 Protocol amendments ........................................................................................................ 32 3.23 Declaration of conflict of interest...................................................................................... 32 3.24 Funding information .......................................................................................................... 32 3.25 Pretesting the Tools ........................................................................................................... 32 3.26 Instruments Validity and Reliability ................................................................................. 33 CHAPTER FOUR ......................................................................................................................... 34 RESULTS ..................................................................................................................................... 34 4.1 Socio-demographic characteristics of respondents ............................................................. 34 4.2 Adherence to anti-retroviral therapy (ART) among woman living with HIV .................... 36 vii University of Ghana http://ugspace.ug.edu.gh 4.3 Socio-cultural factors that affect disclosure of status in HIV women................................. 37 4.4 Relationship between ARV treatment factors and adherence to ART ................................ 39 4.5 Association between HIV status disclosure and adherence to ART ................................... 41 4.6 Adjusted analysis................................................................................................................. 43 CHAPTER FIVE .......................................................................................................................... 44 DISCUSSION ............................................................................................................................... 44 5.0 Introduction ......................................................................................................................... 44 5.1 Discussion ........................................................................................................................... 44 CHAPTER SIX ............................................................................................................................. 48 CONCLUSIONS AND RECOMMENDATIONS ....................................................................... 48 6.1 Conclusion ........................................................................................................................... 48 6.2 Recommendation ................................................................................................................. 48 REFERENCES ............................................................................................................................. 49 APPENDIX ................................................................................................................................... 54 Appendix A: Participant‟s Consent form .................................................................................. 54 Appendix B: Questionnaire ....................................................................................................... 57 viii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1 Study variables, operational definition and scale of measurement ……………………17 Table 4.1 Socio-demographic characteristics of HIV positive women………………………….26 Table 4.2 Bivariate analysis of cultural factors and adherence to ART among HIV positive women……………………………………………………………………………………………29 Table 4.3 Adjusted analysis for between ARV treatment and adherence to ART among pregnant women…………………………………………………………………………………………....31 Table 4.4 Preferred HIV status disclosure audience among women in selected health facilities..33 Table 4.5 Bivariate association between HIV disclosure option and adherence to ART among PMTCT mothers………………………………………………………………………................33 Table 4.6 Multivariate analysis of association between dependent and independent variables.........................................................................................................................................34 ix University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1.1: Conceptual framework for HIV/AIDS status disclosure among pregnant women and compliance to anti-retroviral therapy……………………………………………………………13 Figure 4.1: Adherence to ART among HIV positive women in selected facilities……………28 Fig. 4.2: HIV/AIDS disclosure status of women in selected facilities………………………….32 x University of Ghana http://ugspace.ug.edu.gh LISTS OF ABBREVIATIONS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Clinic ART Anti-Retroviral Therapy AZT Zidovudine CD4 Cluster of Differentiation Four DOT Directly Observed Therapy HIV Human Immune Deficiency Virus MTCT Mother to Child Transmission PLHIV Persons Living with HIV PLWHA Persons Living with HIV and AIDS PMTCT Prevention of Mother to Child Transmission WHO World Health Organisation VCT Voluntary Counselling and Testing CT Counselling and Testing MOH Ministry of health xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1Background of study Since the beginning of the epidemic, more than 70 million people have been infected with the HIV virus and about 35 million people have died of HIV. Globally, 36.9 million people were living with HIV at the end of 2017. An estimated 0.8% of adults aged 15–49 years globally are infected with HIV, the extent of epidemic varies considerably among countries and regions however, WHO African region remains most severely affected, with nearly 1 in every 25 adults (4.1%) living with HIV and accounting for nearly two-thirds of the people living with HIV worldwide, 70% of which is made up of newly diagnosed infections. (Global Health Observatory, 2018). About 2.6 million children under age of 15 are living with HIV/AIDS globally, 91% of this number are from Sub-Saharan Africa (UNAIDS, 2017). Expanded access to antiretroviral therapy (ART) and a declining incidence of HIV infection have led to a fall globally in the number of adults and children dying from HIV-related causes. The estimated 940 000 people who died from HIV globally in 2017 were 52% fewer than in 2004 (the peak) and 34% fewer than in 2010 in spite of a period of substantial population growth in many high burden countries.(GHO data,2018). HAART defined as "highly active antiretroviral therapy," The term was coined in the late 1990s for describing the effectiveness of combination drug therapies used to manage HIV. Before the use of HAART, the use of one or two antiretroviral drugs had generally limited treatment success in patients with HIV, resulting in treatment failure as well as the inability to limit viral activity significantly. 1 University of Ghana http://ugspace.ug.edu.gh The introduction of protease inhibitors in 1996 enabled health practioners to have the convenience of combining three or more drug agents in a way that effectively stopped HIV from replicating at different points in its life cycle. Multi-drug approach also known as "triple therapy" or "triple drug cocktail was introduced for the management of HIV and AIDS. Currently, the term has been replaced with other titles, including cART (combination antiretroviral therapy) or, even more simply, ART (antiretroviral therapy). Cichocki, M. (2017). ART medication are categorized into 5 classes depending on the stage of the viral life cycle. Currently, there are 27 individual agents also known as drug molecules and 12 fixed dosed combination (FDC) drugs comprised of two or more molecules. Seven of the FDCs, can be used as a single-pill, once-daily dose, ensuring higher treatment adherence and ease of use. Before the use of the first dose of medication, the following issues must be discussed. Treatment therapists and counselors must explain the following points thoroughly and clients confirm a clear understanding before initiating treatment. This discussions is to ensure that client fully understands the treatment regimen and accepts that there may be some side effects but they agree to adhere to medications accordingly.  Reasons for selecting a particular treatment regimen.  A drug/regimen's past efficacy and expected treatment outcomes.  All dosing issues, especially how a medication is taken, how often, how much, and when (time) to take medication.  Possible and/or potential side-effects during treatment.  Education on expected drug reaction and a severe unexpected adverse reaction that merits reporting in to the clinic. 2 University of Ghana http://ugspace.ug.edu.gh  Interactions with other drugs the person may already be taking example herbal medicine. Adequate information on certain drug reaction example, skin rashes, diarrhea, drowsiness, dizziness and stomach pain to a large extent makes a person ready to deal with drug reaction positively. A good understanding and expectation of possible side effects reduces the risk of medication dropouts and improves medication adherence significantly. World Health Organization works to increase access to HIV testing, antiretroviral therapy (ART) and viral load monitoring, to improve the clinical management of HIV as an urgent public health priority to prevent HIV-related morbidity and mortality. (WHO, 2018) The international community through global UNAIDS developed an initiative (90-90-90 target) that seeks to ensure that all persons living with HIV has been diagnosed, started antiretroviral treatment and can reach a fully suppressed viral load within 12months of initiating treatment by the end of year 2020. (L2TR 90-90-90 Ghana campaign, 2016). As part of efforts to reach this target in Ghana, the Ghana Health Service through the NACP developed a five-year roadmap document which sets out national health sector plans to mobilize community health workers and other stakeholders to locate, test, treat and retain PLHIV in ART care, to ensure effective viral load suppression. (L2TR 90-90-90 Ghana campaign, 2016). The NACP‟s collaborative effort with respective stakeholders in developing this roadmap seeks to strengthen Ghana‟s commitment towards achieving the 90-90-90 targets. HIV treatment and prevention programmes must stress more on preventive benefits of antiretroviral use for managing HIV/AIDS. (WHO, 2018) 3 University of Ghana http://ugspace.ug.edu.gh WHO recognizes that awareness of treatment and prevention benefits of Antiretroviral should be promoted, in order to encourage HIV testing uptake, and to support people to access and adhere to antiretroviral therapy early. (WHO, 2018). Globally it is believed that most children with HIV infection were infected either during conception, during labor or during the breastfeeding period. This mode of transmission is a common means of infection among children although other means is possible (Chukwuemeka, 2014). Through implementation of PMTCT interventions HIV transmission can be reduce to less than 5% if HIV and AIDS infected mother and infants have access to and participate fully in the range of PMTCT services (Kak et al. 2014). HIV transmission rate is high, ranging between 15% and 45% without any interventions, (Global Health Observatory, 2011). Interventions to prevent HIV transmission from mothers to their infants include routine HIV/AIDS education, routine HIV testing and counseling for pregnant women and their partners, comprehensive antenatal care (ANC), prophylactic management of child immediately after delivery, skilled delivery practices and counseling on safer infant feeding (comprehensive) and proper home personal hygiene of the exposed infant. (Kak et al. 2014). Prevention of mother-to-child transmission of HIV programs are now available in many low and middle -income countries (Kak et al. 2014). PMTCT comprehensive approach is comprised of four key elements. a. Avoid infection of HIV among women and their partners. b. Prevent unplanned pregnancy among women living with HIV/AIDS. c. Hold back generational transmission of HIV/AIDS from mothers to their babies. d. Adequate supply of care, treatment and support to women living with HIV/AIDS and their families 4 University of Ghana http://ugspace.ug.edu.gh One of the main means of preventing HIV transmission is by disclosing of HIV status to prospective sexual partners as it promotes safer sex practices and minimizes the risk of transmission to sex partners. HIV status disclosure also helps improve social support and reduce depression among infected persons as a positive responses from relatives gives the client the hope that all will be well with the ART management regimen (Obermeyer 2011). Despite the benefits attached to HIV status disclosure, the rate of disclosure is low as it ranges between 16.7% and 86% in most developing countries. (Medley, 2004). Disclosure however can bring about undesirable outcomes such as stigmatization, discrimination, rejection, blame, and so on. These outcomes are otherwise major hindrances to disclosing ones HIV positive status. (Nyaribo, 2015). Trust is a major theme and core value for disclosure among people living with HIV/AIDS. Commonly, disclosure is between the patient and whom he/she prefers and feels comfortable to tell. Studies has indicated that individuals who fail to disclose their HIV status are less likely to adhere to their ART medications, change sexual behavior and practice safer sex than individuals who disclose their HIV status. Studies have shown that, in Africa some health care providers help clients in deciding who to reveal the HIV positive status to, thus whether spouse, parents or children (Gallo, 2009). This is to help develop a good social and family support for client. The relative involved is expected to assist and encourage client to comply with medication dosages and avoiding behaviors that interferes with the effective functioning of the antiretroviral. However, in some situations involving family members in HIV disclosure, has resulted in discrimination and psychological distress (Mwanga, 2012). Women experience a higher degree of negative consequences than men in Africa. (Vyavaharkar et al. 2011). Status disclosure is a sensitive phenomenon among person living with HIV especially women. Hence possible benefits or harm is considered before 5 University of Ghana http://ugspace.ug.edu.gh deciding whether to disclose status or not (Vyavaharkar et al. 2011). Many studies have shown that domestic violence, partner abandonment and community rejection are socio-cultural factors that prevents individuals from disclosing their HIV status (Worth et al, 2008; Deribe et al. 2008; Nachega et al. 2005; Akani and Erhabor, 2006). These impact makes disclosure of one‟s status nearly impossible for many, particularly for newly diagnosed individuals who are trying to absorb the shock of their status. In Ghana for instance, some ethnic groups believe that HIV is inflicted by witchcrafts or it could be punishment or a curse from an enemy (Adinkrah, 2015). Experience on field work has proved to me that some families goes to the extent of disowning an HIV infected person believing that their presence in the family will bring on them curses. Some people believe that taking the ART medications will make HIV more permanent as it‟s a curse and can be reversed by pleasing the gods, hence their refusal to comply to medication. A rudimentary determining factor for the successfully management of HIV/AIDS according to Hasabi, (2016), is by adhering to Antiretroviral Therapy (ART). The degree to which individuals follow their medication plan, according to Lal et al (2010), constitute compliance, otherwise known as “adherence with medications”. To guarantee success in managing HIV and AIDS, it is imperative to attain over ninety-five percent adherence rates so as to subdue the reproduction of viral load and circumvent resistance to medication (Shah, 2007). Viral load rate in excess of fifty percent have been shown in some researches to be linked with optimum compliance rate of ninety five percent and adherence rate of ninety five percent (Osterberg et al, 2005). It is near impossible to attain optimum adherence rate for reason that management procedure comprise numerous and costly medications interspersed by intricate medicating plan which is likely to result in numerous food exchanges and hostile effects ensuing in low adherence (Stone et al. 6 University of Ghana http://ugspace.ug.edu.gh 2001). Also, sedentary behavioral factors and patient-health personnel interaction has a detrimental effect on adherence. (Stone et al. 2001). Inferring from the reviews and for the purpose of this study, ART is defined as “the extent to which a person‟s behavior in taking medication, following dietary specifications and/or executing lifestyle changes corresponds to the advised recommendations from a doctor/ healthcare provider” (Ajithkumar et al. 2011: 45). Inadequate adherence to ART, however, is common in most groups of individuals being managed for HIV. To attain a twenty-one percent decline in the progression of the disease, a ten percent upgrade in adherence is indispensable. There are many elements that have detrimental effect on adherence levels; among these elements are “social aspects like motivation to begin and adhere to therapy, socioeconomic status, educational status, financial status, family support, lifestyle pattern, advantages and disadvantages of starting therapy like tolerability of regimen, availability of drugs, regimens-pill burden, frequency of dosing, food requirements, convenience, toxicity and drug availability” (Nischal et al. 2005; Bangsberg et al. 2001). 1.2 Statement of the Problem Adherence to ART can be influenced by a number of factors including the patient‟s social situation and clinical condition, the prescribed regimen, and the patient-provider relationship (AIDSinfo, 2017). Adherence to ART in women is an important public health concern, since non-adherence can lead to resistant strains of the virus in the individual, debilitating health for the mother and possible HIV transmission to the baby, particularly the potential for vertical transmission of resistant virus (Nachega et al., 2012) The new trend option of combined management for treating patients infected with HIV is the reason for the evidence increment in non-adherence complications for infected individuals and 7 University of Ghana http://ugspace.ug.edu.gh medical health givers. In some health selected health facilities in Accra, clients have complained verbally of the size of the tablets (big), the strict regimen in relation to dosages, timing and the accompanying side effects that sometimes interferes with their daily activities. Nevertheless, eating constraints, status disclosure difficulties, inadequate family support and the overall system of care are contributing factors. HIV status disclosure and adherence is central to improving both maternal and child health outcomes (Spangler et al. 2014). From literature, it is argued that lifelong ART may reduce stigmatization of pregnant and lactating women (Ngarina et al. 2014; Adino, 2016; Lincoln, 2016). Nationally, HIV prevalence among adults is estimated to be 1.8% in 2009. However, prevalence is much higher among women attending ANC, at 2.9%. Levels of infection are nearly 3 times higher among young women (1.3%) than young men (0.5%), [9] and generally higher among urban residents than rural residents. It is for this reason that this study seeks to acknowledge the factors that affects adherence to ART among women in selected facilities in Greater Accra Region. Although the internet is loaded with information on HIV, little is documented about HIV treatment adherence among women and how other factors such as disclosure can affect adherence to treatment especially in Ghana. One on one undocumented interaction with HIV positive women in selected HIV centers has shown that they prefer to hide their medications in other to prevent stigmatization, but in so doing they forget to take as prescribed. This study is designed to study some factors that affects adherence to HIV treatment regimen among women in selected health facilities in Accra. 8 University of Ghana http://ugspace.ug.edu.gh 1.3 Main Objective To determine factors affecting adherence to Anti-retroviral Therapy among women in selected health facilities in the Greater Accra Region. 1.4 Specific Objectives 1. To determine the level of adherence to anti-retroviral therapy among HIV positive women receiving care and treatment at selected health facilities in Accra. 2. To identify the socio-cultural factors linked to ART among women living with HIV. 3. To determine the relation between ARV treatment factors and how it affects adherence to ART among PMTCT mothers receiving care at selected health facilities in Accra. 4. To determine preferred HIV status disclosure audience among women attending for care at selected Health Facilities in Accra. 1.5 Research Questions 1. What is the level of adherence to anti-retroviral therapy among HIV positive women (PMTCT) attending for care and treatment at selected health facilities in Accra? 2. What socio-cultural factors are linked with disclosure to anti-retroviral therapy among HIV positive women (PMTCT) attending selected health facilities in Accra? 3. What are the ARV treatment factors that affect adherence to ARV in selected health facililities in the Greater Accra Region? 4. What relationship exist between HIV status disclosure and compliance to antiretroviral therapy among HIV positive women positive (PMTCT) attending selected health facilities in Accra? 9 University of Ghana http://ugspace.ug.edu.gh 5. What is the preferred HIV status disclosure audience among women with HIV positive women (PMTCT) and its association on compliance to antiretroviral therap 1.6 Justification for the study HIV counseling and testing has become increasingly important in HIV prevention and management. Knowledge of sero-status through CT can be a motivating force for HIV-positive and negative people behavior, which enables sero-positive people to prevent their sexual partners from getting infected and those who test sero-negative to remain negative. Also, those found to be positive alike to adopt safer sexual practices and get counseling and treatment. The study will be conducted on women on PMTCT strategy because according to GHS standards, every pregnant woman attending antenatal must be tested for HIV status hence they know their status. This is important since it helps to prolong and improve the quality of life for those infected with HIV (Commonwealth Regional Health Community Secretariat, 2002). This study will provide information to policy makers and the Ghana AIDS commission to devise strategies aimed at encouraging adherence to ART especially among PMTCT women on. Discussions and explanations during data collection in this study will be significant to participants in addressing their consents and understanding challenges that PLWHA face after disclosing their status and how it affects adherence to treatment. Consequently, results of this study may serve as a basis for the development of compliance promotion programs by the Ministry of Health and other Non-governmental organizations to encourage support for persons, especially women, living with HIV/AIDS. 1.7 Conceptual Framework Figure 1.1 presents the conceptual framework for the study. The cultural ramifications, such being a disliked, tagged as promiscuous and a misfit for society impacts on disclosure. A patient‟s decision and motivation to disclose her status could also be influenced by trust, as some 10 University of Ghana http://ugspace.ug.edu.gh will confide in their partners, whiles others will confide in the families or friends. It is likely for infected individuals not to disclose their status to enjoy the wealth and comfort from their partners. Disclosing one HIV status requires endless support and motivation. Thus, identifying someone who will provide such support and motivation can be daunting resulting in non- disclosure. Accepting one‟s status after disclosure of their HIV status could affect their rate of compliance. According to Horne et al. (2013), adherence to ART can be complex as a range of factors can undesirably influence treatment outcome. They identified factors such as ART regimen and its side effects, psychosocial and socioeconomic factors and, access to health-care, support from health-care staff and health-care system issues as factors that influence adherence. (Horne et al., 2013). However in this study, the identified factors that influence adherence from various literature have been grouped into socio-economic factors, medical support/facility based factors, cultural factors, socio-demographic factors and preferred disclosure audience. The three drug combination (pill burden) to be taken once daily in addition to other prescribed medicines, the quantity and size of the tablets may make adherence difficult (Hardon et al., 2006). Some side effects of the medicines such as nausea, skin rash, frightening dreams, dizziness and adverse drug reactions such as Stevens Johnson‟s syndrome may be difficult to bear if not well explained and understood and may result in a reluctance to comply with treatment. At the facility setting, negative attitude of the health providers, bad communication skills and long waiting time can negatively affect compliance, however, consistent development of confidential and trusting relationship with the patient may improve compliance remarkably (Merten et al., 2010). Transportation cost is directly related to access to the facility. The closer the facility is to the patient, the less the cost required to reach it. Patients who must travel long 11 University of Ghana http://ugspace.ug.edu.gh distances to the clinic are often not able to raise the money required (Spoor, 2013). Boyce (2009) discovered that being married was associated with high rates of compliance while being single was a predictor of non-compliance. Availability of social support influence adherence, when a patient have friends and families who offer support in diverse forms it helps motivate patient to comply to the treatment regimen. 12 University of Ghana http://ugspace.ug.edu.gh Socio-demographic factors Personal factors Age, Marital status, Disclosure, poverty, Employment status, Educational level, income, distance to Number of children, health facility, cost of Age of children. medication, knowledge. ADHERENCE TO ANTI Medical support/facility RETROVIRAL based factors THERAPY Waiting time, confidentiality, privacy, patient-doctor communication, confidentiality, trust, drug ARV regimen factors Pill burden, side effects, and drug interactions. Socio cultural factors Curse, family rejection, trust in keeping status secret, divorce. Figure 1.1: Conceptual framework for PMTCT mothers and adherence to anti-retroviral therapy (Adopted and modified from Zegeye and Sendo, 2015) 13 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO REVIEW OF LITERATURE 2.1 Introduction A literature review is an evaluative report of information found in the literature related to selected area of study. Literature review describes, summarizes, evaluates and clarify literature already used for similar area of study.(CQuniversity Library oline,2018) This literature review was done by referring from scholarly articles on the internet and other sources relevant to the topic of research. Information gathered here provides a description, summary, and critical evaluation of all related to the research problem being investigated. The following will be discussed in this chapter;  Epidemiology of HIV  HIV among women in reproductive age in Ghana  Disclosure of HIV status  HIV treatment regimen  Treatment compliance and adherence 2.2 Epidemiology of HIV The global burden of infectious HIV/AIDS is the severest infirmity that threatens the existence and wellbeing of individuals in contemporary times. The disease is most felt in Sub- Saharan Africa and Asia, which undermines people, their families, networks, and their future wellbeing, advancement, and security of countries. Almost twenty long years of exertion, despite everything the condition has no permanent cure, an antibody, or a compelling microbicide. While there have been accomplishments in HIV counteractive action in emerging nations, the scourge, 14 University of Ghana http://ugspace.ug.edu.gh a long way from being contained, keeps on extending internationally, and now debilitates tremendous populaces in China, India, and Russia. HIV/AIDS was initially considered as another illness in Los Angeles, and San Francisco when medical practitioners started to diagnose young gay men with “Pneumocystis carinii (now P jiroveci) pneumonia (PCP) and Kaposi's sarcoma (KS). The primary report that alarmed the world to this new immunodeficiency disorder was seen in 1981 in June and portrayed five youthful, gay men in Los Angeles with PCP. Different reports was told of an equivalent disorder contracted by infusing drug clients. These people shared a significant immunodeficiency disorder, the sign of which was a reduced rates of CD4-positive, or T-assistant, lymphocytes. The Centers for Disease Control and Prevention (CDC) in mid-nineteen eighty two, distributed a report of thirty-four instances of KS and opportunistic infections (OIs) in Haitians living in a few distinct states in the United States, none of whom revealed gay conduct. After 7 days, the CDC wrote about PCP affecting people with hemophilia. The primary case in a transfusion beneficiary was accounted for from San Francisco in a newborn child towards the end of 1982. For a brief span, the illness was referred to as gay-related immunodeficiency disorder (GRIDS), yet in September 1982, the CDC had distributed a case definition, utilizing the acquired immunodeficiency syndrome (AIDS), and it was quickly received by scientists. 2.3 HIV Situation in Ghana On a national scale, the proportion of HIV in 2016, among ladies seeking prenatal care was 2.4% while the proportion of the young particularly, those in the 15-24 years age bracket, an intermediary for new diseases stayed unaltered at 1.1percent. Proportion of individuals in the 45- 15 University of Ghana http://ugspace.ug.edu.gh 49 age bracket recorded the most 5.6percent, trailed by individuals in the 35-39 years age bracket at 3.5percent with those in 15-19 years age bracket being the least at 0.6percent. On the regional scale, the highest cases of HIV (2.7percent) was recorded in the Volta and Brong Ahafo with in Northern part (0.7percent) recording the least. In the urban setting, the cases recorded at Nalerigu was 0.4percent whiles Agomanya and Sunyani recorded 4.2percent increase in the number of cases. This was followed by Wa with 3.7percent. The proportions in the rural parts of the country in 2016 extended from 0.5percent in Builsa, Kintampo and Salaga to 3.3perent in Fanteakwa. “A linear trend analysis of ANC HIV prevalence since 2001 shows a declining epidemic despite the increase from last year prevalence of 1.8%. The proportion of HIV subtype 1 is 98.5% compared to 1.5% for dual HIV type 1 and 2 infections in the 2016 survey”. Comparatively HIV prevalence is higher in urban areas while Syphilis is higher in rural areas 2.4 HIV among Women in Reproductive Age in Ghana ` Discoveries from the sixth Ghana Demographic and Health Survey [GDHS], in 2014 demonstrated that 70percent of ladies and 82percent of men were in the known that using condoms decreases the danger of spreading HIV. Nonetheless, just 18percent of ladies and 30 percent of men have extensive information about HIV and AIDS and thirteen percent of ladies and six percent of men were diagnosed for HIV in recent months and got the outcome of the diagnosis. Concerning the young, eleven percent of young ladies and nine percent of young fellows in the 15-24years age bracket had sex before they turned 15 years and just sixteen percent of young ladies and three percent of young men who had sex in recent months were diagnosed for HIV in recent months and got the aftereffects of the diagnosis. Condom use among 16 University of Ghana http://ugspace.ug.edu.gh the adolescent is additionally stumpy. The evaluated proportions of HIV in Ghana as per the 2014 GDHS is two percent. In 2014, of six hundred and one, seven hundred and twenty six pregnant ladies who were diagnosed for HIV, twelve thousand, five hundred and eighty three, representing two percent tested positive for HIV. Of the pregnant ladies who tested positive to HV, eight thousand two hundred and ninety nine, (sixty-six percent) were put on ART as either “prophylaxis” or management. 2.4 HIV Testing and Counselling (HTC) HIV testing and counselling administrations fill in as the purpose of passage into HIV treatment, care and sustenance services. The point of service incorporated in medical centers in Ghana sum up to one thousand six hundred and fifty six. What is more, transportable centers and outreach centers set up for diagnosis were put up by private sector associations and medical personnel amid get-togethers to make diagnosis administrations accessible particularly in the communities. An aggregate of seven hundred and ninety eight thousand, seven hundred and sixty three individuals in 2014 were disgnosed for HIV nationwide, via HTC centers and the constrained "Know Your Status Campaigns" that were directed. This number is half of expected target earmarked for the year under HTC. Among those diagnosed, seven thousand and seventeen six hundred and thirty eight, representing eighty-nine percent were women. The expansion in the numbers diagnosed was because of enhanced supplies of HIV test units in the nation particularly for PMTCT diagnosing activities. The proportions of HIV between HTC customers was four percent as against six percent for 2013. Urging pregnant ladies to know their HIV sero-status keeping in mind the end goal to diminish the danger of transmission of the infection from the mother to kid is a key segment of PMTCT service delivery and serves as “entry of care for moms”. A key component of reducing 17 University of Ghana http://ugspace.ug.edu.gh HIV transmission common among all PMTCTs is testing and counselling. Since 2010, the nation has been utilizing the WHO choice B convention in the treatment of HIV positive pregnant ladies to additionally diminish Mother-to-Child Transmission (MTCT) rates. In 2014, out of six thousand and one, seven hundred and twenty six pregnant ladies that tried for HIV, twelve thousand five hundred and eight three (two percent) were observed to be HIV positive. Of these positive pregnant ladies, eight thousand two hundred and ninety nine (sixty six percent) of pregnant ladies diagnosed got ARVs as “either prophylaxis or treatment”.. 2.5 Disclosure of HIV Status The available literature discusses Asian & Pacific Islander PLWHA as experiencing both beneficial and damaging emotional consequences from disclosure of their HIV positive status (Chin & Kroesen, 1999; Kang, Rapkin, & DeAlmeida, 2006; Nyamathi et al., 2011). This factor is highly important as disclosure of HIV status to one's intimate partners, family members, and medical providers is generally encouraged in HIV/AIDS prevention and treatment programs. While the experience of HIV stigma is often population dependent (Ownby, Jacobs, Waldrop- Valverde & Gould, 2010), depression is a correlate of HIV status disclosure in some populations as well, i.e. the gay male community (Frost, Parsons, & Nanin, 2009). Research indicates that the emotional stress of a homosexual orientation coupled with HIV-positive status can result in depression in gay men (Frost, Parsons, & Nanin, 2007). This may be due to the stigma associated with homosexual sex especially outside of geographic regions where variations in sexual orientations are accepted. Extending beyond geography, homosexuality is still a taboo in many A&PI cultures mainly due to the association with loss of social role and lack of family obligation fulfillment (Hahm, 2009). Much of the available literature employs the use of stigma Theory to conceptualize the social risks of HIV disclosure leading to depression. The present paper examines stigma theory as introduced by Erving Goffman in 1963 to explicate this link. 18 University of Ghana http://ugspace.ug.edu.gh 2.6 HIV Treatment The nation proceeded with the making ready of ARVs to PLHIV as a feature of its technique of diminishing diseases and deaths among affect individuals and to drag out life. At present, one hundred and ninety six medical centers are giving ART administrations which incorporate seventeen private self-financing offices. In 2014, an aggregate of fourteen thousand nine hundred and ninety four PLHIV, made up of thirteen thousand eight hundred and nine grown-ups and one thousand one hundred and eighty five kids were enlisted on ARVs. A sum of eighty three thousand, seven hundred and twelve PLHIV are living and on ARV treatment as toward 2014. These comprised seventy nine thousand one hundred and thirty one grown-ups constituting forty seven thousand and eighty four women and twenty four thousand seven hundred and seventy one men and four thousand five hundred and eighty one kids made up of two thousand and thirty nine young ladies and one thousand eight hundred and sixty eight young men. “In the course of the year, one thousand five hundred and twenty three deaths among those on ARVs were recorded whilst one hundred and forty three of those on ARVs stopped treatment due to adverse clinical events; five thousand three hundred and seventy eight were declared as lost to follow ups”. “In effect, ninety two percent of those on ARVs are still alive and supporting the socioeconomic development of the country” (Ghana AIDS Commission, 2014 Status Report) 2.7 Treatment Compliance/Adherence For ART, a sustained optimal adherence is important to subdue viral reproduction and increase immunological and clinical outcomes; drop the risk of developing ARV drug resistance; and diminish the risk of transmitting HIV (WHO, 2013). Non-compliance can lead to increase of the viral load, impairment of the immune system, progression of HIV/AIDS, and the development of drug resistance to ART medications (Population Council et al 2004; Family Health International 2007). To emphasize the importance of compliance, Lewis et al (2006) 19 University of Ghana http://ugspace.ug.edu.gh detected that a non-adherent patient is 3.8 times more likely to die than an adherent one who takes medication religiously. Each year, worldwide, about 1.4 million HIV positive women get pregnant. If not treated, the probability of transmitting the infection to the unborn child is 15-45% through pregnancy, labor or breastfeeding. Nevertheless, the risk decrease to less than 2% if mothers are put on antiretroviral treatment early enough. Children born every year have reduce from 400000 in 2009 to 240000 in 2013. With intensification, it will be easy to achieve the global target of having less new born infections every year (WHO news release June, 2015). Coverage rise to 62% among pregnant women living with HIV in 2012 and newborn infections reduced by 35% the year 2009 (UNAIDS, 2013). However there are factors that affect compliance to ART, which have been identified as patient/ individual factors, socio-demographic factors, provider and facility based factors, drug regimen factors and social support [Hardon et al 2006]. To optimize compliance and reduce non-compliance, researchers have identified a few interventions in that respect. These include patient reminders like mobile phones, text messaging, alarms, calendars and diaries (WHO, 2013). Again, research has shown that effective social support from friends, family and social groups influence compliance positively. 20 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Introduction Research methodology is described as the study of how research is to be carried out. Essentially, methodology entails the procedures researchers go through to gather information, describing information gathered and explain their work. It is also defined as the study of methods by which knowledge is gained. (ResearchGate, 2018) The following topics were discussed in the chapter; Research design Study area Variables Study population Sampling Data collection procedures Ethical considerations Quality control 3.2 Research Design A descriptive cross-sectional study was done using selected health facilities with ART centers in the Greater Accra Region. The study was done using women infected with HIV and has been on ART for at least three months. 21 University of Ghana http://ugspace.ug.edu.gh 3.2 Study area The study was done in selected health facilities in Accra. The areas used for this study includes, health facilities in the Ga East Municipalility, located at the Northern part of Greater Accra Region. Health facilities used in this municipality includes, Abokobi Health Center, International Health Care Center, Ghana Atomic Energy Hospital. It is one of the Sixteen (16) Districts in the Greater Accra Region and covers a land area of about 85.7 square kilometers. The capital of the Municipal is Abokobi. Other health facilities such as Pantang Psychiatric Hospital, and Pentecost Mission Hospital found in La-Kwantanang municipality also located in the northern part of Accra was used. Participants were purposively selected as focal points for respondents‟ selection. These Health facilities were selected for this study because they have exclusive ART centers where HIV positive clients are referred to from other health facilities to receive ART. They confirm HIV status and do further investigations to commence treatment. They have sound councelling facilities that prepares client psychologically before commencement of therapy. Proper documentation is done in these facilities as GAC,NACP and other health organizations collaborate with them in managing HIV in Ghana. 3.3 Variables 3.3.1 Dependent variable Adherence to treatment may be defined as the extent to which the patient's history of therapeutic drug-taking coincides with the prescribed treatment.(WHO resource,2017). Treatment adherence was measured using the morinsky‟s 8 point compliance measurement tool. 22 University of Ghana http://ugspace.ug.edu.gh 3.3.2 Independent variables Socio-demographic factors: age, marital status, educational level, number of children, number of years living with HIV, number of children who tested positive to HIV. Socio-economic factors: employment status, income, distance to health facility, cost, access to treatment. Socio-cultural factors: beliefs, stigmatization, promiscuous lifestyle, religious beliefs, rejection, discrimination, abandonment. Medical support/facility based factors: confidentiality, privacy, attitude of staff, pill burden, drug interactions and patient-doctor communication. PLWHA factors; poverty, social support, employment status, disclosure. ARV Regimen factors: side effects, pill burdens, drug interactions. The above variables and their operational definition as well as scale of measurement have been detailed in Table 3.1. Table 3.1 Study variables, operational definition and scale of measurement Independent variables Operational definition Scale of measurement Socio-demographic factors Age Age at last birthday Continuous Sex Male or female Nominal Education None, primary, Ordinal secondary/vocational/technical, tertiary Number of children born alive None 1 2…… Ordinal 23 University of Ghana http://ugspace.ug.edu.gh Socio-economic factors Employment status Employed, unemployed Ordinal Distance to facility Nearness or farness to facility Ordinal Cost of treatment Resources needed to access Ordinal treatment Access to treatment Convenience of health facility Nominal Socio-cultural beliefs Witchcraft Curse from enemies Nominal Religion Spiritual injection with virus Nominal Misfortune Inviting mishaps on the family Nominal Mischievous conduct Promiscuous behavior Nominal Ostracized Neglected by friends and family Nominal Medical support/facility based factors Waiting time Time spent at facility to see a doctor Nominal Disclosure Revealing patients status to Nominal relations/partner Drug factors Pill burden, drug interactions and its Ordinal side effects Attitude of staff Encouraging clients to disclose Nominal status and compliance Patient-doctor relationship Paying attention to patients Nominal emotional and psychological needs Hospital settings/structure Convenient or not convenient, Ordinal 24 University of Ghana http://ugspace.ug.edu.gh allows for stigmatization or not Preferred HIV status disclosure audience Disclosure audience Husband, boyfriend, fiancée Nominal mother, father, siblings, uncles and aunties, grandparents, confidants, benefactors, colleagues Dependent variable Compliance to ART Recall of missing dosage or Categorical conformation to medication 3.4 Study population The study was done using pregnant women and women with children who are more than or equal to 2 years of age. Women, who have initiated ART were selected from Ghana Atomic Energy Hospital, Abokobi Health center, Pantang Psychiatric hospital, International Health care Center and Pentecost Mission Hospital at the various antenatal and HIV care centers. 3.5 Inclusion criteria HIV positive women who are pregnant or has a child more than or equal to than 2 years old, who attend treatment centers in the various selected health facilities, aged 18 years and above, have received ART for at least 3months and above, either first or more than one pregnancy after infection and gave their consent was included in the study. 3.6 Exclusion criteria All pregnant and non-pregnant women who are HIV positive, have severe morbidity or mentally unstable to give their consent for the study. 25 University of Ghana http://ugspace.ug.edu.gh 3.7 Sampling Four (5) health facilities, Ghana Atomic Energy Hospital, Abokobi Health Center, Pantang Psychiatric Hospital, Pentecost Mission Hospital and International Health Care Center, were purposively selected as focal points for respondents‟ selection. This is because these facilities attend to all HIV positive clients in the areas of study. Because of the sensitivity of study, two health professionals each from the four facilities was trained to assist with selection of participants for the study. Participants were selected through convenience sampling because they are a hard to reach group. Convenience sampling (also known as availability sampling) is a specific type of non-probability sampling method that relies on data collection from population members who are conveniently available to participate in study. However, only clients who were on ART for at least three months were selected. Clients who has had a child after testing positive also took part in the study, ART treatment defaulters were also included in the study. Health care givers at these facilities assisted in getting these clients to take part in the study. Prior to selection of participants, health professionals was made aware that participation is voluntary. They were also informed to tell their patients that declining to participate in the study will not have effect on their treatment and care. Recruitment inclusion criteria was explained to the health professionals with emphasis on the variation in socio-demographic characteristics in terms of age, duration of knowledge of HIV/AIDS status. Participants who agreed to participate in the study was then be introduced to the principal investigator. The principal investigator enlighten the participants a little further on the purpose of the study and seek their consent to take part in the study. 26 University of Ghana http://ugspace.ug.edu.gh 3.8 Sample size Sample size was determined with the use of Yamane (Hazell et al., 2013) equation for sample size calculation. Using the Yamane (Hazell et al., 2013) equation N= N/1+Ne^2 =150/1+150(0.05) ^2 =109 Where n = sample size N is the population (150) e is the error margin of 0.05. 3.9 Data Collection Process A letter of introduction from the School of Public Health (SPH) and ethical clearance from the Ghana Health Service Ethics Review Committee was sent to the medical directors of the respective health facilities to seek their permission to use their facility for the study. This was done to ensure easy access to information from selected participants without any hindrances from hospital staff. At each health facility, participants who satisfy the inclusion criteria was consecutively selected to participate in the study. The selected participants was taken through a brief orientation to allay their fears on secrecy of information they will provide. To administer the questionnaire to solicit for responses, participants were given consent forms to read and sign. Alternatively, the consent forms was read out and explained to participants who could not read and write and the consent form signed by thumb printed. To respond to the questionnaire, 27 University of Ghana http://ugspace.ug.edu.gh participants available for a particular day converged in the conference room at each facility after seeking treatment. Prior to meeting in the conference room, participants were grouped into two, those that can read and write and those that cannot read and write. For those who could not read and write, the questionnaire were read out and explained to them for them to choose their best option. Those that can read and write was served with the questionnaire to solicit their responses. However, some participants were called on phone with assistance from their focal person or counselor to respond to questionnaire after they gave their approval and consent. This was done to reduce the stress of calling them to come to the facility or waiting for them to attend on their own. Phone interview helped to save both researcher and participant time. The data collection exercise lasted for a period of four weeks, thus, one week was spent at each health facility. The principal investigator supervised the administration of the questionnaire. It took each participant a maximum of 10 minutes to complete a questionnaire this process took place on both clinic and other walk in days. The different data collection methods did not affects the quality of the data as all participants were informed accordingly of the willingness to participate or withdraw from research, however some participants who responded to questionnaire on phone were a little bit hesitant as they were not sure of the confidentiality of the information they were giving. Others did not agree to take part on phone. 3.10 Training of Field Staff (Research Assistant) Eight data collectors (two each from the four health facilities) were trained on the tools and ethical issues and each data collector was assigned a facility and others who finished on time assisted their colleagues at other facilities to obtain the data. 28 University of Ghana http://ugspace.ug.edu.gh 3.11 Data collection Tools Structured questionnaires were be administered to clients to gather quantitative data. Interviewer- administered questionnaires was used to solicit participant‟s response. The investigator carried out the data collection with two research assistants from each health facility, who have trained before the data collection. The questionnaire contained close ended questions and comprised 6 sections. Section A solicited information relating to: Socio-demographic factors; marital status, Age, educational level, number of children. Section B solicited information relating to: Socio-cultural factors; Promiscuous lifestyle, misfortune, discrimination, stigmatization, rejection. Section C solicited information relating to; Provider and facility based factors: Waiting time, confidentiality and privacy, attitude of staff, patient-doctor communication, distance to health facility and health policies. Section D solicited information relating to: PLWHA factors; disclosure, poverty, social support, employment status and experience with opportunistic infections. Section E gathered information on; ARV Regimen factors; pill burden, side effects, Drug interactions. Section F gathered information on drug complains using the Morinsky 8 point compliance scale. 3.12 Quality control At the end of each day after data collection, the researcher examined all the data collected by the two trained assistants‟ for correctness or mistakes. For proper data taking, the principal researcher plus the two trained assistants worked at the same facility at a time and move to another facility together. Data gathered from client‟s folder was cross checked to correct possible mistakes recorded. 29 University of Ghana http://ugspace.ug.edu.gh 3.13 Data analysis To ensure accuracy and completeness of information gathered, the data was cleaned by running frequencies of all variables to check for incorrect coding using Stata 15. After double checking with raw data, all corrections were made before analysis. In carrying out the analysis, descriptive statistics such as means ± standard deviation, frequency and percentage were used to describe the socio-demographic characteristics of the study population. Chi square test statistic was used to determine association between each independent (socio-cultural, institutional, socio- economic factors and preferred HIV status disclosure audience) and dependent variable (adherence to ART process). A confidence interval of 95% was used to show significant relations between the dependent (adherence to ART) variable and the independent variables (socio-cultural, institutional, socio-economic factors and preferred HIV status disclosure audience). Binary logistic regression was then used to determine the association between dependent variable and independent variables. Level of significance was set at 5%. 3.14 Ethical considerations/Issues Ethical issues involved in the study was addressed by doing the following. 3.15 Ethical clearance Ethical clearance was obtained from the local Ethics Review Committee of the Ministry of Health/Ghana Health Services as a requirement to conduct a research in each health facility selected in Accra. 3.16 Approval from study area An introductory letter from the School of Public Health (SPH) was sent to the Medical Director of Ghana Atomic Energy Hospital, Pantang Psychiatric Hospital, Abokobi Health Center, 30 University of Ghana http://ugspace.ug.edu.gh Pentecost Mission Hospital and International Health Care Center to disseminate information to the various departments for easy access to information needed to complete the study. 3.17 Description of subjects involved in the study Consent were obtained from HIV positive participants who meet the inclusion criteria. That is to say that, the subjects of the study were PMTCT mothers who are HIV positive and seeking care at Ghana Atomic Energy Hospital, Pantang Psychiatric Hospital, Abokobi Health Center, Pentecost Mission Hospital and International Health Care Center in selected health facilities in the Greater Accra Region. 3.18 Potential risks/benefits The study may have caused some emotional and psychological discomforts to participants due to the sensitive nature of some of the questions however no participant reported a such. Participants did not receive direct benefits from this study however, they agreed that results obtained for this study could be used by policy makers and families in particular to either improve upon existing ways of receiving people who disclose their HIV status or support them through their ARV therapy. 3.19 Privacy/Confidentiality Participants were assured of confidentiality and privacy of the information provided. Their real names and residential addresses was not needed for this study. 3.20 Data storage and usage Information were gathered with a structured questionnaire. The research instrument (questionnaire) containing the data will be saved in a locker for two years before discarding them 31 University of Ghana http://ugspace.ug.edu.gh 3.21 Description of the consenting process The purpose of the study was provided to the research participants. A participant‟s consent form (Appendix A) was designed and used for the participants. 3.21.1 Voluntary withdrawal Participants were assured that participation in the research was entirely voluntary. They were free to withdraw consent and discontinue participation in the study at any time they felt the need to withdraw. 3.21.2 Compensation Respondents were not provided any reward/compensation to respond to the questionnaire. However, participants were congratulated and appreciated verbally. 3.22 Protocol amendments As per the recommendation from the Ghana Health Service Ethical Review Committee, the protocol was amended. 3.23 Declaration of conflict of interest There was be no conflict of interest. 3.24 Funding information The entire work was funded by the principal investigator 3.25 Pretesting the Tools The questionnaire was pretested in an HIV care center in the Ga West municipal hospital. The pretesting enabled the research team identify the potential problems and obstacles in the survey hence some variables were revised before starting the actual research. 32 University of Ghana http://ugspace.ug.edu.gh 3.26 Instruments Validity and Reliability To ensure the validity of the instrument, the questionnaires was developed with the assistance of the supervisor. The questionnaires was also made available to expert in the field to determine its validity. Again, the questionnaires was pre-tested to eliminate errors and ensure reliability. 33 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Socio-demographic characteristics of respondents The characteristics of participants in the study is shown in Table 4.1. More than half, 54.2% were women who have been living with HIV for at least 3 years, 35.9% were predominantly aged between 25-30years, 26.2% had JHS education, and 90.5% employed, 81.4% Christians. Also, 58.7% were not married and 61.0% were not married but were living with a partner. Table 4.1 Socio-demographic characteristics of HIV positive women in selected facilities in Accra. Frequency Percent Age groups (years) 19-24 14 13.5 25-30 37 35.9 31-36 36 35.0 37-42 14 13.6 ≥43 2 1.9 Educational level completed No formal education 10 9.4 Primary 21 19.6 JHS 28 26.2 SHS/Tech/Voc 27 25.2 34 University of Ghana http://ugspace.ug.edu.gh Tertiary 21 19.6 Employment status Currently employed 95 90.5 Unemployed 10 9.5 Religion affiliation Christian 83 81.4 Muslim 19 18.6 Marital status Single 61 58.7 Married 43 41.3 Living with partner Yes 61 61.0 No 39 39.0 Number of years living with HIV (years) 0-3 58 54.2 4-7 33 30.8 8-11 11 10.3 12-15 5 4.7 35 University of Ghana http://ugspace.ug.edu.gh Number of children living with HIV 0 96 91.4 1 8 7.6 2 1 1.0 JHS: Junior high school, SHS: senior high school, Tech: technical, Voc: vocational 4.2 Adherence to anti-retroviral therapy (ART) among woman living with HIV Adherence to ART among women infected with HIV, is shown in Figure 4.1. Adherence to ART treatment among the women was poor (defined as low adherence). According to Morinsky (2008) adherence scale, response score of 0-5 is considered low adherence; 6-7 as medium adherence and 8 as high adherence. That is, from the adherence score scale, adherence rate was poor, 73.27% (74/102) as compared with good adherence rate 26.73% (27/102). Frequency percentage Poor adherence 74 73.27 Good adherence 27 26.73 Figure 4.1: Adherence to ART among HIV positive women in selected facilities 36 University of Ghana http://ugspace.ug.edu.gh 4.3 Socio-cultural factors that affect disclosure of status in HIV women The relationship between socio-cultural factors and adherence on ART among pregnant women is shown in Table 4.2. Socio-cultural factors (using herbal treatment instead of medical treatment; blame for family mishap; indifferent treatment from friends and family, loss of respect) had no significant association with adherence to ART (p>0.05). However, there was a significant association between adherence to ART and being perceived as promiscuous (χ2=6.2740; p=0.020). No significant statistical association was observed between discontinuation of medical treatment and adherence to treatment (p>0.05). There was also no significant association between the variable “fear of children being discriminated against ” and adherence treatment (p>0.05). There was no significant association between the variable “I feel friends and family will treat me differently” and adherence to ART (p>0.05). No significant association was recorded between the variable “I may lose support and respect for fear of disclosure” and adherence to ART (p>0.05). No significant association was identified between fear of losing employment and ART adherence (p>0.05) Table 4.2 Bivariate analysis of socio-cultural factors and adherence to ART among HIV positive women from selected health facilities. Reasons for non-disclosure of Adherence HIV status N (%) Poor Good χ2 p-value Discontinuation of medical 0.4036 0.844 treatment for herbal treatment Yes 27 (27.84) 23 (32.39) 4 (15.38) 37 University of Ghana http://ugspace.ug.edu.gh No 54 (55.67) 37 (52.11) 17 (65.38) Don‟t know 16 (16.49) 11 (15.49) 5 (19.23) Discrimination against 3.0777 0.264 children Yes 70 (74.51) 50 (70.42) 20 (80.00) No 18 (17.65) 13 (18.31) 5 (20.00) Don‟t know 8 (7.84) 8 (11.27) 0 (0.00) Blame of family mishap 1.8354 0.426 Yes 64 (66.67) 46 (63.01) 18 (69.23) No 24 (25.00) 20 (27.40) 4 (15.38) Don‟t know 11 (11.46) 7 (9.59) 4 (15.38) Tagged as promiscuous 0.020*¥ Yes 4 (3.88) 2 (2.82) 2 (7.69) No 86 (83.50) 56 (76.87) 34 (92.31) Don‟t know 13 (12.62) 13 (18.31) 0 (0.00) Indifferent treatment from 0.413¥ friends and family Yes 72 (73.47) 51 (69.86) 21 (84.00) No 22 (22.45) 18 (24.66) 4 (18.18) 38 University of Ghana http://ugspace.ug.edu.gh Don‟t know 4 (4.08) 4 (5.48) 0 (0.00) Lose of respect and support 0.9568 0.791 Yes 74 (75.51) 53 (73.61) 21 (80.77) No 16 (16.33) 12 (16.67) 4 (15.38) Don‟t know 8 (8.16) 7 (9.72) 1 (3.85) Fear of losing employment 1.6461 0.394** Yes 66 (67.35) 51 (70.83) 15 (57.69) No 19 (19.39) 12 (19.67) 7 (26.92) Don‟t know 13 (13.27) 9 (12.50) 4 (15.38) ¥: p-value was obtained from Fischer‟s exact test, *p<0.05,**p<0.01,***p<0.001 4.4 Relationship between ARV treatment factors and adherence to ART Details of the relationship between ARV treatment factors and adherence to ART is shown in Table 4.3. ARV treatment factors (tablets swallows daily, other medication other than ARV, ease of swallowing tablet, loss of appetite because of ART intake) did not predict ART adherence (p>0.05). Nonetheless, the effect of ART intake on daily activities predicted adherence to ART (p=0.026). The odds of not adhering to ART is 1.4 times higher among HIV/AIDS women who took two tablet daily as compared to women who took one tablet daily. The odds of not adhering to ART 39 University of Ghana http://ugspace.ug.edu.gh is 0.2 times higher among women who take herbal medication apart from ARV. The ease with which women swallowed the pills is 0.6 times higher among women who did not adhere to ART. The odds of ART affecting the appetite of HIV/AIDS women is 1.4 times higher among women who did not adhere to ART. The odds of not adhering to ART was 1.4 times higher among women who did not consume alcohol. Table 4.3 Adjusted analysis for between ARV treatment and adherence to ART among pregnant women in Ga East Municipality Adjusted OR (95%CI) p-value Number of daily tablets to take 0.744 1 1.00 2 1.4 (0.2-8.5) ART intake on daily activity 0.026* No 1.00 Yes 0.3 (0.1-0.9) using medication other than ARV 0.071 No 1.00 Yes 0.2 (0.0-1.2) medication is easy to swallow 0.384 No 1.00 Yes 0.6 (0.2-1.8) Loss of appetite because of ART intake 0.818 No 1.00 40 University of Ghana http://ugspace.ug.edu.gh Yes 1.4 (0.1-25.8) Drinks Alcoholic Beverage 0.582 No 1.00 Yes 1.4 (0.4-5.3) *p<0.05,**p<0.01,***p<0.001 4.5 Association between HIV status disclosure and adherence to ART Details of HIV disclosure status, disclosure audience and the relationship between HIV status disclosure and adherence to ART is shown below. More than half of the women (67.6%) indicated they have disclosed their HIV status (Figure 4.2). A large proportion of the women 40.70% (35/886) indicated their preferred HIV disclosure audience was their parents (Table 4.4). However, there was no association between HIV/AIDS disclosure option and adherence to ART (p>0.05) (Table 4.5) 41 University of Ghana http://ugspace.ug.edu.gh 32.4$ yes 67.6% no Fig. 4.2 HIV/AIDS disclosure status of women in selected facilities Table 4.4 HIV/AIDS disclosure audience among women in selected Disclosure audience Frequency Percent Parent 71 58.6 Children 34 36.4 Pastors 3 3.0 Sex partners 2 2.0 Table 4.5 Bivariate association between HIV disclosure option and adherence to ART among PMTCT mothers in selected health facilities Adherence N (%) Poor Good χ2 p-value Parent 35 (40.70) 15 (33.3) 10 (55.56) 5.8660 0.207 Children 8 (9.30) 4 (8.89) 1 (5.56) 42 University of Ghana http://ugspace.ug.edu.gh Pastor 7 (8.14) 3 (6.67) 3 (16.67) Friend 3 (3.49) 2 (4.44) 0 (0.00) Sex partner 33 (38.37) 21 (46.67) 4 (22.22) 4.6 Adjusted analysis The odds of adhering to ART is 0.35 times higher among women who do not disclose their status to save their marriage. Adjusting for all other variables, ARV factor (effect of drugs on daily activity) and cultural factors (non-disclosure of status to save) did not predict adherence to ART (P>0.05). Table 4.6 Multivariate analysis of association between dependent and independent variables Adjusted OR p-value Crude OR p-value Link of HIV with promiscuity No 1.00 1.00 Yes 0.42 0.126 0.35 0.048* Effect of drugs on daily activity No 1.00 1.00 Yes 2.26 0.437 2.33 0.410 * Significance at 5% 43 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.0 Introduction The study assessed the factors that affects adherence to ART among women in selected health facilities in Greater Accra.The study had specific objectives to estimate the level of adherence to anti-retroviral therapy among HIV/AIDS women attending for care and treatment at selected health facilities, it also examined cultural factors to ART adherence among women. In addition, it described ARV treatment factors and adherence to ART among women and lastly examined the relationship between preferred HIV status disclosure audience and adherence to ART. 5.1 Discussion Adherence to ART treatment among the women seeking treatment in the selected health facilities was poor at 26.7%. The low adherence to treatment could be partly as a result of the insensitivity of nurses towards patients. In other words „shouting‟ at and not giving patients the needed respect could result in non-adherence. In addition, it could be as a result of the distance patients have to travel to seek treatment. It could also be as a result of the side effect of taking the drugs. In furtherance, the low adherence of women to treatment could be as a result of being financially handicapped to pay for laboratory investigation (cost), although medication is free. Another reason could be attributable to an „inexperienced‟ counsellor who fail to communicate the right information to the patients. 44 University of Ghana http://ugspace.ug.edu.gh This finding is similar to a study that examined non-adherence and drug acquisition costs in a national population as well as a study that assessed strategies to improve drug adherence (Hovstadius & Petersson, 2011; Laufs, Rettig-Ewen & Böhm, 2011). Socio-cultural factors were found to have a negative effect on adherence to ART among the women. The knowledge of the fact that the disease has several negative connotation makes adherence near impossible. Family are more likely to distance themselves from women living with HIV; thus, serves as less support for women living with the condition. In addition, for families of the affected women not to be called names such curse, prostitutes among others, they do not adhere to their treatment regime to quell any suspicion of their HIV status. The finding corroborates that depression and active substance abuse especially alcohol and intravenous drugs and lack of perceived social support are predictive of poor adherence rates to medication (Do et al., 2010; Boateng et al., 2013). Anti-retroviral related factors did not predict adherence to ART. Even though most of the women reported enjoying healthy and productive life on ART, this though did not stand upon data analysis. That is, enjoying healthy and productive life on ART did not statistically significant predict adherence to ART among the women. This could be attributable to the negative side effect including dizziness, nausea, weight increase and phobia of consistently taking drugs. Again, the time involved in visiting hospital for treatment conflicts with their work schedule. Neither ART as the only effective treatment available to manage HIV nor knowing the use of ART could predict adherence outcome. This could be attributable to the discomfort associated with taking the drug. Also, the physiological changes experienced as the continual intake of the 45 University of Ghana http://ugspace.ug.edu.gh drugs. Similarly, loss of appetite because of ART intake could predict adherence outcome. This could be as a result of patients skipping medication and defaulting on appointment. This study is supported by results from literature where knowledge and beliefs patients have about their illnesses, the motivation to manage it, the confidence in their ability to engage in illness- management behaviors, and their expectations regarding the outcome of treatment fails to be a major predictor of adherence (WHO, 2013). Nonetheless, knowing the effect of taking ART on daily activity statistically predicted adherence. The thought of dying for defaulting could be a reason to adhere to treatment. Again, the thought of building resistance to the drug which will result in death could be attributed to adherence. This is consistent with studies by which found that patients with good knowledge about HIV/AIDS and ART and a positive attitude towards the disease tend to be more adherent to ART than those with poor knowledge (Olowookere et al. 2012; Boateng et al. 2013). Preferred status disclosure audience could not predict adherence. It is interesting to note that relationship with parents did not predict adherence to ART. That is, irrespective of the fact that the parents listens to their children (women), are approachable, freely provides counsel, could not predict adherence to ART. This could be attributed to the fact the drugs does not provide complete cure as such establishing good rapport with parents by disclosing one‟s status is not reason enough to strictly adhere to treatment. It could likewise be attributed to rejection by parents so as to safeguard their reputation. This result is not similar to a much recent evidence from literature that suggests that provision of privacy and treatment and readiness of counselling services can impact adherence (Reda & Biadgilign, 2012; WHO, 2013). 46 University of Ghana http://ugspace.ug.edu.gh 5.2 Study limitations Self-reported drug adherence is method which suggests a possibility of recall bias. Self-report when compared to other methods of drug adherence assessment is generally believed to overestimate adherence level. Also influence of the interviewer on patients‟ response can be added as a limitation in such type of studies. Another limitation is that the study did not compare between patients according to disease severity, disease type, or drug class. These factors are believed to be less significant when compared to other patient related factors such as patient attitudes or beliefs. Although participants (were) assured of confidentiality and anonymity of information, they were not forthcoming with their responses. As such, there is possibility of results biasness to avert being stigmatized. 47 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS 6.1 Conclusion This study highlighted several issues HIV/AIDS disclosure and its association with anti- retroviral therapy among women in selected health facilities in the Greater Accra Region. Adherence to ART among women was low. The study established an insignificant association between socio-cultural factors and adherence to ART among women. An insignificant association was observed between ARV factors and adherence to ART. The study showed an insignificant associations between HIV/AIDS disclosure audience and adherence to ART. 6.2 Recommendation In order to enhance good adherence to ART among women, the Ghana Health Service (GHS) should ensure that effective adherence assessment tools like Morinsky drug adherence scale are developed and used at the clinical setting in order to assess adherence objectively. The Ministry of Health (MoH) should ensure that easy dosing are supplied adequately to improve adherence. The Ghana AIDS Commission must develop strategies to educate the population on managing HIV through the media. HIV treatment centres must also liaise with herbal clinics, prayer camps and shrines to educate their operators on effective ways of managing HIV and AIDS. Last but not the least, client relatives must be involved in the counselling process of clients, this will help improve their acceptability of the situation and provide support to HIV positive women. The MoH and GAC must develop policies that ensures that women who test positive to HIV are bonded under law to disclose their status particularly to their sex partners as this will encourage safer sex practices and help reduce the rate of spread of the disease. 48 University of Ghana http://ugspace.ug.edu.gh REFERENCES Adinkrah, M. (2015). Witchcraft, Witches and Violence in Ghana. New York and Oxford: Berghahn Books. 325 pp. Ajithkumar K, Neera P.G, Rajani P.P. (2011). Relationship between social factors and treatment adherence: A study from South India. Eastern Journal of Medicine; 16(2):147152. Akani C.I. & Erhabor O. (2006). Rate, pattern and barriers of HIV serostatus disclosure in a resource-limited setting in the Niger Delta of Nigeria. Trop Doct. 36:87–89. Bangsberg D.R, Perry S, Charlebois E.D, Clark R.A, Roberston M, Zolopa A.R. (2001). Nonadherence to highly active antiretroviral therapy predicts progression to AIDS. AIDS; 15:1181–83 Boateng, D., Kwapong, G. D., Agyei-Baffour, P. (2013). Knowledge, Perception about Antiretroviral therapy (ART) and Prevention of Mother-to-Child Transmission (PMTCT) and Adherence to ART among HIV positive women in the Ashanti Region, Ghana: a cross-sectional study. BMC Women's Health 13:2. Chukwuemeka, I.K Fatima, M.I Ovavi, Z.K & Olukayode, O. (2014). The impact of a HIV prevention of mother to child transmission program in a nigerian early infant diagnosis centre. Niger Med J. 55(3): 204–208. doi: 10.4103/0300-1652.132039 Commonwealth Regional Health Community Secretariat. (2002). HIV/AIDS voluntary counselling and testing: review of policies, programmes and guidelines in east, central and southern Africa. Arusha, Tanzania. Arusha: CRHCS. 49 University of Ghana http://ugspace.ug.edu.gh Deribe K. Woldemichael K. Wondafrash M. Haile A. & Amberbir A. (2008). Disclosure experience and associated factors among HIV positive men and women clinical service users in southwest Ethiopia. BioMed Central Public Health J; 8:1–34. Do, N. T., Phiri, K., Bussmann, H., Gaolathe, T., Marlink, R. G., Wester, C. W. (2010). Psychosocial Factors Affecting Medication Adherence among HIV-1 Infected Adults Receiving Combination Antiretroviral Therapy (cART) in Botswana. AIDS Research and Human Retroviruses. 26 (6): 685-691. Gallo, A.M. Angst, D.B. & Knafl, K.A. & Fox, F.H. (2009). Disclosure of Genetic Information within Families: How nurses can facilitate family communication: Am J Nurs. 109(4): 65–69. doi: 10.1097/01.NAJ.0000348607.31983.6e Global Health Observatory (2011). Global HIV/AIDS statistics: Available from: http://apps.who.int/ghodata Kak, L. Chitsike, I. Luo, C. & Rollins, N. (2014).Prevention of mother-to-child transmission of HIV/AIDS programmes. World Health Organization Lal V, Kant S, Dewan R, Rai S.K. (2010) Reasons for Non-adherence to Antiretroviral Therapy among Adult Patients Receiving free Treatment at a Tertiary Care Hospital in Delhi. Indian Journal of Community Med, 35(1):172–73. Mayfield A.E, Rice E, Flannery D, & Rotheram-Borus M.J. (2008). HIV disclosure among adults living with HIV. AIDS Care; 20(1):80-92. Medley, A. Garcia-Moreno, C. & Maman, S. (2004). Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: implications for 50 University of Ghana http://ugspace.ug.edu.gh prevention of mother-to-child transmission programmes. Bulletin of the World Health Organization; 82:299-307 Murphy D.A. (2008). HIV-positive mothers‟ disclosure of their serostatus to their young children: a review. Clin Child Psychol Psychiatry 13(1):105-122. Nachega J.B. Lehman D.A. Hlatshwayo D. Mothopeng R. Chaisson R.E. & Karstaedt A.S. (2005). HIV/AIDS and antiretroviral treatment knowledge, attitudes, beliefs, and practices in HIV-infected adults in Soweto, South Africa. J Acquir Immune Defic Syndr; 38:196–201. Nischal K.C, Khopkar U, Saple D.G. (2005). Improving adherence to antiretroviral therap. Indian Journal of Dermatol Venereol Leprol; 71(5):316–20. Obermeyer, C.M. Baijal, P. & Pegurri, E. (2011). Facilitating HIV Disclosure across Diverse Settings. Am J Public Health 101(6): 1011–1023. doi: 10.2105/AJPH.2010.300102 Olowookere, S. A., Fatiregun, A. A., Adewole, I. F. (2012). Knowledge and attitudes regarding HIV/AIDS and antiretroviral therapy among patients at a Nigerian treatment clinic. Journal of Infection in Developing Countries. 6 (11):809-816. Doi: 10.3855/jidc.2086 Osterberg L, & Blaschke T. (2005). Adherence to Medication. N Engl J Med; 353:487–97. Passin W.F, Kim A.S, Hutchinson A.B, Crepaz N, Herbst J.H, & Lyles C.M. (2006). A systematic review of HIV partner counseling and referral services: client and provider attitudes, preferences, practices, and experiences. Sex Transm Dis. 33(5): 320-328. 51 University of Ghana http://ugspace.ug.edu.gh Reda, A. A. and Biadgilign, S. (2012). Determinants of Adherence to Antiretroviral Therapy among HIV-Infected Patients in Africa. AIDS Research and Treatment 2012. Doi: 10.1155/2012/574656 Shah C.A. (2007). Adherence to high activity antiretrovial therapy in pediatric patients infected with HIV: issues and intervention. Indian Journal of Pediatrics; 74(1):55–60. Smith R, Rossetto K, & Peterson B.L. (2008). A meta-analysis of disclosure of one‟s HIV positive status, stigma and social support. AIDS Care 20(10):1266-1275. Stone V.E, Hogan J.W, Schuman P. (2001). Antiretroviral regimen complexity, self-reported adherence and HIV patients‟ understanding of their regimen: survey of women in the HER study. J Acquir Immune Defic Syndr 28:124–31. Sullivan K.M. (2005). Male self-disclosure of HIV-positive serostatus to sex partners: a review of the literature. J Assoc Nurses AIDS Care; 16(6):33-47. Vyavaharkar M, Moneyham L, Corwin S, Tavakoli A, Saunders R, Annang L. (2011). HIV disclosure, Social support and Depression among HIV infected African American Women Living in the Rural Southeastern United States. AIDS Education and Prevention 23 (1): 78-90 WHO (2013). Data on the size of the HIV/AIDS epidemic: number of adults, women and children living with HIV by country. Accessed at http://apps.who.int/gho/data/node.main.621 (Retrieved 20th November, 2017). Ho P. M, Bryson C. L., Rumsfeld J. S. (2009). Medication Adherence https://doi.org/10.1161/CIRCULATIONAHA.108.768986.Circulation. 2009;119:3028-3035 52 University of Ghana http://ugspace.ug.edu.gh Originally published June 15, 2009 Cichocki, M. (2017). How Triple Therapy Turned the HIV Epidemic Around. https://www.verywellhealth.com/haart-highly-active-antiretroviral-therapy-48967 James Myhre and Dennis Sifris, MD. (2018). List of Approved HIV Antiretroviral Drugs, https://www.verywellhealth.com/list-of-approved-hiv-antiretroviral-drugs-49309 Ayisi A.S (2016). L2TR 90-90-90 Ghana Campaign. National AIDS/STI Control Programme. saddo@nacp.org.gh. July 2016. file:///C:/Users/ADWOA/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/ TempState/Downloads/90-90-90%20Roadmap%20to%20Treat%20All_July%202016%20 (1).pdf http://www.who.int/gho/hiv/en/, Global Health Observatory (GHO) data.2018. https://libguides.library.cqu.edu.au/litreview 53 University of Ghana http://ugspace.ug.edu.gh APPENDIX Appendix A: Participant’s Consent form Title of study HIV Status Disclosure and its Association with Anti-retroviral Therapy Compliance Among Pregnant Women in GA East Municipality Researcher Adwoa Prims Essel Department Population, Family and Reproductive Health Phone number 0242251293 Purpose of the study Dear participant, Adwoa Prims Essel is my name, a student of the School of Public Health, University of Ghana, Legon. I am undertaking a study on HIV/AIDS status disclosure and compliance to treatment. The study aims to assess the indicators of HIV/AIDS that influence disclosure among pregnant women seeking care in selected healthcare facilities in Ga East Municipality. Potential risks/benefits The study may cause some emotional and psychological discomforts to participants due to the sensitive nature of some of the questions. Participants will not receive direct benefits from this study however, it is foreseen that results obtained for this study will be used by policy makers and families in particular to either improve upon existing ways of receiving people who disclose their HIV status or support them through their ARV therapy. 54 University of Ghana http://ugspace.ug.edu.gh Privacy/Confidentiality Information provided will be handled with strict confidentiality and will be used purely for the research purposes. Your data will not be shared with anybody who is not part of the research team. Data analysis will be done at the aggregate level to ensure anonymity. Your identity will not be disclosed in the material that will be published. Data storage and usage Information will be gathered with a structured questionnaire. The research instrument (questionnaire) containing the data will be saved in a locker for two years before discarding them Voluntary withdrawal and compensation Participation in this study is voluntary and participants can choose not to answer any particular question or all questions. You are at liberty to withdraw from the study at any time you feel the need to withdraw. However, it is encouraged that you participate since your opinion is important in determining the outcome of the study. Respondents will not be provided any reward/compensation to respond to the questionnaire. Dissemination of results The results of this study will be mailed to you if you provide your address below. Before taking the consent, do you have any question you wish to ask about the study? Yes No 55 University of Ghana http://ugspace.ug.edu.gh Participant's Consent I declare that the purpose of the study has been thoroughly explained to me in English language and Twi and I have understood. I hereby agree to answer the questions. Signature…………………………. Date……………………………… Thumb print Interviewer’s Statement I, the undersigned, have explained this consent form to the subject in the English language that he/she understands the purpose of the study, procedures to be followed as well as risks and benefits involved. The subject has freely agreed to participate in the study. Interviewer‟s signature………………………… Date…………………………….. If you have questions later, you may contact me on 0242251293 or the Administrator, Ghana Health Service Ethical Review Committee, Miss Hannah Frimpong – (0507041223/0243235225). 56 University of Ghana http://ugspace.ug.edu.gh Appendix B: Questionnaire HIV STATUS DISCLOSURE AND IT’S ASSOCIATION WITH ANTI RETROVIRAL THERAPY COMPLAINCE AMONG PREGNANT WOMEN IN GA EAST MUNICIPALITY PARTICIPANT CONSENT I am a student of the School of Public Health, University of Ghana. The administration of this questionnaire is to solicit your response on the above topic. All the information is strictly for academic purposes and will be highly treated with the greatest level of confidentiality. Thank you. Participants consent: Yes[ ] No[ ], If No, end of interview SECTION A. Socio-demographic factors QID QUESTIONS Coding categories 1 How old were you at your last birthday? ………….years 2 What‟s your educational level? No formal education…………...1 Primary…………………………2 JHS……………………………..3 SHS/Tech/Voc…………….........4 Tertiary…………………………5 3 Are you currently married? Yes…………………………….1 No……………………………..2 4 Are you living with your husband/partner? Yes……………………………1 No…………………………….2 57 University of Ghana http://ugspace.ug.edu.gh 5 What‟s your religion? Christian………………………1 Muslim………………………..2 Traditionalist………………….3 Others (specify)………………. 6 How many years/months have you known your 1month-3years………………...1 HIV status? 3years-7years………………….2 7years-12years……………...…3 12years-17years……………….4 7 How many children do you have had since you Alive………………………... tested positive to HIV? Dead……………………….. Total children ………………. 8 How many of your children tested reactive to HIV virus? …………………………….. 9 What‟s your Current employment? Unemployed……………..1 Trader……………………2 Self-employed……………3 Student…………………...4 10 What‟s your income last month in Ghana cedis? ----------------------------cedis 58 University of Ghana http://ugspace.ug.edu.gh Section B: Cultural Beliefs 11 Disclosing my status will lead to my discontinuation of Strongly disagree…………..1 medical treatment for herbal treatment Disagree ……. …………….2 Neither agree nor disagree…3 Agree………………………4 Strongly agree……………..5 12 For fear of my children being discriminated, I have not Strongly disagree…………..1 disclosed my status to anyone Disagree ……. …………….2 Neither agree nor disagree…3 Agree………………………4 Strongly agree……………..5 13 If I disclose my HIV status, any mishap on my family Strongly disagree…………..1 will be linked to me Disagree ……. …………….2 Neither agree nor disagree…3 Agree………………………4 Strongly agree……………..5 14 Since HIV has been likened to promiscuous behavior, I Yes…………………………1 have not disclosed my status to save my marriage and No…………………………2 self-respect Other……………………....3 15 I feel friends and family will treat me differently Strongly disagree…………..1 because of my HIV status disclosure Disagree ……. …………….2 Neither agree nor disagree…3 Agree………………………4 59 University of Ghana http://ugspace.ug.edu.gh Strongly agree……………..5 16 I may lose support and respect if I disclose my status Strongly disagree…………..1 Disagree ……. …………….2 Neither agree nor disagree…3 Agree………………………4 Strongly agree……………..5 17 My children will be teased and discriminated if I tell Strongly disagree…………..1 my status Disagree ……. …………….2 Neither agree nor disagree…3 Agree………………………4 Strongly agree……………..5 18 I will lose my employment if I disclose my HIV status? Strongly disagree…………..1 Disagree ……. …………….2 Neither agree nor disagree…3 Agree………………………4 Strongly agree……………..5 SECTION C: Disclosure information 19 Have you been offered disclosure options to choose Yes……………………………...1 from? No…………. ………………......2 20 Are you well informed about the consequences of Yes……………………………...1 non-disclosure? No…………. ………………......2 60 University of Ghana http://ugspace.ug.edu.gh Not sure………………………...3 21 Have you disclosed your HIV status to anyone? Yes…………………………….1 No……………………...……...2 Other…………………………..3 22 If yes, who did you prefer to disclose to? Parent.………………………….1 Children……………………......2 Pastor……………….………….3 Friend………………………….4 Sex partner………………….....5 23 Who is your second preferred person to disclose to? Parent.………………………….1 Children………………………..2 Pastor……………….………….3 Friend………………………….4 Sex partner…………………….5 24 Who is your third preferred person to disclose to? Parent.………………………….1 Children………………………..2 Pastor……………….………….3 Friend…………………………..4 Sex partner…………………......5 25 If no, why not disclosed yet? Fear of divorce……....................1 Fear of stigmatization….............2 Fear of discrimination…………3 No reason………………...........4 61 University of Ghana http://ugspace.ug.edu.gh 26 Has disclosing you status affected your Yes…………………………......1 employment/ business or personal relationship? No………………………………2 Other……………………………3 27 If yes, how did it affect you? Loss of job………………….......1 Promotion………………………2 Lost friends/family……………..3 Lost respect………………….....4 Nothing…………………............5 28 What have you experienced since you tested Weight gain…………………….1 positive to HIV? Weight loss…………………….2 Opportunistic infections………..3 Nothing…………………………4 SECTION D. Provider/facility based factors 29 Is the health care provider easily approachable? Yes………………………..1 No…………. …………….2 Sometimes…………………..3 Other…………………………4 30 Does your health care provider give you the chance to ask Yes………………………..1 questions about your treatment? No…………. …………….2 Sometimes……………….3 62 University of Ghana http://ugspace.ug.edu.gh 31 Does your health care provider call or visit you? Yes often……………………1 Never.………………………..2 Sometimes……………………3 32 Do you trust your health care provider to keep your Yes I do…………………..….1 information confidential as they say? No I don‟t……………………2 Other…………………………3 33 Do you get supply of ART anytime you attend clinic? Yes……………………………1 No…………. …………………2 Sometimes……………………3 Other………………………….4 34 How long does it take you to get to the nearest health center ………..hours………..minutes SECTION E: ARV Regimen factors 35 How many tablets do you swallow a day? Less than 3……………………….1 More than 3………………………2 Don‟t know……………………….3 36 Does taking your medication (side effects) affect your Yes………………………………..1 daily activities? No…………………………………2 Don‟t know……………………….3 37 Are you on other medications that prevent you from Yes………………………………..1 taking your ARV‟s? No…………………………………2 Don‟t know………………………..3 38 Is it easy swallowing your medications Yes………………………………..1 63 University of Ghana http://ugspace.ug.edu.gh No…………………………………2 Don‟t know………………………..3 39 Does the drugs you take interfere with your appetite for Yes………………………………...1 food? No…………………………………2 Not sure……………………………3 Other……………………………….4 40 I sometimes skip my medication because my Yes…………………………………1 medication makes me feel very hungry and I don‟t have No………………………………….2 enough money to buy food. Sometimes…………………………3 Other………………………………4 41 Do you drink alcohol? Yes………………………………...1 No…………………………………2 Sometimes…………………………3 SECTION F. Morinsky 8 Point Medication Compliance Do you sometimes forget to take your ART drugs? Yes………………1 42 No…………. ……2 43 Over the past two weeks, were there any days you did not take your Yes ………………1 ART medication? No ………………..2 44 Have you ever cut, broken or stopped taking your medications Yes……………….1 without telling your doctor because you felt worse when you took it? No………………..2 64 University of Ghana http://ugspace.ug.edu.gh 45 When you travel or leave home, do you sometimes forget to bring Yes………………1 along your medication?? No…………. ……2 46 Did you take your ART drugs yesterday? Yes ………………1 No ……………….2 47 When you feel like your symptoms are under control, do you Yes………………1 sometimes stop taking your medicines? No…………. ……2 48 Do you ever feel hassled about sticking to your ART treatment plan? Yes………………1 No…………. ……2 65 University of Ghana http://ugspace.ug.edu.gh Table 4.7: Schedule or Activities DATE ACTIVITY PERSONS RESPONSIBLE Meeting with supervisor 1ST-7TH October, 2017 Researcher Preparing research topic Presentation of proposal topic to 8TH – 13TH October, supervisor Researcher 2017 Discussing topic with supervisor Recruitment and training of 4-6 April, 2018 Researcher, research assistants research assistants Pre-testing of data collection 5-10TH Aril, 2018 Researcher, research assistants tools May, 2018 Data collection Researcher, Field supervisor Data entry May- June, 2018 Researcher Data analysis Dissertation write up June, 2018 Meeting with academic Researcher supervisor on draft dissertation June, 2017 Reviewing draft dissertation Researcher Presentation of final July, 2017 Researcher, stakeholders presentation 66 University of Ghana http://ugspace.ug.edu.gh Table 4.8 Budget ACTIVITIES COST IN GHANA CEDIS Trips to health facilities, participants and 450 supervisor Cost of producing instruments/survey tools cost of training data collection assistants, 100 incentives for respondents. Data management and analysis 200 Stationary and photocopying 200 Binding of Thesis 100 67